Transorbital penetrating head injury by a wooden chopstick in the cavernous sinus: a case report and literature review.

Penetrating head injury is a relatively rare condition associated with high morbidity and mortality. Although the immediate treatment of penetrating head injury is needed, surgical strategies are varied based on the trajectory of the penetrating objects in the cranium. We present a case of 24-year-old man who sustained a transorbital penetrating injury caused by a wooden chopstick. Neuroimages revealed a linear lesion extending from the left intraorbital segment to the cavernous sinus passing through the superior orbital fissure. The foreign body was successfully removed via the transcranial approach without complications. A careful management based on the perioperative images and correct diagnosis is necessary to avoid unfavorable complications. Four cases of transorbital penetrating injuries have been previously reported, in which the foreign body penetrated through the superior orbital fissure and lodged in the cavernous sinus. The frontotemporal craniotomy with extradural approach can be a useful option to remove foreign bodies around the cavernous sinus regions.

Bilateral Traumatic Carotid-Cavernous Fistula in a Child: Corkscrew Eyelid Vessels as an Indicator of Severe Congestion.

An 11-year-old girl presented with bilateral traumatic caroticocavernous fistula associated with corkscrew eyelid vessels, which were considered indicators of severe congestive disease in this case. Coil embolization was performed; similar to other congestive findings such as proptosis, orbital bruit, increased intraocular pressure, congested scleral and retinal vessels, engorged eyelid vessels resolved immediately after coil embolization. This pediatric case is unique given the caroticocavernous fistula was bilateral and was associated with prominent dilatation of the eyelid vessels, named for the first time as corkscrew eyelid vessels.

Ruptured Persistent Trigeminal Artery Causing Direct Cavernous Sinus Fistula Treated with Pipeline Embolization and Minimal Coiling.

BACKGROUND: Rupture of a persistent trigeminal artery associated with development of a cavernous sinus fistula in a traumatic setting is rare. These arteries are typically treated with coil embolization of the cavernous sinus. CASE DESCRIPTION: We present the case of a 42-year-old woman who developed a direct cavernous carotid fistula after a motor vehicle accident. Angiographic imaging revealed a rupture point of a persistent trigeminal artery as it connected with the cavernous segment of the internal carotid artery, causing a cavernous sinus fistula. Coiling of the cavernous sinus was abandoned after placement of 1 coil because of coil herniation into the internal carotid artery. A Pipeline embolization device was placed to oppose the coil against the intima and keep the lumen open. The combination of coil embolization and flow diversion acutely decreased the fistulous flow. Surprisingly, an angiographic follow-up at 6 months showed complete fistula occlusion despite placement of only 1 coil into the cavernous sinus. CONCLUSIONS: We report a rare case where undercoiling of the cavernous sinus occluded a cavernous sinus fistula because of the adjunct use of a Pipeline embolization device in the presence of a traumatic rupture of a persistent trigeminal artery.

Bilateral Traumatic Caroticocavernous Fistulas: A Case Report and Review of the Literature.

A traumatic caroticocavernous fistula (CCF) is an acquired, abnormal communication between the internal carotid artery and the cavernous sinus, secondary to trauma. This rare condition can initially be misdiagnosed, because its presentation shares features common to those of facial trauma, which can result in serious complications. We describe a case of bilateral CCF in an adult patient after a road traffic accident.

Surviving Penetrating Brainstem Injury by Bamboo Sticks: Rare Case Reports and a Brief Review of Literature.

BACKGROUND AND IMPORTANCE: Chopsticks are common utensils used in many Asian cultures. However, they sometimes can be used as weapons or can cause accidents, particularly in children. Penetrating transorbital/transpharyngeal intracranial injuries with bamboo sticks are peculiar accidents and are relatively rare. Because of their rarity, the management of such injuries is often complex. We discuss 3 cases of penetration of the brainstem by bamboo sticks, 1 case through the foramen magnum, which, to the best of our knowledge, is the first reported case of such an injury. CLINICAL PRESENTATION: The case of a 50-year-old man who was stabbed with a pair of chopsticks in his left eye is presented. The chopsticks passed through the cavernous sinus, and the patient sustained superior orbital fissure syndrome. The other 2 cases were those of a 4-year-old girl having a similar pattern but different mechanism of injury and a 2-year-old boy who sustained transpharyngeal intracranial injury via the foramen magnum. Computed tomography, magnetic resonance imaging, and computed tomographic angiography (CTA) are the key imaging modalities frequently used to determine the course and extent of brain injury. CONCLUSION: Early surgical exploration by a multidisciplinary team approach is essential for attaining a favorable outcome. All cases demonstrated good postoperative recovery and were successfully managed by removing the foreign body through its trajectory. We discuss and briefly review the literature on patterns, complications, and management issues of these less common injuries.

Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan.

