Bosch, Martina

Burkhardt, Jan-Karl

Holzmann, David

Kollias, Spyros

Reisch, Robert

Strobl, Lisa

Woernle, Christoph

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CASE REPORTInterdisciplinary endoscopic assisted surgery of a patientwith a complete transorbital intracranial impalementthrough the dominant hemisphereJan-Karl Burkhardt & David Holzmann & Lisa Strobl &Christoph M. Woernle & Martina M. Bosch &Spyros S. Kollias & Robert ReischReceived: 5 December 2011 /Accepted: 28 December 2011 /Published online: 10 March 2012# Springer-Verlag 2012IntroductionTransorbital injuries are common and represent about 24%to 45% of all penetrating head injuries in adults and children[1]. However, only <1% of the cases show a skull- or brain-penetrating route with consecutive intracranial injuries [1, 2].The direction and orbital entry route depends on the velocityof the impalement and the trajectory of the foreign body. Inlow-velocity injuries, the foreign body may be directed by theconfiguration of the orbital walls and enters most likely throughthe superior and inferior orbital fissures or the orbital canal [3].In cases of higher-velocity impalements, the orbital wall maydirectly fracture following a perpendicular trajectory line. Here,we describe the first case in the literature of a complete impale-ment injury through the dominant hemisphere entering theinner orbital angle, fracturing the medial aspects of the skullbase and leaving the skull contralaterally through the occipitalbone, treated successfully in interdisciplinary cooperation via acombined transnasal–transcranial approach.Case reportPatient history and clinical examinationA 4-year-old left-handed boy was transferred to our depart-ment after a traumatic impalement injury through his lefteye while playing with building bricks at home. Initially, hepresented with a rapid progressive loss of consciousness atthe University Children's Hospital, Zurich, with a woodenstick (30×1 cm) from a building set entering the medialangle of his left eye displacing the left globe laterally andinferiorly (Fig. 1a–c). The assessment of the left pupil wasdifficult due to the surrounding swelling but showed normalafferent and efferent function of the pupil. The right eyeshowed a dilated pupil without reaction to light. The foreignbody penetrated through the left superior eyelid.ImagingCT scan of the head confirmed the impalement with atranscranial penetrating route through the contralateral side,J.-K. Burkhardt : L. Strobl :C. M. Woernle : R. ReischDepartment of Neurosurgery,University Hospital, University of Zurich,Zurich, SwitzerlandJ.-K. BurkhardtDepartment of Neurological Surgery,Weill Cornell Medical College, New York Presbyterian Hospital,New York, NY, USAD. HolzmannDepartment of Otorhinolaryngology,Head and Neck Surgery University Hospital, University of Zurich,Zurich, SwitzerlandM. M. BoschDepartment of Ophthalmology,University Hospital, University of Zurich,Zurich, SwitzerlandS. S. KolliasDepartment of Neuroradiology,University Hospital, University of Zurich,Zurich, SwitzerlandR. Reisch (*)Center for Endoscopic and Minimally Invasive Neurosurgery,Clinic Hirslanden,Witellikerstrasse 40,8032 Zurich, Switzerlande-mail: robert.reisch@hirslanden.chChilds Nerv Syst (2012) 28:951–954DOI 10.1007/s00381-011-1674-8fracturing the occipital bone (Fig. 1). The penetrating route ledfrom the nasal half of the left upper eyelid fracturing thelamina papyracea, the posterior ethmoidal cells to the contra-lateral sphenoid sinus on the right. Here, the wooden foreignbody continued penetrating the right cavernous sinus and wasin close contact with the cavernous segment of the internalcarotid artery. Further posteriorly, the middle cranial fossa wasentered and left the right-sided occipital bone after piercingthrough the temporo-parieto-occipital brain tissue. No majorintracranial bleeding was seen on the CT.Operative courseAfter transferring the boy to the operating room, interdisciplin-ary endoscopic assisted emergency surgery (neurosurgery,ENT