Research ArticleManagement of Penetrating Skull Base Injury A SingleInstitutional Experience and Review of the Literature

Danfeng Zhang Jigang Chen Kaiwei Han Mingkun Yu and Lijun Hou

Department of Neurosurgery Shanghai Institute of Neurosurgery Shanghai Changzheng Hospital415 Fengyang Road Shanghai 200003 China

Correspondence should be addressed to Lijun Hou lijunhoucz126com

Received 7 May 2017 Accepted 18 June 2017 Published 30 July 2017

Academic Editor Hideo Inaba

Copyright copy 2017 Danfeng Zhang et alThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Background Penetrating skull base injury (PSBI) is uncommon among head injuries presenting unique diagnostic and therapeuticchallenges Although many cases of PSBIs have been reported comprehensive understanding of its initial diagnosis managementand outcome is still unavailableMaterials andMethodsA retrospective review was performed for patients treated in neurosurgicaldepartment of Changzheng Hospital for PSBIs Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conductedfor each patient Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed theircommon features Results A total of 5 patients suffering PSBIs were identified Penetrating points as well as the surroundingneurovascular structures were clearly visualized assisting in the presurgical planning of optimal surgical approach and avoidingunexpected vascular injury Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient receivedconservative treatment All of them presented good outcomes after proper management Conclusion Careful physical examinationand radiological evaluation are essential before operation and angiography is recommended for those with suspected vascularinjuries 3D modeling with 3D Slicer is practicable and reliable facilitating the diagnosis and presurgical planning Treatmentdecision should be made upon the comprehensive evaluation of patientrsquos clinicoradiological features and characteristics of foreignbodies

1 Introduction

Penetrating injuries of the skull base caused by foreignbodies are relatively uncommon representing about 04of head injuries [1 2] Various foreign bodies have beenreported in penetrating skull base injuries (PSBIs) includingwood bamboo metallic fragments and toothbrushes PSBIscould present unique diagnostic and therapeutic challengesPatients may be initially asymptomatic but subject to seriousevents for several daysmonths or even years after the injuries[3] It is not difficult to detect most of intracranial foreignbodies by head computed tomography (CT) scan Howeverthe relationships between foreign bodies and its surroundingstructures are hard to decide which is the prerequisite for themanagement of these injuries [4 5]

Treatment for PSBIs includes the surgical retractionof foreign bodies prevention of infection management ofvascular injuries reconstruction of skull base and so forth [35ndash7] Due to the low incidence there is no sufficient literature

about the diagnosis and management of these patients Theaim of our study is to present patients of PSBIs treated in ourdepartment and review related literature in order to highlightthe proper management of PSBIs and improve prognosis inthe long run

2 Materials and Methods

A retrospective review was conducted for patients who weretreated in our hospital between January 2010 and September2016 for PSBIs This study was performed in accordancewith the Declaration of Helsinki (1964) and approved bythe investigational review board of Changzheng HospitalInformed consent was available for each patient Presurgicalhead CT scans were performed for all patients Moreoverdigital subtraction angiography (DSA) was conducted onsuspicion of vascular injuries and magnetic resonance imag-ing (MRI) was performed in case of nonmetallic objectsData concerning patientsrsquo demographics mechanisms of

HindawiBioMed Research InternationalVolume 2017 Article ID 2838167 12 pageshttpsdoiorg10115520172838167

2 BioMed Research International

injury medical managements complications and prognosiswere collected by two authors (D F Zhang and J G Chen)

In order to visualize the location of foreign body and itsrelationship with surrounding structures three-dimensional(3D) Slicer-assisted reconstructions were conducted by aprofessional neuroradiologist (K W Han) according topresurgical imaging data During the reconstruction all theDigital Imaging andCommunications inMedicine (DICOM)images were imported into 3D Slicer (3D Slicer 40sim44Surgical Planning Laboratory Harvard University USA)Segmentation of skull foreign body and cerebral artery wasfirst performed with built-in modules in Slicer Individualmodels of each structure were created which could berotated and viewed from any perspective (Figure 1(g) Figures2(g)ndash2(i) Figure 3(g))

3 Results

A total of 5 patients with PSBIs were identified There were4 males and 1 female aged 29ndash75 years They were all victimsof tumble or work-related accident Four of them underwentsurgical retrieval of foreign bodies and 1 patient receivedconservative treatment Penetrating points as well as thesurrounding neurovascular structures were clearly visualizedin 3Dmodels assisting in the presurgical planning of optimalsurgical approach and avoiding unexpected vascular injuryDetails regarding patientsrsquo demographics locations of foreignbodies and treatment were listed in Table 1

