Transorbital penetrating head injury (PHI) is a rare occurrence but can have severe consequences. While it represents a small percentage of all head injuries, it accounts for a higher proportion of PHIs in both adults and children. The outcomes of these injuries are often associated with significant morbidity and mortality. This case reports a transorbital PHI in a child who had a remarkably positive outcome.
A 7-year-old boy sustained a PHI when he fell onto a garden spike while climbing a fence. Immediately after the fall, his mother noted that the child had slurred speech. However, he did not experience any fainting episodes.
His vaccinations were up to date, including TT.
The child was brought to the emergency department. Physical examination revealed right eye contusion, periorbital swelling, and abrasion below the right eyebrow. No abnormalities were detected on the neurological examination, mild dysarthria, and some minor right-sided weakness.
Investigations included:
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Computed
tomography (CT)
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intraparenchymal
hemorrhage in the right frontal basal lobe
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CT
angiography (CTA)
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Associated
linear tract extending from the posterior aspect of the hematoma to the left
parietal lobe through the genu of the corpus callosum, left globus pallidus,
anterior limb of the internal capsule, and left posterior insula, as well as
a right orbital roof fracture and focal subarachnoid hemorrhage (SAH)
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The garden spike had lodged and penetrated his right orbit on top of his globe, pierced the bony superior orbital roof, bypassing the anterior cerebral arteries and sparing the posterior limb of the internal capsule, and rested on the contralateral side in the left superior temporal gyrus.
Ophthalmological examination showed no visual impairment but minor subconjunctival hemorrhage.
The boy was immediately hospitalized and treated with a prophylactic 5-day course of antibiotics (meropenem and amphotericin) to protect against early and delayed infection from the foreign body.
His follow-up CT/CTA – 8 hours later, showed a stable focus of intraparenchymal hemorrhage in the right basal frontal lobe. His clinical and radiographic follow-up post 6 months was unremarkable.
The child was followed-up until 18 months after injury; he had recovered with occasional headaches and no learning of cognitive deficits. His speech had normalized.
Most penetrating injuries such as this will have serious lifelong consequences, but here was a case of the passage of a sharp object that traversed the midline yet sparing all significant neuroanatomical pathways, leading to complete recovery in follow-up. Relevant outcome-determining factors are early adequate vascular imaging to rule out vascular injury as well as foreign body retrieval and antibiotic prevention against infections.
Source: Lohkamp LN, Holowka S, Widjaja E, et al. J Neurosurg Case Lessons. 2023;5(3):CASE22440.
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