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CC BY 4.0 · Indian Journal of Neurosurgery 2024; 13(01): 084-088
DOI: 10.1055/s-0043-1770907
Clinical Images

Transorbital Intracranial Injury by a Chopstick

Rami Darwazeh
1   Department of Neurosurgery, Arab Women's Union Hospital, Nablus, Palestine
,
Xiaochuan Sun
2   Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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A 5-year-old girl tripped while carrying a bowl of rice and plastic chopsticks. One of the plastic chopsticks penetrated the medial aspect of the right upper eyelid. In the emergency room, she was fully conscious and without any evident neurological damage. From a computed tomography (CT) study ([Fig. 1A and B]) and three-dimensional reconstruction ([Fig. 1C]), the chopstick was found to be passing through the right superior orbital fissure into the cranium. No hematoma was found and an angiogram showed no vascular injury. Under general anesthesia, the chopstick was withdrawn without difficulty in one piece ([Fig. 1D]) and the patient remained well without any complications. Immediate postoperative CT scan showed no evidence of neural damage or intracranial hemorrhage ([Fig. 1E and F]). Postoperative prophylactic antibiotics were administered to prevent infections.[1] [2] [3] [4] Pre- and postoperative ophthalmological examination revealed normal visual acuity and intact ocular movements. The patient was discharged home 5 days after the operation. At a 3-month follow-up, there were no neurological/ophthalmological deficits or intracranial infections.

Zoom Image
Fig. 1 Noncontrast head computed tomography scans (A, axial image; B, sagittal image) and three-dimensional reconstruction (C) showing the chopstick passing through the right superior orbital fissure into the cranium. An intact chopstick, which measured 5.3 cm in length, was removed in one piece (D). Immediate postoperative noncontrast head computed tomography scans (E, axial image; F, sagittal image) showing no evidence of neural damage or intracranial hemorrhage.

Among all head injuries, penetrating transorbital intracranial injury accounts for a small percentage.[1] [2] [3] [4] Additionally, such injuries can result in ophthalmoplegia, blindness, brainstem damage, and intracerebral hemorrhage.[1] [2] [3] [4] The management of these types of injuries is complex and the delay in treatment can result in a poor prognosis.[1] [2] [4] There are various approaches, which are employed to remove transorbital intracranial penetrating foreign objects, which include direct withdrawal, transorbital or transcranial (frontotemporal, frontal orbitozygomatic, bifrontal, subtemporal, and subfrontal) approaches ([Table 1]).[1] [2] [3] [4] Furthermore, all patients with transorbital intracranial injuries by chopstick should receive aggressive broad-spectrum intravenous antibiotics immediately after the injury because of high infection rates.[1] [2] [3] [4]

Table 1

Summary of reported cases of penetrating transorbital intracranial injuries by chopsticks

Number

Authors (year)

Patient's age (y)

Sex

Type of chopstick

Symptoms and signs

Management

Outcome

1

Zheng et al (2022)[5]

53

Male

Wooden chopstick

Diplopia, paroxysmal headaches, and slow light reflection of the left pupil

Medical treatment (no surgery)

Died

2

Chung et al (2022)[1]

1

Male

Wooden chopstick

Mild upper eyelid swelling, fever, and bloody tears in the left eye

Withdrawn by the guardian (no surgery)

Good outcome without any ophthalmic or neurological sequelae

3

Yamashita et al (2007)[6]

4

Female

Wooden chopstick

A cut wound on the medial margin of the right lower lid with no swelling or hematoma. A slight disturbance in ocular motility (adduction and downward rotation) and a slight loss of visual acuity in the right eye

Surgery

Favorable outcome

4

Di Roio et al (2000)[7]

6

Male

Wooden chopstick

Fever, headaches, neck stiffness, and vomiting

Surgery

Favorable outcome

5

Huang et al (2020)[8]

36

Male

Plastic chopstick

Significant swelling to the ecchymosed right eye

Surgery (transorbital approach)

Residual 10% adduction limitation

6

Matsumoto

et al (1998)[9]

3

Female

Plastic chopstick

Complete loss of vision in the left eye

Surgery

Blindness

57

Male

Wooden chopstick

Loss of vision and light reflex in the right eye

Surgery

Blindness

7

Sun et al (2016)[2]

23

Male

Wooden chopstick

Swollen and bruised right eye. Mydriasis and restricted extraocular movements with left-sided hemiplegia, hemihypoesthesia and right central facial nerve palsy

Surgery (frontotemporal “pterional” approach)

Left hemiplegia

8

Mzimbiri et al (2016)[10]

4

Male

Wooden chopstick

Glasgow Coma Scale score of 5/15 and a 4-mm dilated and fixed pupil on the left eye that was unresponsive to light

Surgery (frontotemporal “pterional” approach)

