Year : 1985 | Volume
: 33 | Issue : 2 | Page : 105--107
An unusual case of orbito-cranial gunshot wound
Madhumati Misra, Sanatan Rath, Brahmananda Acharya, Suresh Chandra Mohanty
Department of Neuro-Surgery S.C.B. Medical College, Cuttack, India
Department of Neuro-Surgery, Medical College Cuttack- 753007
|How to cite this article:|
Misra M, Rath S, Acharya B, Mohanty SC. An unusual case of orbito-cranial gunshot wound.Indian J Ophthalmol 1985;33:105-107
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Misra M, Rath S, Acharya B, Mohanty SC. An unusual case of orbito-cranial gunshot wound. Indian J Ophthalmol [serial online] 1985 [cited 2022 Jul 2 ];33:105-107
Available from: https://www.ijo.in/text.asp?1985/33/2/105/30831
Orbit-Cranial injuries by gun shot wounds in both war and civilian practice are rare,. Review of literature show that the cerebral injury was "ipsilateral" to the orbit injury in all such reported cases. The present case is unique in that the missile after perforating the right eye, traversed to the "contralateral" (left) parieto-occipital cortex.
HA, a Muslim male aged 21 was admitted sustaining an accidental gunshot injury which traumatized his right eye. Ocular examination revealed scleral rupture at 3 0' clock position with total haemophalmos and prolapse of uveal tissue. All ocular movements were completely restricted on the right side with soft eye ball, having no perception of light. The left eye, was clinically normal. Systemic and neurological examinations revealed no other deficit. On X-ray, skull orbital fracture was not demonstrated. The bullet could be located in the left parietooccipital area. Enucleation of the right eye was done on the same day of accident and the patient was transferred to the neurosurgical section for further care. On the next day, the patient developed headache, vomiting and mental confusion. Neurological examination revealed left VI palsy, papilloedema in left eye with visual acuity 6/18 and right hemianopic field defect. Urgent computed tomographic study demonstrated the bullet tract traversing through the right orbit transtentorially to the left parieto-occipital cortex [Figure 1]. Haemorrhage 'in the right orbit and haemorrhagic brain oedema were noted along the missile tract [Figure 2].
Under prophylactic antibiotic cover, left post parietal craniotomy was done on 23.8.83 and suction removal of the devitalized brain tissue was done. The bullet could not however, be located in the area and was not removed. Closure of the wound was done after water-tight dural closure. The patient was observed carefully under antibiotic cover in the postoperative period.
At a recent checkup, the patient was found asymptomatic with regression of papilloedema in the left eye and vision improved to 6/9. The right hemianopic field defect however, persisted, the bullet on check X-ray and CT scan was found in its previous position.
The rarity of orbitocranial gunshot injuries in both war and civilian practice has been reported. In a large series of 351 missile head injuries in Vietnam War, Hammon noted orbital penetration in 2 cases (0.6%) only. In 4 cases of Orbitocranial gunshot wounds studied by Calvert, the missile entering the orbit penetrated through the ipsilateral greater wing of the sphenoid and lodged in the cerebral lobes on the same side. In all these reported cases, the cerebral injury was ipsilateral to the orbital injury.
In our patient, however, the cerebral involvement was contralateral (left sided) to the orbital injury (right sided). On CT scan, the bullet tract traversing transtentorially to the opposite 'cerebral cortex was demonstrated and the missile could be located in the left occipital lobe. Such occurrence has not yet been reported in literature. Orbital skiagraphy demonstrated on bony injury, the missile could have possibly passed through the superior orbital fissure, as' described by Calvert. However, non demonstration of bony defects in routine X-rays does not exclude the possibility of a fracture.
Following CT localisation of the bullet in the occipital Cortex, attempt to its surgical removal was made. After debridement of the scalp and periosteum at the site of penetration, Craniotomy with resection of all the bone fragments and devitalized brain tissue from the missile tract was done, Attempt to remove the missile by more extensive search at this stage was not done for fear of inflicting further functional brain damage.
Hagan has outlined similar guidelines for surgical management of penetrating cranial wounds. According to him, if a metallic fragment is easily accessible and removable without inflicting further functional damage, every effort should be made to remove it. In difficult situations and in asymptomatic patients the bullet could be left in situ and these cases should be observed carefully for prolonged periods. Early removal of intraventricular metallic fragments is indicated because free migration can occlude foramina producing obstructive hydrocephalus.
The, brain appears to tolerate the presence of metallic foreign bodies reasonably well. The incidence of delayed brain abscess around a metallic fragment is relatively rare (10 5%) as the debris clinging it is often sterilised by the heat of the metal,. Sterile abscesses may develop due to liquification of the tissue and chemical decomposition. Changes in position of the missile in subsequent check X-rays are suggestive of development of brain abscess around it, or intraventricular or subdural migration. Delayed removal is indicated if complications such as infection, or epilepsy develop.
An unusual case of left parieto-occipital lobe injury due to gunshot wound of contralateral orbit is reported. The guidelines for surgical management of penetrating cranial wounds have been discussed with review of available literature.
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