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CASE REPORT
Year : 2014  |  Volume : 9  |  Issue : 3  |  Page : 267-269
 

Transorbital penetrating brain injury to frontal lobe by a wheel spoke


Department of Pediatric Neurosurgery, The Children's Hospital and the Institute of Child Health, Lahore, Pakistan

Date of Web Publication23-Dec-2014

Correspondence Address:
Lubna Ijaz
428 Nishter Block, Iqbal Town, Lahore
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.147588

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   Abstract 

Penetrating brain injury (PBI) is rare and the severest form of head injury with a high morbidity and mortality. A 3.5-year-old girl presented with PBI with a wheel spoke. Computerized tomography scan with three-dimensional skull reconstruction depicted its extent from the medial side of the roof of the right orbit to the right frontal lobe with a cavitation around the spoke. The spoke was removed by manipulation under general anesthesia from the entry site without a formal craniotomy. Postoperative outcome was uneventful.


Keywords: Frontal lobe injury, penetrating brain injury, wheel spoke


How to cite this article:
Ijaz L, Nadeem MM. Transorbital penetrating brain injury to frontal lobe by a wheel spoke. J Pediatr Neurosci 2014;9:267-9

How to cite this URL:
Ijaz L, Nadeem MM. Transorbital penetrating brain injury to frontal lobe by a wheel spoke. J Pediatr Neurosci [serial online] 2014 [cited 2019 Jul 19];9:267-9. Available from: http://www.pediatricneurosciences.com/text.asp?2014/9/3/267/147588



   Introduction Top


Penetrating brain injury (PBI) with low-velocity nonmissile objects is associated with high morbidity and mortality. It accounts for 0.04% of all head trauma. PBI has been reported with steel rod, screwdriver, knife, fork, wood stick, scissors, pencil, fence rod, javelin, coat hanger, billiard stick, toothbrush, and chopstick, etc., Majority of cases have to be dealt with the removal of the penetrating object by a formal craniotomy. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] We herein report a case of PBI with a wheel spoke, which was removed from the entry wound without a craniotomy.


   Case Report Top


A 3.5-year-old girl presented to the surgical emergency with a metal rod intruded to the medial side of the right eye. The mother of this child had died. The incident occurred while she was playing with a bicycle wheel spoke and accidentally fell over it, resulting in penetrating injury [Figure 1]. The patient bled from the entry wound which could not be quantified. The bleeding, however, ceased spontaneously in the meantime when she arrived at us. She was vitally stable with a Glasgow Coma Scale score of 15/15 with no focal neurological deficit. Ophthalmologic examination ruled out an eyeball injury. Skull radiographs in antero-posterior and lateral views revealed angled end of a long wheel spoke penetrating about 10 cm deep into the cranium through the medial aspect of the roof of the right orbit [Figure 2]. The computerized tomography (CT) scan with three-dimensional reconstruction showed the spoke lying in the right frontal lobe (premotor area), the internal trajectory being perpendicular to roof of the orbit, away from brain vasculature and vital centers, and a cavitation around the spoke [Figure 3]. Blood investigations were within normal limits. The patient was taken to the operation theatre after optimization. The entrance wound was extended slightly and spoke pulled back bit by bit. It took half an hour to retrieve the spoke completely. The patient remained vitally stable throughout the procedure. The dural defect was packed with sponge-stone and bone-wax. Peri-orbita and the skin were closed [Figure 1]. Immediate postoperative recovery was uneventful. The patient was allowed orally on the following day of operation and discharged on the 4 th postoperative day on antibiotics for 2 weeks. The patient has visited us twice; she is in a good state of health without any signs of local and central nervous system infections and cerebrospinal fluid (CSF) leakage.
Figure 1: Wheel spoke intruded transorbitally. Inset showed postremoval image

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Figure 2: Radiographs showing spoke

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   Discussion Top


Penetrating brain injury to Phineas Gage, a railway worker, with an iron rod has been a very popular case in the United States. He, later on, died of posttraumatic epilepsy. [11] The prognosis depends on the site of involvement as to damage to major vessels and vital brain centers. Various complications of PBI are sudden death, life-threatening hemorrhage, intracranial hematoma, local trauma to the brain and its vasculature, brain abscesses, meningitis, CSF leakage, and neurological deficits. Epilepsy, behavioral, and psychological problems are also encountered in patients, especially with frontal lobe injury. [5],[6],[7],[8],[9],[10],[11]

The mode of injury is accidental in most of the pediatric cases; however, homicidal intent should be looked out for. Solarino et al., [2] reported a case where the child got PBI by a coat hanger; the intent was to hit her mother, but the daughter got the brunt. In our case, the mother had died, and all five siblings had been distributed among various relatives. The index case was living with paternal aunt, and any other intent could not be ruled out.