Died

2

Male

Wooden chopstick

Pain in the right eyebrow without loss of vision

Surgery (subfrontal approach)

Good outcome without any neurological deficits

50

Male

Wooden chopstick

Periorbital swelling, headaches, and loss of consciousness for 12 hours after trauma. Glasgow Coma Scale score was 14/15, left diplopia and ophthalmoplegia with partial ptosis. The pupil on the left side was dilated and unresponsive to light with limited eye movements and reduced jaw sensation to touch and pain

Surgery (subtemporal approach)

Favorable outcome

9

Park et al (2006)[11]

9

Female

Wooden chopstick

Eyelid swelling

Surgery (frontotemporal “pterional” approach)

Good outcome without any deficits

1

Male

Metallic chopstick

Eyelid swelling and right-side hemiparesis

Withdrawn without difficulty (no craniotomy)

Minimal weakness of the right side

5

Male

Metallic chopstick

Eyelid swelling, mild left upward gaze limitation, and fever

Withdrawn without difficulty (no craniotomy)

Good outcome without any deficits

2

Male

Metallic chopstick

Eyelid swelling

Withdrawn without difficulty (no craniotomy)

Good outcome without any deficits

10

Kawamura et al (1997)[12]

4

Male

Wooden chopstick

3-year-delayed cerebrospinal fluid rhinorrhea

Surgery (bifrontal craniotomy)

Good outcome without any deficits

11

Ishisaka et al (2017)[13]

1.5

Male

Wooden chopstick

There was only a 1-cm laceration on the right upper eyelid

Surgery

Good outcome without complications

12

Yuan et al (2020)[14]

15

Male

Wooden chopstick

Forehead wound infection, refractory hyperpyrexia, and cerebrospinal fluid leak from the left eye socket

Surgery (frontal craniotomy)

Favorable outcome without reoccurrence of cerebrospinal fluid leak. Neurological examination showed full functional recovery, except for the loss of vision in the left eye

13

Mitilian et

al (2009)[3]

4

Male

Wooden chopstick

Mild confusion, vomiting, mild exophthalmos with the eyeball deviatedupwards, mydriatic reactive pupil, andparesis of the left arm

Withdrawal of the chopstick under computerized tomography control (no craniotomy)

Mild dysmetria in the left arm

14

Shimizu et al (2020)[15]

40

Female

Chopstick (unknown type)

Conjunctival hemorrhage with no direct and indirect light reflex in the left eye

Medical treatment (no surgery)

Loss of vision in the left eye

15

Mzimbiri

et al (2016)[16]

50

Male

Wooden chopstick

Painful left eye, swelling, and inability to open the eye for 2 days before admission

Surgery (subtemporal craniotomy)

Dilated pupil and limited eye movements

16

Kim et al (2005)[17]

1.5

Male

Metallic chopstick

Swelling of the right eyelid

Surgery (bifrontal craniotomy)

Good outcome without any deficits

17

Kadota et al (1988)[18]

38

Female

Wooden chopstick

Left hemiparesis and hemihypesthesia with right cranial nerve palsy of the 2nd, 3rd, 4th, and 6th nerves as well as the 1st branch of the 5th nerve

Surgery (frontotemporal “pterional” approach)

Right hemiparesis

18

Yamazaki et al (2023)[19]

24

Male

Wooden chopstick

Headache, vomiting, and bleeding from the wound site. Swollen eyelid and inability to open the left eye. Fixed and dilated pupil without reaction to light

Surgery (frontotemporal “pterional” approach)

Left trochlear nerve palsy

19

Matsuyama et al (2001)[20]

1

Male

Wooden chopstick

Swollen and bruised eyelid

Surgery (frontolateral craniotomy)

Good outcome without any neurological deficits

20

Shin et al (2012)[4]

38

Male

Plastic chopstick

Pain, swelling, and numbness around his left eye

Withdrawn without difficulty (no craniotomy)

Nonreactive to light and facial weakness

21

Hiraishi et al (2007)[21]

14

Female

Plastic chopstick

Fever, headache, and stiff neck 9 years after the injury

Surgery (frontotemporal decompressive craniectomy)

Slight hyposmia

22

Nishio et al (2004)[22]

13

Female

Wooden chopstick

Fever, nausea, and headache 7 years after the injury

Surgery (frontotemporal “pterional” approach)

Good outcome without any deficits

23

Yamasaki et al (2013)[23]

4

Female

Plastic chopstick

Clinical manifestations of meningitis (fever, headache, and stiff neck)

Withdrawn by the patient (no craniotomy)

Favorable outcome

This study describes an unusual case of transorbital intracranial injury caused by a chopstick. In selective cases with no radiological evidence of vascular and neural injuries, the foreign body can be removed straightforwardly without the requirement for a craniotomy. Moreover, pre- and postoperative imaging along with close observation of the patient's condition is essential.



Publication History

Article published online:
10 July 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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