Complete recovery following transorbital penetrating head injury traversing the brainstem: case report

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Transorbital penetration accounts for one-quarter of the penetrating head injuries (PHIs) in adults and half of those in children. Injuries that traverse (with complete penetration of) the brainstem are often fatal, with survivors rarely seen in clinical practice. Here, the authors describe the case of a 16-year-old male who suffered and recovered from an accidental transorbital PHI traversing the brainstem—the first case of complete neurological recovery following such injury. Neuroimaging captured the trajectory of the initial injury. A delayed-onset carotid cavernous fistula and the subsequent development of internal carotid artery pseudoaneurysms were managed by endovascular embolization.

The authors also review the relevant literature. Sixteen cases of imaging-confirmed PHI traversing the brainstem have been reported, 14 involving the pons and 12 penetrating via the transorbital route. Management and outcome of PHI are informed by object velocity, material, entry point, trajectory, relationship to neurovascular structures, and the presence of a retained foreign body. Trauma resuscitation is followed by a careful neurological examination and appropriate neuroimaging. Ophthalmological examination is performed if transorbital penetration is suspected, as injuries may be occult; the potential for neurovascular complications highlights the value of angiography. The featured case shows that complete recovery is possible following injury that traverses the brainstem.

ABBREVIATIONS CCF = carotid cavernous fistula; CN = cranial nerve; GCS = Glasgow Coma Scale; ICA = internal carotid artery; IVH = intraventricular hemorrhage; PHI = penetrating head injury; SAH = subarachnoid hemorrhage; SOV = superior ophthalmic vein.
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Contributor Notes

Correspondence David B. Clarke: Dalhousie University and Nova Scotia Health Authority, Halifax, Nova Scotia, Canada. d.clarke@dal.ca.INCLUDE WHEN CITING Published online September 6, 2019; DOI: 10.3171/2019.6.PEDS19106.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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