Table Of ContentThe 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