31 Representative Case 1 This 75-year-old female wasadmitted to her local hospital with complaints of headacheand dizziness for 3 days She was conscious and neurologi-cally intact with a slightly elevated body temperature HeadCT scan revealed a low density 4 cm long foreign bodyextending from the left orbit to superior orbital fissure andposteriorly to the left temporal lobe (Figures 1(a)ndash1(c)) Braintissue surrounding the foreign body was swollen and signsof abscess were indicated (Figures 1(d)ndash1(f)) The patientrecalled that while she was walking in a bamboo gardenshe tripped and fell forward striking her left forehead ona bamboo stick She did not feel any discomfort except thepain on her left upper eyelid Symptoms of headache andfever emerged 5 days later and she was taken to the hospitalby her family 8 days after the injury Anti-infective therapieswere given before she was transferred to our hospital Carefulphysical examination revealed a slight skin scar on her leftupper eyelid Head DSA was performed later with no signsof vascular injuries although the bamboo stick was adjacentto the left middle cerebral artery (MCA) in the 3D recon-struction model (Figure 1(g)) Anti-infectious treatment wasadministrated for 12 days to control the brain abscess beforesurgery During operation an orbitozygomatic approach wasadopted and the pterional craniotomy was first performedThen superior orbital fissure was revealed after removing thegreat wing of sphenoid We explored the abscess in the tem-poral lobe After yellowish pus in the abscess was removedthe distal end of the bamboo stick was then visualized Weopened the dura and orbital fascia along the bamboo stickto expose its full length (Figure 1(h)) The stick was removed

completely under direct visualization (Figure 1(i)) and durawas sutured in a water tight fashionThe postoperative coursewas uncomplicated Broad-spectrum antibiotics were givenuntil she was discharged free of symptoms 10 days afteroperation

32 Representative Case 2 This 32-year-old man was hit bythe fragments of a burst grinding wheel on his left cheekduring working hours He was taken to the local hospitalcomplaining of headache and kept neurologically intact onphysical examination Head CT scan suggested a short pieceof metal fragment locating right between the left maxillaryand ramimandibulae and a long piece sticking in the left tem-poral lobe Both pieces presented to be highly dense on theCT scan (Figures 2(a)ndash2(c))The patient was then transferredto our department for further treatment 5 days later DSAsuggested no obvious vascular injury (Figures 2(d) and 2(e))while axial CT scan revealed close relationship between thebone fragment and branch of MCA (Figure 2(f)) The exactlocation of foreign body could be visualized clearly on the3D reconstruction model (Figures 2(g)ndash2(i)) Conservativemanagement was given to control the infection and surgerywas performed 15 days after the injury During operationshort piece of the foreign body was first removed through anintraoral incision Then a temporozygomatic approach wasperformed to remove the long piece which was visualized atthe infratemporal fossa after the zygomatic archwas detachedand retracted downwardly with temporal muscle Severalpieces of bone fragment were found around the foreign bodyAfter the lateral portion of infratemporal fossa was drilledoff the object was removed in a retrograde fashion Duringthis process yellowish pus was drained into infratemporalfossa through the intracranial trajectory of foreign bodyThis trajectory was not explored and defect of dura wassealed with muscle flap (Figures 3(a)ndash3(e)) Postoperativeskull radiography showed complete removal of the foreignbody (Figure 3(f)) A small bone fragment was left in placedue to its close relationship with branch of MCA whichwas found to be stenotic during follow-up (Figure 3(g)) Thepatient was discharged 1 week after operation with sporadicfocal epilepsy which was controlled well with carbamazepineand he recovered well without abscess formation at three-month follow-up (Figures 3(h) and 3(i))

4 Discussion

41 Literature Review Clinicoradiological features of PSBIsin previous literatures were reviewed and summarized inTable 2 [2 3 8ndash24] Most of the subjects were males (662132) with an average age of 24 years old 41 (1332) ofthe patients were children under 10 years of age As for themechanism of injury children injuries were all caused bytumbling or falling while the injury of 4 adults resultedfrom suicidal or homicidal attempt which was absent in ourcase series The most common foreign body was metallic(1232) followed by wooden (932) and plastic (932) Onepatient was injured by a wild deerrsquos antler and another onewas attacked by bear paws both of which had no retainedforeign bodies As a weak area of skull the orbit was the most

BioMed Research International 3

(a)

(a)

