The Transorbital Intracranial Penetrating Injury This book is dedicated to my wife, children and four grandsons The Transorbital Intracranial Penetrating Injury A review of the literature from a neurosurgical viewpoint By: Martin Th. A. van Duinen MD PhD SPRINGER SCIENCE+BUSINESS MEDIA, B.V. A CLP. Catalogue record for this book is available from the Library of Congress ISBN 978-94-010-5911-4 ISBN 978-94-011-4457-5 (eBook) DOI 10.1007/978-94-011-4457-5 All Rights Reserved © 2000 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 2000 Softcover reprint of the hardcover 1st edition 2000 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner. Table of contents 1. Introduction 2. Historical aspects regarding transorbital intracranial penetrating injury (TIP!) 7 3. Defining the concept of TIPI 12 4. Experimental research on cadavers 15 5. The nature of the penetrating object 20 6. Incidence 23 7. Anatomical data 27 8. Pathogenesis 39 9. Clinical presentation and initial evaluation 48 10. Physical examination 51 11. Neuroimaging 57 12. Treatment 71 13. Antibiotic therapy 78 14. Complications 80 15. Aggression 91 16. Accident 94 17. Fall injuries 96 18. TIPI caused by umbrellas 103 19. TIPI caused by pencils, slate pencils and ballpoint pens 105 20. Suicide by TIPI 108 21. Mortality and morbidity 113 22. Medicolegal aspects; prevention ofTIPI 116 23. Brief review of a patient series from the literature 118 List of patients 124 vi TABLE OF CONTENTS References 138 List of reprints of illustrations from other authors 155 Index 159 1 Introduction The brain, as befittingthe most importantorgan ofthe human body, is well protected by a roughly spherical, thick, bony covering, consisting of the crown and the base ofthe skull, which shields against penetrating injury. However, this strong, bony cover has several weak points at the cranio facial transition, i.e. both orbits and the lamina cribrosa lying between them, which are areas ofpoor resistance. It is easy for a pointed, long, thin and strong object to penetrate into the brain via the orbit through the thin roof or the thin medial orbit wall via the paranasal sinuses. Penetration is also possible through the natural openings at the back ofthe orbit, i.e. the superior orbital fissure (SOF) and the canalis opticus (CO). This is particularly true of children, whose immature orbits permit easy access to the intracranial cavity (Figure 1). A penetrating injury ofthe orbit, thus, notonlythreatens the visual organ butcan also be lifethreatening- in acaseofperforation through theorbital wall - due to cerebral complications. Such an injury falls within an area of (a) Figure 1 Small lowereyelidwound, butdeepintracranial penetrationwiththestem of a fern. (a) Photograph of right eye showing the site of penetration of the right lower eyelid (arrowhead). (b) Axial CT scan of the head, revealing a blood tract passing from the orbital apex through the middle cranial fossa into the posterior cranial fossa (small arrowhead). There is associated intracranial air (large arrowhead), but no evidence ofaretained forreign body 2 INTRODUCTION overlap between the spheres of expertise of the ophthalmologist and the neurosurgeon and thus the patientshould be examined and treated by both disciplines. For the neurosurgeon, it is important to realize the high likelihood of infection associated with penetration through the orbit [1-3] and accompa nied with, at least for war wounds, a mortality rate twice as high as that due to penetrating trauma through the crown of the skull (12.5% versus 6.4%) [4]. An ophthalmologist [5] is usually the first doctor to examine these patients, along with the family physician, pediatrician or emergency physician. Often the patients initially present with an innocent-appearing wound involving the eyelid, though hiding acomplicated, comminutive, impacted fracture oftheorbit, accompanied by asevere brain lesion notyet manifest. Thesedoctors run aserious risk iftheyjusttreattheeyelid wound without considering a potential deep penetration. When this is suspected, a neuro surgeon should be called in for a consultation. Theophthalmologistshould remain involved inthecaretopreventfurther damagetothevisual organsandtopromotehealingoftheorbital wound [5]. Detailed studies of penetrating orbitocranial injuries are scarce in the literature. Even the majortextbooks rarely mention thistypeoftrauma, with the exception of articles for example by De Villiers [2] and Chapman and Grove [6]. In Chapter23, several smallerreviewsofTIPI arecited, includingMorrant Baker [7], Duke-Elder [8], Greig [9], Kjer [10] and Wesley et al. [11]. It is indeed a rare injury [12,13]. Courville and Schillinger [14] found only one instance of an intracranial complication associated with an orbital lesion among 30000 autopsies, and this was not even a perforating injury [12]. Rowbotham [15] reported only two patients with a transorbital injury among 1000 craniocerebral injuries. McClure and Gardner [16] wrote in 1949: "Relatively little has been written about wounds which involve the intracranial structures by way of the orbits. This is difficult to understand