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.

Article Information

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.

© AANS, except where prohibited by US copyright law.

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Figures

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    Admission imaging consistent with left-sided transorbital PHI. A: Unenhanced CT showing normal-appearing extraocular muscles and optic nerves, as well as IVH (arrow). Periorbital edema and proptosis were also identified. B: CT angiogram demonstrating asymmetrical enhancement of the left SOV (arrow). The ICAs and circle of Willis vessels (not shown) were intact.

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    Axial T2-weighted gradient echo MR image demonstrating antenna injury traversing the brainstem. The point of brainstem entry anteriorly is just to the left of midline, immediately lateral to the basilar artery and superior to the posterior cerebral artery—flow voids in these and all other major intracranial arteries were preserved. The tract of injury extends posterolaterally through the right superior cerebellar peduncle and inferior colliculus.

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    Delayed-onset, high-flow CCF with cortical venous reflux. A and B: Axial 3D time-of-flight (TOF) MRA studies showing orbital proptosis and a left-sided CCF originating from the horizontal cavernous segment of the ICA, with SOV dilation (arrows). C: Rotational MRA showing a CCF with prominent left hemispheric vasculature (arrow). D: Precoiling rotational angiogram, anteroposterior view, showing the left ICA; three discrete arteriovenous connections were noted. E and F: Postcoiling digital subtraction and rotational angiograms, anteroposterior views, showing the left ICA. Ninety percent embolization was achieved, with no cortical venous reflux or ophthalmic vein filling and minimal persistent filling of the petrosal sinuses.

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    Axial T2-weighted FLAIR MR image (A) obtained before repeat embolization, showing enlargement of the larger superolateral pseudoaneurysmal outpouching (arrow). Rotational MR angiogram (B) and digital subtraction angiogram (C) obtained after repeat embolization, showing obliteration of the pseudoaneurysms and preservation of the left ICA.

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