(b)

(b)

(c)

(c)

(d)

(d)

(e)

(e)

(f)

(f)

(g)

(g)

f

to

(h)

(h)

(i)

(i)

Figure 1 Head CT scan demonstrated a bamboo stick (hollow arrow) penetrating into the temporal lobe via superior orbital fissure Thebamboo stick presented as high density on the CT scan (a b c) Contrast enhanced MRI revealed an abscess (simple arrowlarr) around thebamboo stick in temporal lobe (d e f) 3D reconstruction of the skull cerebral artery and bamboo stick (hollow arrow ) was performedby 3D Slicer software to visualize the relationship among these structures (g) Intraoperative photography (h) displayed the bamboo stick inoriginal place (o orbital side f frontal side t temporal side) Photography showed the removed bamboo stick (i) 3D three-dimensional CTcomputed tomography MRI magnetic resonance imaging

common penetrating point followed by oral or nasal cavityand maxillofacial region

42 Diagnosis of PSBIs After careful physical examinationproper radiological examination on the basis of patientsrsquocondition is necessary Although the importance of head CTscan in the management of PSBIs has been emphasized in

previous literatures several instructions should be noticedFirstly the density of foreign bodies on CT scan variesaccording to their types For example metal presents as highdensity while wood or plastics are of isodensity or lowdensityand difficult to identify Secondly the density of some foreignbodies would change over time For example bamboo is oflow density on initial CT scan but it would be of high density

4 BioMed Research International

(a)

(a)

(b)

(b)

(c)

(c)

(d)

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 2 Preoperative image of foreign body (burst outer rim of a grinding wheel) in the face andmiddle skull base Anterior-posterior skullradiography (a) and lateral skull radiography (b) demonstrated the short piece (simple arrowlarr) in the face and long piece (hollow arrow) penetrating into the middle skull base Sagittal reconstruction of CT (c) showed the long piece penetrating into the middle cranial fossathrough infratemporal fossa A small piece of bone fragment (hollow arrowhead ) was noticed above the long piece The bone fragmentarose from the hit of the long piece on the middle skull base DSA (d amp e) proved the integrity of MCA Axial CT revealed close relationshipbetween the bone fragment (hollow arrow head ) and branch of MCA (f) 3D reconstruction (g h i) with 3D Slicer software displayedspatial correlation of two pieces of foreign body with the face and skull base 3D three-dimensional CT computed tomography DSA digitalsubtraction angiography MCA middle cerebral artery

later which frequently leads to misdiagnosis (Case 1) [25]Therefore MRI is a useful supplement to CT in the detectionof nonmetallic foreign bodies

Angiography such as the CT angiography MR angiogra-phy or DSA is highly recommended for patients in suspicion

of artery injuries or traumatic aneurysms [7 26 27] Asdemonstrated in Case 2 foreign bodies may not causeimmediate vascular injury sometimes but lead to cerebralvasospasm or stenosis in the long run highlighting theimportance of angiography in the setting of PSBIs

