Tiirkisli Neurosiirgery 9: 133 - 136, 1999 Ersnhill: Trniisorbilnl Slnb W01l11d From A Spenrgiiii

Transorbital StabA

Wound FromCase Report

A Speargun:

Zipkin ile Transorbital DeHci YaralanmaBir Olgu Sunumu

YUSUF ERSAHIN, MEHDI SADAT, TASKIN YURTSEVEN, SAFFET MUTLUER

Division of Pediatric Neurosurgery, Ege University Faculty of Medicine, Izmir, Turkey

Gelis Tarihi: 1.5.1998 <;:::> Kabul Tarihi: 25.8.1999

Abstract: Penetrating stab wounds of the skuIJ rarely occurin civilians. In the absence of direct injury to the brainstemor laceration of a major intracranial vessel, the prognosisfor these injuries is good. Transorbital stab wounds causingintracranial complications are more common in childrenthan in adults, and are reported more often in boys thangids. A 9-year-old gid presented with a spear penetratingher left orbita. A cranial computed tomographic seanconfirmed that the tip of the spearhead had passed throughthe left orbital roof and was penetrating the left temporallobe. The barbed spearhead was removed via craniotomyafter cutting oH three of the spear's prongs. The childrecovered completely after surgery and was neurologicallyintact 1 year following the injury. Postoperative magneticresonance angiography (MRA) was also normaL. Barbedobjects should not be removed by retracing their route ofentry. MRA can be used to screen for important potentialvascular complications.

Key word s: Transorbital injury, speargun, magneticresonance angiography, stab wound

INTRODUCTION

Penetrating stab wounds of the skul1 are veryra re in civilians (5,6,10,13,22). These are typicaIly seenin the young adult male, and are usuaIly related tointerpersonal violence, assaults, and gang warfare(5,6,10,11,12,13,22). Only a smaIl number ofreportedcases, particularly in children, have resulted fromaccidental stabbing (3,4,8,9,18). Here we report a caseof transorbital stab wound from a speargun.

Özet: Sivillerde kafatasinin penetran yaralanmalarinadirdir. Beyin sapinin dogrudan yaralanmasi ya dabüyük intrakranial damarlarin laserasyonun olmadigidurumlarda prognoz iyidir. Intraknial komplikasyonlarayolaçan transorbital delici yaralanmalar çocuklardaeriskinlere göre daha siktir ve kizlardan daha çokerkeklerde bildirilmistir. Sol orbitaya penetre zipkinla 9yasinda bir kiz çocugu klinigimize getirildi. Bilgisayarlitomografide zipkinin uçlarindan bir tanesi sol orbitatavanindan sol temporalloba uzanmaktaydi. Zipkinin üçucu kökünden kesildikten sonra kraniotomi ile kancali

uç çikarildi. Operasyondan sonra hasta tamamen düzeldive bir yil sonraki takibinde nörolojik defisitibulunmamaktaydi. Postoperatif manyetik rezonansanjiografi (MRA) normal bulundu. Ucu kancali nesnelergirdikleri yoldan çikarilmamalidir. MRA'in vaskülerkomplikasyonlari taramada kullanilabilecegi akildatutulmalidir.

Anahtar Sözcükler: Transorbital yaralanma, zipkin,manyetik rezonans anjiografi, deli ci yaralanma

CASE REPORT

A 9-year-old gir! presented with a spearpenetrating her left orbita. The patient' s brother hadaccidentally shot her with a speargun. She hadvomited several times before admission. On

presentation, the girl was drowsy but coherent andcooperative. One of three prongs of the spearheadhad penetrated near the left iimer canthus, and theleft periorbital region was swollen (Figure 1).

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Figure 1: A photograph taken with the patient on theoperating table shows one of the barbedspearheads in situ.

