An unusual case of orbito-frontal rod fence stab injury with a good outcome
Luca De Martino
Institute of Legal Medicine, Catholic University of the Sacred Heart
Department of Medical and Surgical Sciences and Biotechnologies
Department of Odontostomatologic and Maxillo-facial Sciences, Sapienza University of Rome
Background: High-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features. Case presentation: A 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws. Conclusion: The patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact. The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists.
High-energy non-missile penetrating injuries, also known
as stab injuries, account for a small percentage of
penetrating head injuries. They may be caused by knives, nails,
spikes, forks, scissors, and other assorted objects.
Penetration most commonly occurs through the thin bones of the
skull, especially through the orbital surfaces and in the
squamous portion of the temporal bone. The mechanisms
of neuronal and vascular injury caused by cranial stab
wounds may differ from those caused by other types of
head trauma. Unlike missile injuries, no concentric zone
of coagulative necrosis caused by dissipated energy is
present. Unlike motor vehicle accidents, no diffuse shearing
injury to the brain occurs. Unless an associated hematoma
or infarct is present, cerebral damage caused by stabbing
is largely restricted to the wound tract. Sometimes, a
narrow elongated defect, or so-called slot fracture, is
produced and diagnosed when identified . However, in
some cases in which skull penetration is proven, no
radiological abnormality can be identified. In a series of stab
wounds, de Villiers reported a mortality of 17%, mostly
related to vascular injury and massive intracerebral
hematomas . Infections can easily complicate penetrating
craniocerebral injuries and patients can develop
meningitis, epidural abscess, subdural empyemas, or brain abscess.
Therefore, prevention and proper management of
infectious complications can lead to improved outcomes in
We present the case of a 35-year-old man who suffered
a high-energy non-missile orbito-frontal? penetrating
brain injury after falling five meters from a terrace onto
a rod iron fence. The patient was transported to our
Emergency Department with the rod still embedded into
his right orbit and skull (Figure 1A).
The GCS score on admittance was 6. The rod was
removed in the Emergency Room without any radiological
control; a consequent CT scan revealed that the injury
involved the right orbit floor, roof and zygoma, both the
frontal sinus and the frontal lobes and had caused a
frontal post-traumatic acute subdural haemorrhage. The
right ocular globe was intact because the burst fracture
of the orbital compartment (a comminute fracture of the
Figure 1 Patient at emergency department. A: Patient at our Emergency Department with the metal rod still embedded into the right orbit and
skull. B: Inspection of the right orbit, showing a complete destruction of orbit roof with the ocular globe pushed backwards and downwards.
C and D: CT coronal and sagittal scan reconstructions showing the fracture of both orbit floor and roof. E and F: CT axial scans at admittance,
demonstrating the fracture of frontal bone, with opening of frontal sinus, and signs of subarachnoid hemorrhage in the inter hemispheric cistern.
floor, roof, lateral and medial orbital walls) allowed the
ocular globe to undergo a downward displacement
without being smashed against an osseous wall (Figure 1B-E).
Cranial and maxillo-facial CT scans excluded signs of
According to our imaging and treatment protocols, an
angiogram was not performed because, considering the
location and trajectory of the foreign body, there was no
evidence of possible vascular injury. The patient
immediately underwent surgery to evacuate the subdural
haemorrhage and to repair both cranial and facial
defects. Neurosurgeons and maxillo-facial surgeons
participated simultaneously in the procedure. A bifrontal
craniotomy was performed through a bicoronal flap.
Intracranially, the dura mater and both frontal lobes with
the first third of the superior longitudinal sinus were
lacerated (Figure 2A). Haemorrhagic and necrotic tissue
was debrided and the superior longitudinal sinus was
clipped without difficulty. Rust was found inside the
parenchyma and was removed together with (through??) a
meticulous irrigation of the operative field. The frontal
sinuses were cranialised, the mucosa was removed from
the nasofrontal ducts. After cranialization, the
nasofrontal ducts were obliterated using the temporalis muscle
flap, fibrin sealant was applied over the ducts, and the
pericranial flap appropriately folded in order to
obliterate the dead space of the sinus. A large-scale duroplasty
was performed with a bovine pericardial patch (Figure 2B).
A right eyelid incision was performed to expose and
reduce margin fractures using a titanium plate and screws
(Figure 2C-E). A collagen membrane was used for orbital
floor and roof reconstruction.
The patient was then moved to the intensive care unit
and his neurological status showed a progressive and
constant improvement; after fifteen days, sedation was
stopped and the patient was discharged from the
intensive care unit.
A large spectrum antimicrobial therapy (gram+, gram-,
anaerobics and fungi) was administered continuously for
one month because of the high risk of intracranial septic
complications, which at the end did not occur.
A CT scan, performed one month after injury, showed
a good reconstruction of the cranial vault, of the orbital
floor and of the roof and demonstrated the chronic
evolution of the frontal lobe injury (Figure 3A-B).
The patient was discharged to a rehabilitation unit in
good general condition (GCS 15), without focal
neurological signs. The right ocular globe was completely
undamaged and visual acuity remained intact; however, a
mild paresis of right superior rectus muscle and a slight
ptosis were evident (Figure 3C). The patients
neurological status and visual acuity were unchanged at the
eight-month follow-up and he went back to being a street
musician. He refused to undergo neuro-psychological
testing to assess the frontal abilities.
Penetrating stab intracranial injuries caused by metallic
foreign bodies are very rare among the civilian
population. Only a few cases have been reported in the
literature in the last two decades, but medical reports of stab
wounds of the brain date from as early as 1806 [3-10].