BioMed Research International 5

Table1Dem

ograph

icsa

ndclinicald

atafor

patie

ntso

fPSB

I

Case

Age

and

gend

erMechanism

ofinjury

Type

andsiz

eof

foreign

body

Penetrating

pathway

Symptom

sand

concurrent

cond

ition

s

DSA

finding

s

Interval

toop

eration

Operatio

nSurgicalapproach

Resid

ual

fractio

nAntibioticsu

sed

Symptom

sat

discharge

175fe

male

Accident

Bambo

o7c

m

Left

orbit-s

uperior

orbital

fissure-anterior

skullbase-left

tempo

rallob

e

Headache

dizzinessbrain

abscess

Negative

20days

Yes

Orbito

zygomatic

approach

and

pterional

craniotomy

No

Metronidazole

cefta

zidime

vancom

ycin

linezolid

biapenem

Free

ofsymptom

232m

ale

Accident

Grin

ding

wheel

65c

m

Leftmaxilla-

infratem

poral

fossa-middle

cranialfossa

ciste

rnof

lateral

sulcus

Headachebrain

abscess

Negative

19days

Yes

Tempo

rozygomatic

approach

No

Linezolid

Epilepsy

342m

ale

Accident

Electro

drill

22c

m

Lefteyebrow-

anterio

rcranial

base-le

ftfro

ntal

lobe

Headache

cerebral

contusion

Not

cond

ucted

No

operation

No

mdashYes

Linezolid

biapenem

Slight

headache

429m

ale

Accident

Screw

54c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blurredvisio

nanterio

rsku

llbase

fracture

oculom

otor

nerveinjury

Not

cond

ucted

2days

Yes

Fron

totempo

ral

approach

No

Vancom

ycin

linezolid

Improved

visio

noculom

otor

nerve

injury

540

male

Accident

Hot

projectiv

eoil

paint34c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blindn

essrig

hteyep

enetratin

ginjuryfrontal

hematom

a

Not

cond

ucted

4days

Yes

Subfrontal

approach

Yes

Vancom

ycin

ceftriaxone

B lindn

ess

6 BioMed Research International

Table2Clinicoradiologicalfeatureso

fpreviou

slyrepo

rted

caseso

fPSB

I

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Matsumotoet

al1998

3female

Left3c

mPlastic

chop

stick

Falling

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Matsumotoet

al1998

57m

ale

Right2

cmWoo

den

chop

stick

Stickinto

chop

stick

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Hebecker2009

32m

ale

Leftno

foreign

body

Wild

deerrsquos

antler

Accident

Leftorbit

floorla

teral

orbit

Com

aBifro

ntalintradural

neurosurgical

approach

No

Free

ofsymptom

Ishikawae

tal

2000

4male

Left6c

mWoo

den

chop

stick

Falling

Preauricular

area

topo

sterio

rfossa

Feverheadache

Subo

ccipita

lcraniectom

yBrainabscess

Ataxiaand

dysm

etria

Matsuyamae

tal2001

1male

Right2

5cm

Woo

den

chop

sticks

Falling

Superio

rorbita

lfissure

Swolleneye

Transcranial

approach

Meningitis

Free

ofsymptom

Maruyae

tal

2002

56fe

male

Left1cm

Bambo

oTu

mbling

Tempo

ral

(lateralorbit)

Drowsin

ess

Left

frontotem

poral

craniotomyand

orbitozygomatic

osteotom

y

No

Lateralgazein

theleft

eye

Hayashi

etal

2003

71fe

male

Rightn

oforeign

body

Bear

claws

Animal

assault

Fron

talsinus

Laceratedface

CSFfistulas

Fron

tal

craniectom

iesto

repairCS

Ffistulas

No

Free

ofsymptom

Nish

ioetal

2004

6female

Right2

5cm

Woo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Feverheadache

neck

stiffn

ess

Craniotomy

Brainabscess

Fre e

ofsymptom

Kim

etal2005

1male

Right2

cmMetallic

chop

stick

Falling

Fron

tal(orbital

roof)

Crying

Craniotomy

No

Free

ofsymptom

Tsao

etal2006

45m

ale

Left25c

mlowast

25c

mPlastic

chair

glide

Beassaulted

Sino

nasalcavity

anterio

rsku

llbase

Ptosis

impaire

dvisio

n

Transnasal

endo

scop

icexplorationand

removalof

the

foreignbo

dy

No

Ano

smiaand

diplop

ia

DeT

ommasiet

al2006

20m

ale

Right10c

mScrewdriver

Falling

Rightm

axilla

Scotom

ainthe

lefteyeCS

Fleakage

Leftpterional

approach

NK

Resto

redvisio

n

Park200

69female

RightN

KWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

No

Free

ofsymptom

Park200

61m

ale

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gleft

hemiparesis

NK

No

Leftmild

hemiparesis

Park200

65male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International 3

(a)

(a)

(b)

(b)

(c)

(c)

(d)

(d)

(e)

(e)

(f)

(f)

(g)

(g)

f

to

(h)

(h)

(i)

(i)

Figure 1 Head CT scan demonstrated a bamboo stick (hollow arrow) penetrating into the temporal lobe via superior orbital fissure Thebamboo stick presented as high density on the CT scan (a b c) Contrast enhanced MRI revealed an abscess (simple arrowlarr) around thebamboo stick in temporal lobe (d e f) 3D reconstruction of the skull cerebral artery and bamboo stick (hollow arrow ) was performedby 3D Slicer software to visualize the relationship among these structures (g) Intraoperative photography (h) displayed the bamboo stick inoriginal place (o orbital side f frontal side t temporal side) Photography showed the removed bamboo stick (i) 3D three-dimensional CTcomputed tomography MRI magnetic resonance imaging

common penetrating point followed by oral or nasal cavityand maxillofacial region