BACKGROUND: Orbitocranial penetrating injuries (OPI) are an unfamiliar subset of head injury and are particularly rare in clinical practice. They are usually the result of falls or motor vehicle collisions and occur more commonly in children, who are prone to trauma while playing games improperly. METHODS: We present a retrospective review of 5 cases of OPI treated in the Neurotrauma Department at Xiangya Hospital of Central South University in the last 5 years. Also, we performed comprehensive literature searches using Web of Science and the terms "orbitocranial injury," "penetrating ocular trauma," "penetrating orbital trauma," and "transorbital chopstick penetrating injury" to search for presentation, mechanism of injury, and management of transorbital penetrating injury. RESULTS: In 2 patients, there was right internal carotid artery occlusion while in other 2 patients, the penetrating objects reached the brainstem through the cavernous sinus, resulting in orbital apex syndrome. All patients underwent a thorough physical examination followed by diagnostic imaging. The cases were successfully managed surgically by removing the foreign bodies through their trajectories. CONCLUSIONS: Computed tomography, magnetic resonance imaging, and computed tomography angiography are key imaging modalities that are frequently used to determine the course of the foreign object and the extent of brain tissue injury as well as to rule out vascular injury in these types of cases. Early surgical exploration by a multidisciplinary team approach is essential to attain good recovery and a favorable outcome.

An unusual case of attempted suicide by a depressive woman: self-inflicted intracranial stabbing.

Self-inflicted stab injury to the skull, particularly in the neurocranium, is a rare method used to commit suicide. Herein is presented a case of a 26-year old woman with a temporal wound found by her partner in their home. No weapon was found in the approximate environment and the victim said that she fell. A CT scan performed at admission to the emergency room was interpreted as being compatible with injury from falls. A second CT scan in a neurosurgical unit suggested a cranio-cerebral injury from a sharp object; aggression was suspected. The discording elements led to an interview with a psychiatrist and diagnosis of attempted suicide through the action of a knife in the context of severe depression. This is a rare case that implicates a depressive woman and stabbing directly to the neurocranium.

Cranial nerve injury after Le Fort I osteotomy.

A Le Fort I osteotomy is widely used to correct dentofacial deformity because it is a safe and reliable surgical method. Although rare, various complications have been reported in relation to pterygomaxillary separation. Cranial nerve damage is one of the serious complications that can occur after Le Fort I osteotomy. In this report, a 19-year-old man with unilateral cleft lip and palate underwent surgery to correct maxillary hypoplasia, asymmetry and mandibular prognathism. After the Le Fort I maxillary osteotomy, the patient showed multiple cranial nerve damage; an impairment of outward movement of the eye (abducens nerve), decreased vision (optic nerve), and paraesthesia of the frontal and upper cheek area (ophthalmic and maxillary nerve). The damage to the cranial nerve was related to an unexpected sphenoid bone fracture and subsequent trauma in the cavernous sinus during the pterygomaxillary osteotomy.

Peoría paradójica en fístulas carótido-cavernosas durales: cuando el cuerpo se enferma más para curarse / Paradoxical worsening in carotid-cavemous ductal fistulas: when the body get more sick in order to cure

Las fístulas carótido-cavernosas son comunicaciones arteriovenosas patológicas entre la arteria carótida interna intravenosa y el seno venoso-cavernoso que la rodea. Un sistema de flujo y presión elevados irrumpe sobre otro de bajo flujo y velocidad. Ello origina los síntomas y signos. La gran mayoría, son resultantes de traumatismos craneales siendo de alto flujo y alta velocidad-fístulas traumáticas o directas; menos comunes son las llamadas fístulas espontáneas o durales localizadas en la duramadre y alimentadas por ramas menígeas provenientes de las arterías carótidas externa, interna o ambas y de las arterias vertebrales. Estas últimas raras veces tienen implicaciones graves para la vida, pero la pérdida visual constituye el mayor riesgo; no obstante, con elevada frecuencia, ocurre la oclusión espontánea, por lo que se impone la observación hasta que la sintomatología justifique el tratamiento. En el curso evolutivo puede ocurrir la trombosis aguda de la fístula y más propiamente de la totalidad de la vena oftálmica superior la que produce un distintivo cuadro de notable agravamiento de los síntomas que en forma contradictoria ocurre antes de la mejoría y reversión de los síntomas, el síndrome de empeoramiento o peoría paradójica. Para ilustrar el síndrome se presentan los casos clínicos de los pacientes

Caroid-cavernous fistulas are pathological arteriovenous communications between the intracavernous internal carotid artery and the cavernous sinus. A system of high flow and pressure bursts over another system of low flow and slow velocity. This causes the symptoms and signs. The vast majority are related with head trauma being high flow and high speed fistulas: traumatic or direct. Less common are the so-called spontaneous or dural fistulas located in the duramater and fed by meningeal branches from the external, internal, or both carotic arteries and the vertebral arteries. These latest rarely have serious implications for life, but visual loss is the greatest risk; however, with high frequency spontaneously occlusion occurs, and then observation imposes until symptoms justified the treatment. During its evolution acute thrombosis of the fistula itself can occur along the entire length of the ophthalmic vein which produces a distinctive and paradoxical worserning and reversal of symptoms, which is called the syndrome of paradoxical worserning. Clinical cases of two patients are presented to illustrate the syndrome

Removal of a chopstick out of the cavernous sinus, pons, and cerebellar vermis through the superior orbital fissure.