Penfield described the pathological features of
experimental stab wounds with cannulas . The literature
Figure 2 Skull and maxilla reconstruction: surgical and radiological view. A: Intraoperative view at the opening, with fracture of frontal
bone and necrotic brain through the bone gap. B: Intraoperative view after duroplasty and cranialisation of the frontal sinus by galeal flap.
C, D and E: CT scan, coronal, sagittal and axial scans, demonstrating the reconstruction of the orbit floor and roof and zygoma.
Figure 3 Clinical and radiological outcome. A: 3D CT scan view showing the final reconstruction of the fractured frontal bone. B: CT scan
performed one month after injury, demonstrating the hypodensity of both frontal lobes as chronic consequences of penetrating injury. C: Patient
at discharge with paresis of right superior rectus muscle and ptosis.
provides a long list of objects known to have penetrated
the brain, which include knives, chopsticks, pitchforks,
crochet hooks, knitting needles, brooch pins, umbrella
tips, crowbars and iron rods, car antennas and scissors
To our knowledge, this is the first report of a
high-energy penetrating brain injury caused by such
Penetrating craniocerebral stab injuries are more
amenable to treatment than missile injuries. A stab wound
creates a narrow hemorrhagic infarction which is mainly
restricted to the wound tract. Concentric zones of
coagulative necrosis do not result from stab wounds as
they do from explosives and from the cavitating forces
of missiles. Similarly, contre-coup injuries rarely occur, if
at all, from stab wounds . Unless the stabbing
instrument is swept across the brain before withdrawal, the
resultant lesion is usually focal. Therefore, when there are
no direct injuries to the brain stem or direct lacerations
of a major vessel, the prognosis for recovery in such type
of cranial injury may be good.
Frontal stabs are accompanied by the least morbidity
and mortality, while penetrating orbito-cranial stab
injuries characteristically cause considerable morbidity and
mortality by direct damage to brain structures, vascular
compromise, or infection .
Vascular compromise may be due to direct vascular
trauma of the internal carotid artery both in its
intracavernous and paraclinoid segment, to distortion of the
vessel due to local effects such as haematoma formation
or oedema, or vasospasm .
Non-contrast cranial and maxillofacial CT scan, which
is the best imaging modality for this type of trauma, can
help analyze the trajectory of the foreign body and
observe whether the object went through any areas of
major vascular significance, including the ICA
(especially within the cavernous sinus) and the anterior and
middle cerebral arteries. In case of suspicion for vascular
injury, an angiography should also be performed to
evaluate for traumatic aneurysm, which can develop
soon after a penetrating injury [17,18].
In our case, in spite of the fact that the removal of the
metal rod from the orbit and skull was performed
outside the operating room without any radiological
control, the early surgical treatment proved to be effective.
Patients in whom the penetrating object is left in place
until surgical removal have a significantly lower
mortality than those in whom the objects are inserted and then
removed (26% versus 11%, respectively) .
Blind removal of the intracranial object may cause
neurological and vascular injuries if the trajectory is close to
major vessels or to important neural structures. Therefore,
an adequate surgical access allowing intracranial direct
visualisation of the object should be performed before its
withdrawal . Another possibility is to remove the
foreign body under CT control to enable prompt detection
and management of any complications; in this case, both
operating theatre and angiography should be ready .
In patients in whom there is no CT evidence of
intracranial haemorrhage or possible damage to vascular
structures, the penetrating object can be directly removed
before surgical repair under general anaesthesia . In
our patient, even if the trajectory of the rod excluded a
major vascular injury, the decision to withdraw the object
blindly was made hastily because it could have been fatal
for the optic nerve, compromising the visual acuity.
Surgical reparation of orbito-cranial and facial injuries
was performed in a single surgical procedure by a
multidisciplinary team, which included neurosurgeons and
Despite the high risk of cerebral infection due to
polimicrobial contamination of intracranial compartment,
our patient, who received a large spectrum antibiotics
therapy, did not present any sign of meningo-encephalitis.
Administration of anti-tetanus serum and antibiotics, and
wound debridment by oxygen peroxide may minimise
infectious complications .
According to the literature, antibiotic therapy should
be initiated on admission and, although there are no
data to support continuation of antibiotics after surgical
removal, we strongly suggest to continue their
administration for at least three weeks and in any case not less
than one week [17,18].
Furthermore, surgical interventions can achieve also a
good aesthetic result, with correction of facial and
cranial vault deformities. The patient presented only a
slight paresis of the right superior rectus muscle due
to its lacerations secondary to the passage of the rod
fence through the thin orbital roof. No damage to neural
structures and no sign of internal carotid involvement
In conclusion, this is a unique case of penetrating
orbito-cranial stab injury. Despite the removal of the rod
fence from the intracranial compartment through the
orbit, we obtained a very good result. The positive
outcome obtained in this very challenging case is
attributable to the competency of the Neurotrauma Unit and
to the use of a synergistic approach. This was possible
because in the Unit there is a consolidated tradition of
fruitful cooperation between neurosurgeons,
maxillofacial surgeons, radiologists and anaesthesiologists.
Written informed consent was obtained from the patient
for publication of this Case report and any
accompanying images. A copy of the written consent is available
for review by the Series Editor of this journal.
MM conceived of the study and wrote the paper. PA performed the review
of the literature and helped to write the paper. LDM helped to write the
paper and to design the manuscript. FDG helped to review the literature
and to draft the manuscript. PC helped to write the paper and to design the
manuscript. AR participated in the coordination of the study. All authors read
and approved the final manuscript.