42 Diagnosis of PSBIs After careful physical examinationproper radiological examination on the basis of patientsrsquocondition is necessary Although the importance of head CTscan in the management of PSBIs has been emphasized in

previous literatures several instructions should be noticedFirstly the density of foreign bodies on CT scan variesaccording to their types For example metal presents as highdensity while wood or plastics are of isodensity or lowdensityand difficult to identify Secondly the density of some foreignbodies would change over time For example bamboo is oflow density on initial CT scan but it would be of high density

4 BioMed Research International

(a)

(a)

(b)

(b)

(c)

(c)

(d)

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 2 Preoperative image of foreign body (burst outer rim of a grinding wheel) in the face andmiddle skull base Anterior-posterior skullradiography (a) and lateral skull radiography (b) demonstrated the short piece (simple arrowlarr) in the face and long piece (hollow arrow) penetrating into the middle skull base Sagittal reconstruction of CT (c) showed the long piece penetrating into the middle cranial fossathrough infratemporal fossa A small piece of bone fragment (hollow arrowhead ) was noticed above the long piece The bone fragmentarose from the hit of the long piece on the middle skull base DSA (d amp e) proved the integrity of MCA Axial CT revealed close relationshipbetween the bone fragment (hollow arrow head ) and branch of MCA (f) 3D reconstruction (g h i) with 3D Slicer software displayedspatial correlation of two pieces of foreign body with the face and skull base 3D three-dimensional CT computed tomography DSA digitalsubtraction angiography MCA middle cerebral artery

later which frequently leads to misdiagnosis (Case 1) [25]Therefore MRI is a useful supplement to CT in the detectionof nonmetallic foreign bodies

Angiography such as the CT angiography MR angiogra-phy or DSA is highly recommended for patients in suspicion

of artery injuries or traumatic aneurysms [7 26 27] Asdemonstrated in Case 2 foreign bodies may not causeimmediate vascular injury sometimes but lead to cerebralvasospasm or stenosis in the long run highlighting theimportance of angiography in the setting of PSBIs

BioMed Research International 5

Table1Dem

ograph

icsa

ndclinicald

atafor

patie

ntso

fPSB

I

Case

Age

and

gend

erMechanism

ofinjury

Type

andsiz

eof

foreign

body

Penetrating

pathway

Symptom

sand

concurrent

cond

ition

s

DSA

finding

s

Interval

toop

eration

Operatio

nSurgicalapproach

Resid

ual

fractio

nAntibioticsu

sed

Symptom

sat

discharge

175fe

male

Accident

Bambo

o7c

m

Left

orbit-s

uperior

orbital

fissure-anterior

skullbase-left

tempo

rallob

e

Headache

dizzinessbrain

abscess

Negative

20days

Yes

Orbito

zygomatic

approach

and

pterional

craniotomy

No

Metronidazole

cefta

zidime

vancom

ycin

linezolid

biapenem

Free

ofsymptom

232m

ale

Accident

Grin

ding

wheel

65c

m

Leftmaxilla-

infratem

poral

fossa-middle

cranialfossa

ciste

rnof

lateral

sulcus

Headachebrain

abscess

Negative

19days

Yes

Tempo

rozygomatic

approach

No

Linezolid

Epilepsy

342m

ale

Accident

Electro

drill

22c

m

Lefteyebrow-

anterio

rcranial

base-le

ftfro

ntal

lobe

Headache

cerebral

contusion

Not

cond

ucted

No

operation

No

mdashYes

Linezolid

biapenem

Slight

headache

429m

ale

Accident

Screw

54c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blurredvisio

nanterio

rsku

llbase

fracture

oculom

otor

nerveinjury

Not

cond

ucted

2days

Yes

Fron

totempo

ral

approach

No

Vancom

ycin

linezolid

Improved

visio

noculom

otor

nerve

injury

540

male

Accident

Hot

projectiv

eoil

paint34c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blindn

essrig

hteyep

enetratin

ginjuryfrontal

hematom

a

Not

cond

ucted

4days

Yes

Subfrontal

approach

Yes

Vancom

ycin

ceftriaxone

B lindn

ess

6 BioMed Research International

Table2Clinicoradiologicalfeatureso

fpreviou

slyrepo

rted

caseso

fPSB

I

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Matsumotoet

al1998

3female

Left3c

mPlastic

chop

stick

Falling

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Matsumotoet

al1998

57m

ale

Right2

cmWoo

den

chop

stick

Stickinto

chop

stick

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Hebecker2009

32m

ale

Leftno

foreign

body

Wild

deerrsquos

antler

Accident

Leftorbit

floorla

teral

orbit

Com

aBifro

ntalintradural

neurosurgical

approach

No

Free

ofsymptom

Ishikawae

tal

2000

4male

Left6c

mWoo

den

chop

stick

Falling

Preauricular

area

topo

sterio

rfossa

Feverheadache

Subo

ccipita

lcraniectom

yBrainabscess

Ataxiaand

dysm

etria

Matsuyamae

tal2001

1male

Right2

5cm

Woo

den

chop

sticks

Falling

Superio

rorbita

lfissure

Swolleneye

Transcranial

approach

Meningitis

Free

ofsymptom

Maruyae

tal

2002

56fe

male

Left1cm

Bambo

oTu

mbling

Tempo

ral

(lateralorbit)