Penetrating non-missile orbito cranial injuries are rare in a civilian pediatric setting. We describe a case of a trans-orbital penetration by a wooden chopstick deep down into the cerebellar vermis detected at neuroradiological examination in a child presenting for head injury. The foreign body was successfully pulled out in one piece surgically.

Hemispheric laminar necrosis as a complication of traumatic carotid-cavernous sinus fistula.

A 43-year-old woman presented with a very rare case of hemispheric laminar necrosis as a complication of traumatic carotid-cavernous sinus fistula (CCF). The patient suffered head injury and extensive burns following a car accident. Oral intubation was performed under sedation. When sedation was discontinued 17 days after injury, the patient demonstrated left hemiparesis. Magnetic resonance imaging showed laminar necrosis affecting the right cerebral hemisphere. Angiography revealed a right high-flow direct CCF. Transarterial embolization of the fistula using a detachable balloon achieved complete occlusion of the fistula. However, the left hemiparesis persisted following this intervention. Traumatic CCF may be missed in patients with disturbed consciousness, so clinicians should not overlook possibility of the triad of symptoms of CCF in patients with head injury.

Transvenous embolization of a high-flow, posttraumatic fistula between the posterior communicating artery and retroclival venous plexus.

Traumatic injuries of the posterior communicating artery are distinctly rare. We report an unusual case of traumatic tear of the posterior communicating artery with fistulous communication to the adjacent, retroclival venous plexus. The fistula, and an accompanying large venous aneurysm, was completely occluded via transvenous embolization. The patency of the posterior communicating artery was preserved.

Treatment of traumatic trigeminal-cavernous fistula by coil embolization and compression of carotid artery.

We report a case of a traumatic cavernous fistula supplied by a persistent primitive trigeminal artery. The process of treatment was unique in this case. Fistula was subcompletely occluded by coiling from primitive trigeminal artery. Residual fistula was helped to form thrombosis by compression of the carotid artery with hand in the procedure. Long-term follow-up was satisfactory. Traumatic cavernous fistula supplied by a persistent primitive trigeminal artery could be treated by embolization and temporal compression of the parent artery might be useful for residual minimal fistula.

Taming the cavernous sinus: technique of hemostasis using fibrin glue.

OBJECTIVE: Improved understanding of the microsurgical anatomy of the cranial base region has made surgery in and through the cavernous sinus safer. However, continuous venous oozing that occurs during cavernous sinus surgery can cause significant blood loss and poor visualization. We describe a technique that will help minimize cavernous sinus bleeding and improve the safety of the surgical steps. METHODS: The lateral wall of the cavernous sinus is exposed. Cavernous sinus access windows between the V1 and V2 branches of the trigeminal nerve and posterior to the clinoidal internal carotid artery are used to inject fibrin glue into the different cavernous sinus compartments. Postoperative follow-up cerebral angiography in basilar apex aneurysms clipped using the transcavernous approach were evaluated for cavernous sinus patency during the venous phase. RESULTS: Fibrin glue injection between V1 and V2 obliterated the lateral cavernous sinus compartment. Fibrin glue injection posterior to the clinoidal segment of the internal carotid artery obliterated the medial compartment of the cavernous sinus. These steps were used in 217 surgical procedures (95 benign and 9 malignant neoplastic lesions; 113 aneurysms). There were no significant clinical side effects. Follow-up angiographic controls of basilar aneurysms operated on via the transcavernous approach consistently showed the reestablishment of flow within the cavernous sinus as early as 2 to 3 months postoperatively. CONCLUSION: Presently, the use of hemostatic agents and the better understanding of the microsurgical anatomy of the cranial base and cavernous sinus enable us to tame the cavernous sinus and operate in and around it with a high degree of safety.

Cavernous carotid injury during functional endoscopic sinus surgery: case presentations and guidelines for optimal management.

BACKGROUND: Surgery in the parasellar and paranasal regions is technically challenging because of the complex anatomic relationships between the sphenoid sinus, cavernous sinus, optic nerve, and internal carotid artery. Normal anatomic variations and pathological changes can lead to disastrous outcomes including carotid artery injury. METHODS: We present two cases of carotid injury managed at our institution. The first case involves an elective endoscopic biopsy of a clival tumor encasing a friable carotid artery. The second case features a patient transferred emergently to our medical center when brisk bleeding was encountered during functional endoscopic sinus surgery (FESS). Both carotid injuries were managed via balloon embolization with close interaction between otolaryngology and interventional radiology. We review pertinent anatomic and surgical considerations as a backdrop to a treatment algorithm for cavernous carotid hemorrhage secondary to FESS complication. RESULTS: The treatment algorithm prevented mortality and minimized morbidity in the two cases considered. CONCLUSION: Through rare, injury to the cavernous carotid during FESS can be managed successfully given efficient hemostasis and seamless cooperation among emergency room physicians, otolaryngologists, and interventional radiologists.