Fatal transorbital penetrating intracranial injury caused by a bicycle hand brake
International Journal of Emergency Medicine
Fatal transorbital penetrating intracranial injury caused by a bicycle hand brake
Willemijn B Huiszoon 0
Pieter N Noë 1
Albertus Manten 0
0 Department of Critical Care, Meander Medical Center , Utrechtseweg 160, Amersfoort ES 3818 , the Netherlands
1 Department of Emergency Medicine, Meander Medical Center , Utrechtseweg 160, Amersfoort ES 3818 , the Netherlands
A transorbital penetrating intracranial injury is a rare and severe traumatic brain injury. Patients with this type of injury may present dramatically, but often the injury is subtle and therefore easily overlooked and not recognized in the first place. We present the case of a 45-year-old female admitted to the emergency department after she fell with her bike and the bicycle brake handle penetrated her left eye. A computerized tomography of the cerebrum showed a fracture of the superior orbital roof with multiple bone fragments extending into the brain near the circle of Willis. A pneumocephalus and traumatic frontobasal, intraventricular and subdural hemorrhage was seen. The patient deteriorated suddenly and was transferred to a neurosurgical center where she underwent an emergency craniotomy with evacuation of the intracerebral hematoma and an intraventricular drain was placed. After surgery, the patient's condition deteriorated, and total compression of the brain stem occurred, upon which the patient was declared brain dead. Our case report shows that the Glasgow Coma Scale score at admission is not always a good predictor of the severity of the injury. Even when there is minimal suspicion of a penetrating intracranial injury, a computerized tomography should be performed immediately, independent of the patient's Glasgow Coma Scale score. A direct transfer to a specialized neurosurgical center is recommended because this injury often results in death due to fatal complications such as intracerebral hemorrhage, pneumocephalus and brain stem injury.
Transorbital penetrating intracranial injury; Bicycle hand brake; Glasgow Coma Scale score
and an extremely painful left eye. She had a Glasgow
Coma Scale score (GCS score) of 15, and vital
parameters were normal. Trauma screening only revealed an
isolated injury of the left eye, which was swollen, and a
periorbital hematoma was seen. The eye globe was
perforated with a deformed pupil. There was complete
vision loss, and movement of the left eye was impossible.
Neurological examination revealed no loss of sensibility
or motoric dysfunction.
A computerized tomography of the cerebrum was
made and revealed a fracture of the superior orbital roof
with multiple bone fragments extending into the brain
near the circle of Willis (Figure 1). Pneumocephalus and
traumatic frontobasal, intraventricular and subdural
hemorrhage were seen (Figure 2). After the CT, she was
prepared for emergency transfer to a nearby
neurosurgical center. While waiting for the ambulance, the patient
suddenly developed a generalized epileptic insult not
responding to anti-epileptic medications. Eventually a
status epilepticus developed, managed by intubation and
sedation with propofol. During the ambulance transfer,
Figure 1 CT showing a left orbital roof fracture and pneumocephalus.
the blood pressure increased and heart rate decreased.
The right pupil became wider and did not react to light
anymore. These findings were suggestive of brain
herniation and brain stem compression.
Upon arrival at the neurosurgical center, the patient
was taken directly to the operating room for an
emergency craniotomy. Evacuation of the intracerebral
hematoma was performed, and an intraventricular drain
Figure 2 CT showing a subarachnoid and intraventricular hemorrhage and pneumocephalus.
was placed. A CT, magnetic resonance imaging (MRI)
and magnetic resonance angiography (MRA) were
performed, which revealed an obstructive hydrocephalus
and extended intracerebral hemorrhage. Despite the
emergency exploration, the patient’s condition
deteriorated after surgery. A total compression of the brain
stem occurred, and the patient was declared brain
dead, after which she was found eligible to be a
To the best of our knowledge, this is the first case
report describing a transorbital penetrating intracranial
injury (TPII) in an adult patient caused by a brake handle.
This trauma mechanism has been described in previous
reports mostly in young children [5-9].