Drowsin

ess

Left

frontotem

poral

craniotomyand

orbitozygomatic

osteotom

y

No

Lateralgazein

theleft

eye

Hayashi

etal

2003

71fe

male

Rightn

oforeign

body

Bear

claws

Animal

assault

Fron

talsinus

Laceratedface

CSFfistulas

Fron

tal

craniectom

iesto

repairCS

Ffistulas

No

Free

ofsymptom

Nish

ioetal

2004

6female

Right2

5cm

Woo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Feverheadache

neck

stiffn

ess

Craniotomy

Brainabscess

Fre e

ofsymptom

Kim

etal2005

1male

Right2

cmMetallic

chop

stick

Falling

Fron

tal(orbital

roof)

Crying

Craniotomy

No

Free

ofsymptom

Tsao

etal2006

45m

ale

Left25c

mlowast

25c

mPlastic

chair

glide

Beassaulted

Sino

nasalcavity

anterio

rsku

llbase

Ptosis

impaire

dvisio

n

Transnasal

endo

scop

icexplorationand

removalof

the

foreignbo

dy

No

Ano

smiaand

diplop

ia

DeT

ommasiet

al2006

20m

ale

Right10c

mScrewdriver

Falling

Rightm

axilla

Scotom

ainthe

lefteyeCS

Fleakage

Leftpterional

approach

NK

Resto

redvisio

n

Park200

69female

RightN

KWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

No

Free

ofsymptom

Park200

61m

ale

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gleft

hemiparesis

NK

No

Leftmild

hemiparesis

Park200

65male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

4 BioMed Research International

(a)

(a)

(b)

(b)

(c)

(c)

(d)

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 2 Preoperative image of foreign body (burst outer rim of a grinding wheel) in the face andmiddle skull base Anterior-posterior skullradiography (a) and lateral skull radiography (b) demonstrated the short piece (simple arrowlarr) in the face and long piece (hollow arrow) penetrating into the middle skull base Sagittal reconstruction of CT (c) showed the long piece penetrating into the middle cranial fossathrough infratemporal fossa A small piece of bone fragment (hollow arrowhead ) was noticed above the long piece The bone fragmentarose from the hit of the long piece on the middle skull base DSA (d amp e) proved the integrity of MCA Axial CT revealed close relationshipbetween the bone fragment (hollow arrow head ) and branch of MCA (f) 3D reconstruction (g h i) with 3D Slicer software displayedspatial correlation of two pieces of foreign body with the face and skull base 3D three-dimensional CT computed tomography DSA digitalsubtraction angiography MCA middle cerebral artery

later which frequently leads to misdiagnosis (Case 1) [25]Therefore MRI is a useful supplement to CT in the detectionof nonmetallic foreign bodies

Angiography such as the CT angiography MR angiogra-phy or DSA is highly recommended for patients in suspicion

of artery injuries or traumatic aneurysms [7 26 27] Asdemonstrated in Case 2 foreign bodies may not causeimmediate vascular injury sometimes but lead to cerebralvasospasm or stenosis in the long run highlighting theimportance of angiography in the setting of PSBIs