The objectives of the intervention in case of PBI are to avoid further damage to the brain, remove the offending object, debridement of necrotic brain tissue, and evacuation of the hematoma. These objectives are, in the majority, accomplished by a formal craniotomy around the wound of entrance. [4],[7],[8],[9],[10],[11],[12],[13],[14],[15] In our case, we also planned a craniotomy, however, a cavitation phenomenon around the metal rod as divulged on CT scan and a safe trajectory of the wheel spoke led us to alter our strategy. The rod was an angled, but as it was in the frontal lobe away from the major brain vasculature. Therefore, we attempted to remove it through the entrance wound. Bit by bit retrieval with strict monitoring of the patient led to the successful removal.

Postoperative monitoring and follow-up are important as in the immediate postoperative period, brain edema, intracranial hematoma, CSF leakage, or meningitis may develop. A short postoperative course of anti-convulsant is quite useful in preventing immediate convulsions; however, epilepsy may develop months to years after the trauma. [8],[9],[10],[11] Postoperative course of prophylactic antibiotics is of equal importance for the prevention of infectious sequel. We gave antibiotics for 2 weeks to our patient. In the case of suspicion of any epileptic activity, electroencephalogram should be done. A perusal of the literature did not reveal any case of transorbital PBI with an angled wheel spoke.

 
   References Top

1.
Pascual JM, Navas M, Carrasco R. Penetrating ballistic-like frontal brain injury caused by a metallic rod. Acta Neurochir (Wien) 2009;151:689-91.  Back to cited text no. 1
    
2.
Solarino B, Reckentwald K, Burrows-Beckham AM. An unusual case of child head injury by coat hanger. J Forensic Sci 2008;53:1188-90.  Back to cited text no. 2
    
3.
Arslan M, Eseoglu M, Güdü BO, Demir I. Transorbital orbitocranial penetrating injury caused by a metal bar. J Neurosci Rural Pract 2012;3:178-81.  Back to cited text no. 3
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4.
Nishihiro S, Takeuchi A, Aihara H, Arisawa T, Kashitani N. A case of penetrating brain injury by a javelin. No Shinkei Geka 2014;42:243-8.  Back to cited text no. 4
    
5.
Chan SK, Pang KY, Wong CK. Transnasal penetrating intracranial injury with a chopstick. Hong Kong Med J 2014;20:67-9.  Back to cited text no. 5
    
6.
Bodwal J, Sreenivas M, Aggrawal A. Intracranial penetrating injury by screw driver: A case report and review of literature. J Forensic Leg Med 2013;20:972-5.  Back to cited text no. 6
    
7.
Skoch J, Ansay TL, Lemole GM. Injury to the temporal lobe via medial transorbital entry of a toothbrush. J Neurol Surg Rep 2013;74:23-8.  Back to cited text no. 7
    
8.
Miscusi M, Arangio P, De Martino L, De-Giorgio F, Cascone P, Raco A. An unusual case of orbito-frontal rod fence stab injury with a good outcome. BMC Surg 2013;13:31.  Back to cited text no. 8
    
9.
Turkalj I, Stojanovic S, Petrovic K, Njagulj V, Mikov I, Spanovic M. Psychosis following stab brain injury by a billiard stick. Hippokratia 2012;16:275-7.  Back to cited text no. 9
    
10.
Eren B, Cetin S, Türkmen N, Akan O, Gürses MS, Gündogmus UN. An unusual case of penetrating intracranial injury due to scissors. Soud Lek 2013;58:29-30.  Back to cited text no. 10
    
11.
Phineas gage. Available from: . [Last accessed on 2014 Jan 26].  Back to cited text no. 11
    
12.
Lin HL, Lee HC, Cho DY. Management of transorbital brain injury. J Chin Med Assoc 2007;70:36-8.  Back to cited text no. 12
    
13.
Koestler J, Keshavarz R. Penetrating head injury in children: A case report and review of the literature. J Emerg Med 2001;21:145-50.  Back to cited text no. 13
    
14.
Park SH, Cho KH, Shin YS, Kim SH, Ahn YH, Cho KG, et al. Penetrating craniofacial injuries in children with wooden and metal chopsticks. Pediatr Neurosurg 2006;42:138-46.  Back to cited text no. 14
    
15.
Karim T, Topno M. An unusual case of penetrating head injury in a child. J Emerg Trauma Shock 2010;3:197-8.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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