surgery, and ophthalmology) was performed. Since wewere uncertain whether the internal carotid artery (ICA) wasinjured by the foreign body or could be injured bymanipulatingthe latter, we decided to expose the contact area of the foreignbody with the ICA from below and above to guarantee a secureexposure and to be able to manage potential bleeding out of theICA. First, a transnasal endoscopic approach was performed(D.H.) exposing the ICA in its proximal segment as well as theforeign body from below using a wide right sphenoethmoidec-tomy. To expose the cavernous segment of the ICA and theoptic canal, the small sphenoid sinus was widely opened, andthe foreign body was seen exactly in the right lateral opto-carotid recess (Fig. 2). Thereafter, a pterional craniotomy wasperformed (R.R.), and the skull base was inspected through thetranscranial way. The wooden stick was found entering themiddle fossa through the lateral wall of the cavernous sinus.The stick was completely blocked within the skull base andcould not be removed. As there was a high potential risk ofrupturing adjacent vessels by rough removal of the stick, wedecided to cut it into two pieces above the level of the anteriorknee of the ICA using a high-speed drill (Fig. 2). The anteriorFig. 1 a–b Preoperativeclinical images of the patientwith the transorbital intracranialimpalement. c–g Axial CTimages show the penetratingroute of the wooden foreignbody (arrow). h CT 3Dreconstruction of the skullshows the fractured occipitalbone952 Childs Nerv Syst (2012) 28:951–954piece was carefully removed first under continuous transnasalendoscopic monitoring and then by transcranial microscopicmonitoring. The simultaneous visualization allowed safeproximal and distal control of the carotid artery; there wasno severe bleeding; however, the right optic nerve showed acomplete rupture. The right ICA appeared spastic, and onlylimited blood flow was detected by Doppler sonography.Therefore, after removal of the posterior part of the stick, thepterional craniotomy was enlarged for additional decompres-sion prior to closure. The upper eyelid wound was suturedafter inspection by the ophthalmic surgeon (M.M.B.). Postop-erative CT scan showed no severe brain injury. However, CT-angiography revealed a slight displacement and stenosis of theICA, and we supposed a traumatic fistula. A digital subtrac-tion angiography verified a carotid–cavernous fistula, and anocclusion of the vessel was performed in light of sufficientcollateral supply of the affected dominant hemisphere (S.S.K.)(Fig. 3).Postoperative courseAfter surgery, the patient was stable and transferred to thepediatric ICU. Intracranial pressure monitoring showed nor-mal values; after weaning and extubation, the patient showeda high-grade left-sided hemiparesis and global aphasia due tothe injured dominant right hemisphere. The ophthalmic ex-amination revealed ophthalmoplegia with mydriasis and am-aurosis on the right side, whereas the left eye showed a normalreactive pupil, adequate motility, and an unremarkable fundus.Three months after surgery, the frontoparietal bone was re-Fig. 3 a Postoperative DS-angiography in the sagittalplane verified a carotid–cavernous fistula. b Occlusionof the right internal carotidartery was performed aftersufficient collateral supply ofthe right dominant hemispherethrough the left arterial territorywas confirmedFig. 2 a–b Transnasalintraoperative endoscopic view:a the wooden foreign body(asterisk) was exposed next tothe lateral wall of the rightsphenoid sinus (SS) and theplanum sphenoidale (PS). bAfter removal of the woodenforeign body, the ICA wasintact without signs of injury.c–d Transcranial intraoperativemicroscopic view before (c),during (d), and after (e) high-speed drilling of the woodenforeign body (asterisk) in twopartsChilds Nerv Syst (2012) 28:951–954 953implanted with an uneventful postoperative course. At 1-yearfollow-up and after neuro-rehabilitation, the boy showed anearly complete regression of his hemiparesis with a slightremnant