BioMed Research International 5

Table1Dem

ograph

icsa

ndclinicald

atafor

patie

ntso

fPSB

I

Case

Age

and

gend

erMechanism

ofinjury

Type

andsiz

eof

foreign

body

Penetrating

pathway

Symptom

sand

concurrent

cond

ition

s

DSA

finding

s

Interval

toop

eration

Operatio

nSurgicalapproach

Resid

ual

fractio

nAntibioticsu

sed

Symptom

sat

discharge

175fe

male

Accident

Bambo

o7c

m

Left

orbit-s

uperior

orbital

fissure-anterior

skullbase-left

tempo

rallob

e

Headache

dizzinessbrain

abscess

Negative

20days

Yes

Orbito

zygomatic

approach

and

pterional

craniotomy

No

Metronidazole

cefta

zidime

vancom

ycin

linezolid

biapenem

Free

ofsymptom

232m

ale

Accident

Grin

ding

wheel

65c

m

Leftmaxilla-

infratem

poral

fossa-middle

cranialfossa

ciste

rnof

lateral

sulcus

Headachebrain

abscess

Negative

19days

Yes

Tempo

rozygomatic

approach

No

Linezolid

Epilepsy

342m

ale

Accident

Electro

drill

22c

m

Lefteyebrow-

anterio

rcranial

base-le

ftfro

ntal

lobe

Headache

cerebral

contusion

Not

cond

ucted

No

operation

No

mdashYes

Linezolid

biapenem

Slight

headache

429m

ale

Accident

Screw

54c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blurredvisio

nanterio

rsku

llbase

fracture

oculom

otor

nerveinjury

Not

cond

ucted

2days

Yes

Fron

totempo

ral

approach

No

Vancom

ycin

linezolid

Improved

visio

noculom

otor

nerve

injury

540

male

Accident

Hot

projectiv

eoil

paint34c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blindn

essrig

hteyep

enetratin

ginjuryfrontal

hematom

a

Not

cond

ucted

4days

Yes

Subfrontal

approach

Yes

Vancom

ycin

ceftriaxone

B lindn

ess

6 BioMed Research International

Table2Clinicoradiologicalfeatureso

fpreviou

slyrepo

rted

caseso

fPSB

I

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Matsumotoet

al1998

3female

Left3c

mPlastic

chop

stick

Falling

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Matsumotoet

al1998

57m

ale

Right2

cmWoo

den

chop

stick

Stickinto

chop

stick

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Hebecker2009

32m

ale

Leftno

foreign

body

Wild

deerrsquos

antler

Accident

Leftorbit

floorla

teral

orbit

Com

aBifro

ntalintradural

neurosurgical

approach

No

Free

ofsymptom

Ishikawae

tal

2000

4male

Left6c

mWoo

den

chop

stick

Falling

Preauricular

area

topo

sterio

rfossa

Feverheadache

Subo

ccipita

lcraniectom

yBrainabscess

Ataxiaand

dysm

etria

Matsuyamae

tal2001

1male

Right2

5cm

Woo

den

chop

sticks

Falling

Superio

rorbita

lfissure

Swolleneye

Transcranial

approach

Meningitis

Free

ofsymptom

Maruyae

tal

2002

56fe

male

Left1cm

Bambo

oTu

mbling

Tempo

ral

(lateralorbit)

Drowsin

ess

Left

frontotem

poral

craniotomyand

orbitozygomatic

osteotom

y

No

Lateralgazein

theleft

eye

Hayashi

etal

2003

71fe

male

Rightn

oforeign

body

Bear

claws

Animal

assault

Fron

talsinus

Laceratedface

CSFfistulas

Fron

tal

craniectom

iesto

repairCS

Ffistulas

No

Free

ofsymptom

Nish

ioetal

2004

6female

Right2

5cm

Woo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Feverheadache

neck

stiffn

ess

Craniotomy

Brainabscess

Fre e

ofsymptom

Kim

etal2005

1male

Right2

cmMetallic

chop

stick

Falling

Fron

tal(orbital

roof)

