|Year : 1993 | Volume
| Issue : 2 | Page : 84-86
Penetrating orbitocranial injuries - Report of two cases
B Indira Devi, Sanjay Bhatia, Vijay K Kak
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Vijay K Kak
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
|How to cite this article:|
Devi B I, Bhatia S, Kak VK. Penetrating orbitocranial injuries - Report of two cases. Indian J Ophthalmol 1993;41:84-6
|How to cite this URL:|
Devi B I, Bhatia S, Kak VK. Penetrating orbitocranial injuries - Report of two cases. Indian J Ophthalmol [serial online] 1993 [cited 2013 Jun 18];41:84-6. Available from: http://www.ijo.in/text.asp?1993/41/2/84/25615
Penetrating orbitocranial injuries are uncommon. They may appear to be innocuous and minor, but unsuspected intracranial injuries and/or their complications may ultimately prove fatal. Hence early recognition, proper investigation and appropriate management of these injuries is imperative.
We report two cases of orbitocranial injury, one caused by a large serrated metallic object and the other, by an iron rod. Both patients had small external wounds and significant intracranial damage, but no neurological deficit.
| Case reports|| |
A 26-year-old male, while working on a mechanized cotton fluffing machine, suddenly heard a snap and felt a sharp twinge of pain in his left eye. There was no bleeding or loss of consciousness. He was brought to the hospital 8 hours later, with loss of vision in the left eye. He was fully conscious and oriented with no neurological deficit or neck stiffness. Examination of the left eye showed conjunctival chemosis preventing closure of the eyelids. A 2 mm x 2 mm scleral perforation was seen at 5 0' clock position, 4 mm from the limbus. The ciliary body was seen prolapsing through this wound. The cornea was clear and a hyphema was present. There was no perception of light in the left eve and the intraocular pressure was markedly decreased.
Plain skull X-rays revealed a long metallic foreign body with a serrated edge, similar to a piece of a saw blade, lying partly intraorbital and partly intracranial [Figure - 1]. A CT scan showed the foreign body extending from the left orbit into the left frontal lobe.
A left frontal trephine craniotomy was performed. The foreign body was seen lying within a contused area of the orbital surface of the left frontal lobe. The contused brain was removed to expose the tip of the foreign body, which was then extracted in line with the direction of its projection. It was a 6 cm long fragment of a saw blade, of which 3 cm lay in the orbit and the remainder in the cranial cavity. The dura was closed after securing haemostasis and the wound closed in the usual manner. The scleral perforation was then repaired. The postoperative course was uneventful.
The patient returned to his previous job two weeks later. There was no recovery of vision in the left eye.
This 31-year-old male was involved in an accident when an iron rod entered his left eve. He was brought to the hospital 24 hours later with progressive swelling of both the eyes and a blood stained discharge from the region of the inner canthus of the left eye. There was no loss of consciousness, visual disturbance or bleeding from the nose or eyes.
Examination revealed tense edematous eyelids in both eyes. There was marked proptosis and conjunctival chemosis of the left eye with increased retrobulbar resistance. There was no injury to the globe and the patient's vision was unaffected. The fundi were normal. Both the pupils were equal in size and reacted to light. There was no neurological deficit or neck stiffness.
Plain skull X-rays showed a fragment of the orbital roof driven intracranially [Figure - 2]. The CT scan showed a fractured left orbital roof, destroyed ethmoid air cells and a right frontal intracerebral haematoma with associated air [Figure - 3].
A bifrontal craniotomy was performed. The tear in the orbital dura on the left side was exposed and repaired. The right frontal intracerebral haematoma was evacuated and the indriven bone fragments were removed. His postoperative course was uneventful and the patient was discharged one week later.
| Discussion|| |
The orbit has certain peculiarities relevant to penetrating orbitocranial injuries. To achieve intracranial penetration, an object may pass through two natural pathways, viz. the optic canal and the superior orbital fissure, or through the orbital roof. The optic canal and superior orbital fissure routes will result in injury to the optic nerve and the third, fourth and sixth cranial nerves respectively, with no evidence of bone injury in the skull x-rays. The thin and delicate orbital roof offers little resistance to penetrating objects entering the cranial cavity. This thinness is also responsible for the usual non-visualization of the corresponding bony injury. It is, however, well seen in the second case.
The proper mangement of transorbital intracranial penetration is dependent upon its early recognition. Intracranial penetration may not be suspected if the entry wound is small. A high index of suspicion, therefore, is mandatory in such cases. A complete neurological examination and plain x-rays of the skull and orbit should be performed. A CT scan is necessary to delineate the trajectory and position of the penetrating object as well as the presence of any intracranial haemorrhage or air 
Since transorbital intracranial wounds may be associated with injuries to the internal carotid artery or proximal portions of the middle or anterior cerebral arteries, arteriography has been recommended by Kieck and DeVilliers  for all such patients. DeVilliers reported internal carotid artery injury in 5 out of 6 patients with transorbital stab wounds.  A traumatic aneurysm of the anterior choroidal artery has been reported following a transorbital stab wound. Haddad et ah  in their study of traumatic intracranial aneurysms following penetrating missile injuries of the head, suggested that angiography should be performed on all patients of injury by shrapel or a spent bullet having no exit wound, and those associated with an intracerebral haematoma in the distal part of the trajectory. However, the indications for angiography in non-missile injuries in civilian life are less clear. Both our patients were managed without angiography.
Transorbital injuries are also associated with a high risk of intracranial infection. Meningitis has been known to develop as early as 12-24 hours to as long as 2-3 months after the injury  High doses of antibiotics against likely organisms are usually given in the absence of an established infection.
Surgical procedures aim to remove the non-viable brain, haematomas, bone fragments and foreign bodies, and to repair the dura and any vascular injury. In the first case described here, the serrations on the penetrating object and the desire to preserve the eyeball influenced the decision to remove the object through a craniotomy, while the second patient had a primary intracranial problem meriting an intracranial approach.
| References|| |
|1.||De Villiers JC and Grant AR. Stab wounds at the craniocervical junction. Neurosurgery. 71: 930-936, 1985. |
|2.||Kieck CF and De Villiers JC. Vascular lesions due to transcranial stab wounds. J Neurosurg. 60: 42-46,1984. |
|3.||De Villiers JC. Stab wounds of the brain and skull. In Hand Book of Clinical Neurology; Injuries of the skull. Part I.Vinken PJ, and Bruvn GW (eds). Amsterdam. North Holland Publishing Co. Vol. 23. 477-503, 1975. |
|4.||Cressman MR and Haves CH. Traumatic aneurvsm of the anterior choroid artery. J Neurosurg. 24: 102-104, 1965. |
|5.||Haddad FS, Haddad GF and Taha J. Traumatic intracranial aneurysms by missiles: Their presentation and management Neurosurgerv. 28: 1-7,1991. |
|6.||Bard LA and Jarrett WH. Intracranial complications of penetrating orbital injuries. Arch Ophthalmol. 71:332-343,1964. |
[Figure - 1], [Figure - 2], [Figure - 3]