since this is one of the most accessible modes ofentry to the brain for stabbing instruments". Kjer [10] noted in 1954 that: "No particular attention has been paid to this type of lesion; in the ophthalmologic and neurosurgical literature the contributions to the discussion are usually confined to case reports". Lavergne [17] in 1959 stated: "Les traumatismes directs de la base du crane avec l'orbite comme voie d'acces de l'agent perforant sont extremement rares". DeVilliers said in [2] 1975: "The literatureonthis subjectconsistsmainly of individual case reports, few series comprising more than five cases have been reported". THE TRANSORBITAL INTRACRANIAL PENETRATING INJURY 3 On the other hand, however, he also remarks that transorbital stab wounds ofthe head as agroup are extensively described in the literature. AUTHOR'S NOTE I can confirm the rarity of this lesion. During my 35-year career as a neurosurgeon, I never saw a single case. In contrast, Bard and jarrett [12] treated 7 cases in 11 months and Bullock et at. [18] 5 cases in 5 years. Out of curiosity for this rather neglected subject in neurosurgery, I started an exhaustive literature search in order to add to the description of these injuries, thus filling a hiatus in the neurosurgical literature. The initiating impulse was given by press reports in the Netherlands about a possible accident (or attempted murder?) in which the autopsy revealed an intra cranially positioned ballpoint pen having entered through the orbit. The literature perused was primarily obtained as photocopies requested from the Royal Library in The Hague, The Netherlands. References at the end of these articles were used to track down further articles. In addition, I requested a corresponding literature list from the Library of Congress, Washington DC, USA, which was compared with my own literaturecollec tion. Several additional publications were found by this method. Two dissertations on this topic were discovered, Wertheim's (Figure2) written in 1904 [19] and Coqueret's (Figure3) in 1905 [20]. Photocopies ofthese were obtained from Giessen (Germany) and Paris (France), respec tively. Via the Internet, the largemedical database in Minnesotawas repeat edly searched with various key words (Medline, US National Library of Medicine, NLM).The university libraryin Keio,japan ([email protected]) was extremely helpful in sending me japanese literature. I could not read the japanese texts, but fortunately japanese authors tend to include a detailed English summary, usually very informative. Several Italian, Polish, Russian, japanese, Norwegian and Czech articles had to be leftoutbecause they did not have an English summary. In the collected patient series, primarily only those with a transorbital intracranial penetrating injurywere included. Theophthalmologic literature contains many reportsofpenetrating injuryoftheorbits without intracranial complications. These injuries do not fall within the neurosurgeon's sphere of expertise and thus are notincluded in our patient database. This volume includes many data from a large number of other authors. As far as possible, reference has been madeto the respective author, trying not to compromise the readability ofthis work. The neurosurgical literature contains many articles on penetrating injury through the cranial vault, but transorbital brain injury is rarely mentioned and then often just as a case history. We are concerned here with as thorough a literature search as possible to produce a sound description 4 INTRODUCTION Zur Kasuistik cler clurch clie Orbita erfolgten Fremdkorperverletzungen des Gehirns. Inaugural-Dissertation Erlangung cler Doktorwtirde der Hohen medizinischen Fakultiit der Grossherzoglich Hessischen Ludwigs-Universitat zu Giessen vorgel~gtvon Sigmund Wertheim approb.ArztausGiessen. MiteinerTafel. GIESSDf1904 'fanYant!low'ub.Her·UAttUnll'lftitua-Druckttei(0.IUQdc). Figure 2 Front page ofWertheim's dissertation summarizingtheclinical syndrome: the transorbital intracranial penetrating injury (TIP!). We shall also try to create a subcategory of fall traumata of children because of some of its characteristic features. In Dutch literature, Verbiest [21] summarized the subject in issue. Two cases were reported by de Grood [22,23] while Copper [24] presented a review offour cases in 1957. To produce this study, more than 500 publications were examined (Figure4). Ofthese, more then 160 were rejected once it became obvious thattheydid notcontain specific information on the subject. The remaining 340 (360 at the end of the project) publications described 347 patients (Figure5), constituting the basis ofthis investigation. Near the end of the project, eleven new cases were added [23,25-32]. The investigation being closed, details ofthese casescould only be partially assimilated into the present series. The data of these 347 patients were handled in two ways. The general non-clinical data (author, year of publication, nature of penetrating object, right-left localization, type of trauma, etc.) were entered in tabular format inMicrosoftWord97and processedwiththesortingtool. Apatientdatabase