Three reports described a fatal TPII in children who
were all unconscious at the time of presentation to the
emergency department [7-9]. In contrast to these
reports, our patient was fully conscious when she
presented to the emergency department. This shows that
the GCS score at admission is not always a good
predictor. It also underlines the importance of an early
CT in patients with an occult injury or subtle
presentation to determine the extent of the injury and detect
intracranial lesions. When there is a suspicion of a
non-metallic intracerebral foreign body, it is better to
perform an MRI as CT misses 42% of the
nonmetallic foreign bodies .
The patient in our case report underwent an
emergency neurosurgical intervention. The other reports
did not describe the performance of a neurosurgical
intervention in children with TPII caused by a brake
handle. A possible explanation could be the low GCS
score on admission and the extent of the injury
associated with a worse prognosis. Overall, the literature
about the effect of neurosurgical treatment in the
acute management of TBII is scarce, and the
prognostic effect is not clearly described.
We described an adult patient with a transorbital
penetrating intracranial injury caused by a bicycle
handbrake. It is important to recognize this type of injury at
the time of presentation because it can lead to fatal
complications such as intracerebral hemorrhage,
pneumocephalus and brain herniation . Despite the maximum
GCS score at presentation and an emergency
craniotomy, our patient did not survive.
CT: Computerized tomography; GCS score: Glasgow Coma Scale score;
TPII: Transorbital penetrating intracranial injury; MRI: Magnetic resonance
imaging; MRA: Magnetic resonance angiography.
PN and AM were involved in direct patient care. PN obtained verbal consent
from the husband of the patient for publication of this case report. WH
researched the current literature and wrote the case report. PN and AM
oversaw and critically revised the manuscript. All authors read and approved
the final manuscript.
1. Webster J , Schneider M , Lofstrom M : Observations upon the management of orbito-cranial wounds . J Neurosurg 1946 , 3 : 329 - 36 .
2. Chibbaro S , Tacconi L : Orbito-cranial injuries caused by penetrating nonmissile foreign bodies . Experience with eighteen patients . Acta Neurochir 2006 , 148 : 937 - 942 .
3. Mackerle Z , Gal P : Unusual penetrating head injury in children: personal experience and review of the literature . Childs Nerv Syst 2009 , 25 : 909 - 913 .
4. Satyarthee GD , Borkar SA , Tripathi AK , Sharma BS : Transorbital penetrating cerebral injury with a ceramic stone: Report of an interesting case . Neurol India 2009 , 57 : 331 - 3 .
5. Ng JD , Payner TD , Holck DE , Martin RT , Nunery WT : Oribtal trauma caused by bicycle hand brakes . Opthal Plast Reconstr Surg 2004 , 20 (Suppl 1): 60 - 63 .
6. Agrawal A , Pratap A , Agrawal CS , Kumar A , Rupakheti S : Transorbital orbitocranial penetrating injury due to bicycle brake handle in a child . Pediatr Neurosurg 2007 , 43 : 498 - 500 .
7. Ahmad FU , Suri A , Mahapatra AK : Fatal penetrating brainstem injury caused by bicycle brake handle . Pediatr Neurosurg 2005 , 41 : 226 - 228 .
8. Gopalakrishnan MS , Devi BI : Fatal penetrating orbitocerebral injury by bicycle brake handle . Indian J Neurotr 2007 , 4 ( Suppl 2 ): 123 - 124 .
9. Chattopadhyay S , Sukul B , Das SK : Fatal transorbital head injury by bicycle brake handle . J Forens L Med 2009 , 16 : 352 - 353 .
10. Tubin RE , Maxwell DN , Langer PD , Frohman LP , Hubbi B , Wolansky L , Mori M : Patterns of transorbital intracranial injury: a review and comparison of occult and non-occult cases . Surv Opthalmol 2006 , 51 : 449 - 460 .
11. Bard L , Jarrett W : Intracranial complications of penetrating orbital injuries . Arch Opthalmol 1964 , 71 : 332 - 42 .