Penetrating Transorbital Brain Injury: Case Series and Literature Review

Transorbital brain injuries (TOBIs) due to penetrating foreign bodies are relatively rare and represent a unique type of trauma because of the different kinds of objects, mechanisms, trajectories, and structures that can be compromised. The diagnosis of TOBI requires a high degree of suspicion, thorough clinical examination, and appropriate imaging to characterize the presence of damage. The treatment options described in the literature include conservative and surgical approaches, with little evidence of their effectiveness and superiority; therefore, patient management must be individualized. We report our consecutive case series of TOBI describing the penetrating foreign body, traumatic path, surgical approach, intraoperative findings, outcomes, and complications. We also review the available literature.

Introduction: Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide and the leading cause of trauma-related death and disability in Latin America. Penetrating TOBIs represent nearly 25% of adults and 50% of children suffering from penetrating head trauma.

The conical shape of the orbit drives foreign bodies into the intracranial compartment, potentially transecting essential structures along its trajectory. Clinical and imagenologic evaluations for TOBI aim to identify possible neurovascular damage and injuries to the orbit and paranasal sinuses.

Prompt surgical management is the cornerstone of TOBI, and the decision-making process relies on factors such as damage to neurovascular structures, foreign body extraction, and risk of infection. Transorbital neuroendoscopic surgery (TONES) is commonly used for anterior and middle fossa skull base tumors but is rarely used in trauma. Herein, we report our experience of four cases with TOBI, including a single patient treated by TONES, and discuss its operative caveats and postoperative outcomes.

Methodology: We describe a series of four cases that include patients diagnosed with TOBI and managed surgically at two institutions in Bogota-Colombia (“Hospital Universitario Mayor Mederi” and “Hospital del Occidente de Kennedy”) between January 2015 and December 2022. Clinical manifestations, the type of FB, traumatic path, imaging data, surgical approach, and postoperative outcomes were described.

Results: We included four patients with TOBI, all male. The mean age was 35.7 years (IQR: 23–56). One patient presented with a normal neurologic exam, two presented with altered mental status, and one presented with a right ocular globe rupture. All patients received antibiotic management for a mean time of 14 days (7–21 days). The zygomaticofacial and zygomaticotemporal hypoesthesia was the most common complication in two out of four patients; however, it resolved within 3 months without further intervention.

Conclusions: TOBI is a rare condition requiring high clinical suspicion and a thorough diagnostic workup. The pillar of treatment for this pathology is the surgical removal of the FB under direct visualization to avoid further neurovascular damage.

We conclude that among other traditional surgical methods, TONES is a technique scarcely used in the trauma setting but with excellent functional and cosmetic results. It is worth noting that TONES should be considered a viable and secure surgical approach to manage TOBI; however, further studies are required ([Figs. 1]–[4]).

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Publication History

Article published online:
05 February 2024