Transorbital Penetrating Intracranial Injury Caused by Sheppard’s Hook

Journal of Surgical Case Reports, Sep 2010

Sams, Valerie, Nagarsheth, Khanjan H, Nickloes, Todd A

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Transorbital Penetrating Intracranial Injury Caused by Sheppard’s Hook

JSCR Journal of Surgical Case Reports http://jscr.co.uk Transorbital Penetrating Intracranial Injury Caused by Sheppard's Hook 0 Authors: Valerie Sams, Khanjan H Nagarsheth and Todd A Nickloes Location: University of Tennessee Medical Center , Knoxville, USA Citation: Sams V, Nagarsheth KH , Nickloes TA. Transorbital Penetrating Intracranial Injury Caused by Sheppard's Hook. JSCR. 2010 7:3 , USA Intracranial injury resulting from transorbital penetrating objects is rare in a noncombat setting. As such there is a significant lack of data pertaining to the management of non-projectile traumatic brain injuries due to foreign bodies entering the brain.  Intracranial complications can include intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury, and carotid cavernous sinus fistula. This is the first report of a transorbital penetrating intracranial injury caused by a Sheppard's hook, which was managed utilizing a multi-disciplinary, non-operative approach. Intracranial injury resulting from transorbital penetrating objects is rare in a noncombat setting. As such there is a significant lack of data pertaining to the management of non-projectile traumatic brain injuries due to foreign bodies entering the brain. It is pertinent to understand the mechanism of injury, anatomy of injury, and treatment of such injuries. This is the first report of a transorbital penetrating intracranial injury caused by a Sheppard's hook, which was managed utilizing a multi-disciplinary, non-operative approach. INTRODUCTION After obtaining a four view skull series x-ray (Figure 2), it became evident the object traveled through the right orbital fossa superiorly, with the tip projecting over the medial right frontal lobe anterior to the pituitary, fracturing the posterior supero-medial orbital wall. Secondary to the size of the object, and with the assistance of emergency medical services and the fire department, the patient was taken outside to the ambulance bay where a plasma saw was utilized to separate the hook from the stanchion post in preparation for removal (Figure 3). In consultation with neurosurgery, ophthalmology and oral maxillofacial services, it was decided to intubate the patient and remove the object, with a CT scan of the head to follow immediately upon removal. After adequate sedation and intubation, and with continued stabilization of the head and cervical spine, the Sheppard’s hood was removed by pulling in a rotational motion along the natural curve of the hook. There was a minimal amount of bleeding from the orbit, and a pressure dressing was applied. Upon removal of the hook, the patient was taken immediately to the CT scanner for a CT angiogram of the head. The CT scan demonstrated some leftward deviation of the anterior page 2 / 4 cerebral arteries, but there was no evidence of vascular injury or active hemorrhage. There was evident some recent parenchymal and subarachnoid hemorrhage with small subdural hygroma over the right frontal convexity. There was also hemorrhage and edema of the inferior orbit with displaced medial right orbital wall fracture. The globe was slightly dysmorphic, although the lens was intact, and there was no gross evidence of intraocular hemorrhage. The right orbit extruded such that 75% was beyond the orbital rim (Figure 4). A repeat CT scan was obtained two hours later which demonstrated no change and that the injury was stable. The patient was admitted to the intensive care unit, weaned from the ventilator, and extubated without incident the following morning. Upon extubation the patient complained of a slight headache and right eye pain. She was transferred to an acute care floor the following day. A final CT scan demonstrated slight improvement of the intracranial and orbital findings. The patient was discharged to home with no apparent neurological deficits or personality changes per her own admission, and per her family. The patient was seen in the outpatient clinic approximately one week after discharge doing well, and without evident sequelae. Ophthalmology determined her globe and lens to be intact, and felt she would suffer no untoward effects of the injury once her edema resolved, with only a slight loss of visual acuity. Neurosurgical follow up three weeks post-injury revealed no complications associated with the injury. Oral maxillofacial follow-up likewise revealed no evident difficulties. DISCUSSION Transorbital penetrating brain injury secondary to a non-projectile foreign body is a rare incident. Intracranial complications can include intracerebral hematoma, cerebral contusion, intraventricular hemorrhage, pneumocephalus, brain stem injury, and carotid cavernous sinus fistula. Infection is a later complication that has to be kept in mind. The direction of the penetration is the major determinant of what type of injury will occur. If the penetration is parallel to the orbital roof, it will violate the cranium t (...truncated)


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Sams, Valerie, Nagarsheth, Khanjan H, Nickloes, Todd A. Transorbital Penetrating Intracranial Injury Caused by Sheppard’s Hook, Journal of Surgical Case Reports, 2010, pp. 3, Volume 2010, Issue 7, DOI: 10.1093/jscr/2010.7.3