of his motor dysfunction and no impairment in un-derstanding and speech production. The right-sided ophthal-moplegia and mydriasis recovered completely; however, theright amaurosis remained unchanged (Fig. 4).DiscussionIn this report, we present a case of a complete transcranialimpalement through the patient's dominant hemisphere. Sharpor blunt transorbital impalement injuries are rarely describedin children and occur most of the time during playing, as inthis case [1, 2, 4–6]. Due to the thin anatomy of the orbita,where the bone is of least resistance, high-velocity injuriesmay lead to a continuation of the impalement intracranially.In our case, the penetrating channel of the wooden foreignbody involving the cavernous sinus potentially indicated in-jury of the carotid artery, thus necessitating safe proximal anddistal control of a possible intraoperative fatal bleeding; thiscould be achieved through the combined transnasal–transcra-nial approach by exposing the wooden foreign body frommedial and below and from lateral and above, respectively.With this combined approach, the ICA could be exactly dis-played, and a bleeding event would have been preciselycontrolled, had it occurred.Endoscopic transnasal skull base surgery for young chil-dren is rarely described in the literature, especially if thecavernous sinus and the cavernous segment of the ICA needto be exposed [7]. We showed for the first time that ourinterdisciplinary transnasal–transcranial approach is a feasibleand secure method to treat a traumatic impalement in a 4-year-old child. Since age-related differences in the anatomy of theskull base may limit endoscopic transnasal surgery in chil-dren, this technique should be performed by experiencedendoscopic surgeons [8].Here, we describe to our knowledge the first case of acomplete transcranial penetration of a wooden foreign body,treated successfully via a combined transnasal–transcranialapproach with a favorable clinical patient outcome after1 year.References1. Turbin RE, Maxwell DN, Langer PD, Frohman LP, Hubbi B,Wolansky L, Mori M (2006) Patterns of transorbital intracranialinjury: a review and comparison of occult and non-occult cases.Surv Ophthalmol 51:449–4602. Dunn IF, Kim DH, Rubin PA, Blinder R, Gates J, Golby AJ (2009)Orbitocranial wooden foreign body: a pre-, intra-, and postoperativechronicle: case report. Neurosurgery 65:E383–E384, discussion E3843. Balasubramanian C, Kaliaperumal C, Jadun CK, Dias PS (2009) Trans-orbital intracranial penetrating injury-an anatomical classification. SurgNeurol 71:238–2404. Lee JS, Lee JE, Oum BS, Cha SH (1999) Orbitocranial injurycaused by wood. Korean J Ophthalmol 13:128–1325. Orszagh M, Zentner J, Pollak S (2009) Transorbital intracranialimpalement injuries by wooden foreign bodies: clinical, radiologicaland forensic aspects. Forensic Sci Int 193:47–556. Park SH, Cho KH, Shin YS, Kim SH, Ahn YH, Cho KG, Yoon SH(2006) Penetrating craniofacial injuries in children with wooden andmetal chopsticks. Pediatr Neurosurg 42:138–1467. Kassam A, Thomas AJ, Snyderman C, Carrau R, Gardner P, MintzA, Kanaan H, Horowitz M, Pollack IF (2007) Fully endoscopicexpanded endonasal approach treating skull base lesions in pediatricpatients. J Neurosurg 106:75–868. Tatreau JR, Patel MR, Shah RN, McKinney KA, Zanation AM(2010) Anatomical limitations for endoscopic endonasal skull basesurgery in pediatric patients. Laryngoscope 120(Suppl 4):S229Fig. 4 a and b Postoperativeclinical images of the patientshow the favorable patientoutcome with a regression ofthe left-sided hemiparesis andthe right-sided ophthalmoplegia954 Childs Nerv Syst (2012) 28:951–954

Interdisciplinary endoscopic assisted surgery of a patient with a complete transorbital intracranial impalement through the dominant hemisphere

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Interdisciplinary endoscopic assisted surgery of a patient with a complete transorbital intracranial impalement through the dominant hemisphere

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