Neurological examination revealed no remarkabledeficit. Plain x-ray films of the skull showed a spearwith three barbs at the tip, one of which hadpenetrated the cranium (Figure 2). A cranialcomputed tomography (CT) sean confirmed that onetip had penetrated the left temporallobe through the

Er~nhIlI: Trniisorbitnl Stnb Woiiiid From A Spenrgiiii

left orbital roof (Figure 3). Tetanus prophylaxis wasadministered and the patient was started onantibiotics that covered gram-positive, gram­negative, and anaerobic organisms. The patient wastransported to the operating room. Once she wasanaesthetized, the three prongs of the spear were cutwith a metal saw used by orthopedic surgeons andthe shaft of the spear was then removed anddiscarded. Next, a frontotemporal craniotomy wasperformed and the one barbed tip was located a fewmillimeters beneath the surface of the cerebral cortex.

An incision was then made through the cortex andthe TIP was removed through this new dean wound,as opposed to the route of entry. The wound wasirrigated and the surgical site was then dosed instandard fashion.

Within a week, the periorbital swelling andchemosis had subsided. The vision in the patienfsleft eye was normaL. Postoperative magneticresonance imaging (MRI) showed the trajectory ofthe spear in the temporal lobe (Figure 4), andmagnetic resonance angiography (MRA) was normal1week after the injury. MRA was repeated 6 monthslater, and revealed no vascular complications. Thepatient was asymptomatic and neurologically intact1year after the injury.

DISCUSSION

The mechanism of injury in transcranial stabwounds differs from that of missile or gunshotinjuries in that here is no concentric zone ofcoagulative necrosis (7).AIso, unlike in motor vehideaccidents, brain damage is restricted to the woundtract (l5). In the absence of direct injury to the

Figure 2: (a) Posterior-anterior and (b) lateral x-ray films of the skul1show the penetrating spear.

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TlIrkish Neiirosiirgery 9: 133 - 136, 1999

Figure 3: A CT sean shows one of the spearheadspenetrating the left temporal lobe through theleft orbital roof.

brainstem or la ce ra tion of a major intracranial vessel,the prognosis is good for this type of injury.Transorbital stab wounds causing intracranialcomplications are more common in children than inadults, and are reported more of ten in boys than girls(6). Objects entering the orbit tend to be funneledtoward the apex. Typically, the superior orbitalfissure, or the thin orbital plate allows access to theintracranial contents in these cases. it has been noted

that the globe often eseapes injury if a slender­pointed instrument is used. In low-velocity stabbings,the eyeball moves into the space occupied by thecopious orbital fatty tissue that surrounds the eye.However, the eyeball is frequently injured when alarge object is involved (17,20).

Birch-Hirchfield (1) and Kjer (14) reported 30cases of tetanus caused by transorbital injury.Ventricular damage, pneumocephalus, subdural,intracerebral and intraventricular hemorrhagedamage to the cavernous sinus, carotid-cavernousfistulae traumatic cerebral aneurysms, occlusion ofthe carotid artery, and brain abscesses have all beenreported as cerebral complications of transarbital stabwounds (2,6,13). CT scanning can detect intracranialdamage or hematoma (19), but interpretation of CTscans may be seriously impaired by artifad when apenetrating metal object is embedded in the cranium.

Kieck and Villiers (13) found five cerebral

aneurysms at the base of the brain in 20 casesfollowing transorbital stab wound. They adviseddoing repeat cerebral angiograms to detect vasculardamage. In 1969, Chadduck (4) operated on a 6-year-

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Figure 4: Note the blood in the trajeetory of the spearheadon MRI.

old girl with a traumatic aneurysm of the middlecerebral artery following a speargun injury. Atraumatic aneurysm usually ruptures between 2 and6 weeks, and it has be en recommended that

angiography be done 7 to 10 days af ter injury (16).Transorbital speargun injuries are very ra re, and, toour knowledge, only two cases have been reportedin the English literature (17,21).

Maximal tissue damage with a barbed objectoccurs when the removal attempt retraces the routeof entry. if we had removed the penetrating barbedspearhead this way, there could have been seriousdamage to the optic nerve and globe. In conclusion,tetanus prophylaxis and antibiotics may prevent theinfectious complications of a stab wound. Barbedobjects should not be removed by retracing the routeof entry. MRA is advised as screening for potentialimportant vascular complications.

Correspondence: Yusuf ErsahinP.O. Box 30

Karsiyaka,35602 Izmir, Türkiye

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