Crying

Craniotomy

No

Free

ofsymptom

Tsao

etal2006

45m

ale

Left25c

mlowast

25c

mPlastic

chair

glide

Beassaulted

Sino

nasalcavity

anterio

rsku

llbase

Ptosis

impaire

dvisio

n

Transnasal

endo

scop

icexplorationand

removalof

the

foreignbo

dy

No

Ano

smiaand

diplop

ia

DeT

ommasiet

al2006

20m

ale

Right10c

mScrewdriver

Falling

Rightm

axilla

Scotom

ainthe

lefteyeCS

Fleakage

Leftpterional

approach

NK

Resto

redvisio

n

Park200

69female

RightN

KWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

No

Free

ofsymptom

Park200

61m

ale

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gleft

hemiparesis

NK

No

Leftmild

hemiparesis

Park200

65male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International 5

Table1Dem

ograph

icsa

ndclinicald

atafor

patie

ntso

fPSB

I

Case

Age

and

gend

erMechanism

ofinjury

Type

andsiz

eof

foreign

body

Penetrating

pathway

Symptom

sand

concurrent

cond

ition

s

DSA

finding

s

Interval

toop

eration

Operatio

nSurgicalapproach

Resid

ual

fractio

nAntibioticsu

sed

Symptom

sat

discharge

175fe

male

Accident

Bambo

o7c

m

Left

orbit-s

uperior

orbital

fissure-anterior

skullbase-left

tempo

rallob

e

Headache

dizzinessbrain

abscess

Negative

20days

Yes

Orbito

zygomatic

approach

and

pterional

craniotomy

No

Metronidazole

cefta

zidime

vancom

ycin

linezolid

biapenem

Free

ofsymptom

232m

ale

Accident

Grin

ding

wheel

65c

m

Leftmaxilla-

infratem

poral

fossa-middle

cranialfossa

ciste

rnof

lateral

sulcus

Headachebrain

abscess

Negative

19days

Yes

Tempo

rozygomatic

approach

No

Linezolid

Epilepsy

342m

ale

Accident

Electro

drill

22c

m

Lefteyebrow-

anterio

rcranial

base-le

ftfro

ntal

lobe

Headache

cerebral

contusion

Not

cond

ucted

No

operation

No

mdashYes

Linezolid

biapenem

Slight

headache

429m

ale

Accident

Screw

54c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blurredvisio

nanterio

rsku

llbase

fracture

oculom

otor

nerveinjury

Not

cond

ucted

2days

Yes

Fron

totempo

ral

approach

No

Vancom

ycin

linezolid

Improved

visio

noculom

otor

nerve

injury

540

male

Accident

Hot

projectiv

eoil

paint34c

m

Right

orbit-a

nterior

cranial

base-right

frontallobe

Headache

blindn

essrig

hteyep

enetratin

ginjuryfrontal

hematom

a

Not

cond

ucted

4days

Yes

Subfrontal

approach

Yes

Vancom

ycin

ceftriaxone

B lindn

ess

6 BioMed Research International

Table2Clinicoradiologicalfeatureso

fpreviou

slyrepo

rted

caseso

fPSB

I

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Matsumotoet

al1998

3female

Left3c

mPlastic

chop

stick

Falling

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Matsumotoet

al1998

57m

ale

Right2

cmWoo

den

chop

stick

Stickinto

chop

stick

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Hebecker2009

32m

ale

Leftno

foreign

body

Wild

deerrsquos

antler

Accident

Leftorbit

floorla

teral

orbit

Com

aBifro

ntalintradural

neurosurgical

approach

No

Free

ofsymptom

Ishikawae

tal

2000

4male

Left6c

mWoo

den

chop

stick

Falling

Preauricular

area

topo

sterio

rfossa

Feverheadache

Subo

ccipita

lcraniectom

yBrainabscess

Ataxiaand

dysm

etria

Matsuyamae

tal2001

1male

Right2

5cm

Woo

den

chop

sticks

Falling

Superio

rorbita

lfissure

Swolleneye

Transcranial

approach

Meningitis

Free

ofsymptom

Maruyae

tal

2002

56fe

male

Left1cm

Bambo

oTu

mbling

Tempo

ral

(lateralorbit)

Drowsin

ess

Left

frontotem

poral

craniotomyand

orbitozygomatic

osteotom

y

No

Lateralgazein

theleft

eye

Hayashi

etal

2003

71fe

male

Rightn

oforeign

body

Bear

claws

Animal

assault

Fron

talsinus

Laceratedface

CSFfistulas

Fron

tal

craniectom

iesto

repairCS

Ffistulas

No

Free

ofsymptom

Nish

ioetal

2004

6female

Right2

5cm

Woo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Feverheadache

neck

stiffn

ess

Craniotomy

Brainabscess

Fre e

ofsymptom

Kim

etal2005

1male

Right2

cmMetallic

chop

stick

Falling

Fron

tal(orbital

roof)

Crying

Craniotomy

No

Free

ofsymptom

Tsao

etal2006

45m

ale

Left25c

mlowast

25c

mPlastic

chair

glide

Beassaulted

Sino

nasalcavity

anterio

rsku

llbase

Ptosis

impaire

dvisio

n

Transnasal

endo

scop

icexplorationand

removalof

the

foreignbo

dy

No

Ano

smiaand

diplop

ia

DeT

ommasiet

al2006

20m

ale

Right10c

mScrewdriver

Falling

Rightm

axilla

Scotom

ainthe

lefteyeCS

Fleakage

Leftpterional

approach

NK

Resto

redvisio

n

Park200

69female

RightN

KWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

No

Free

ofsymptom

Park200

61m

ale

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gleft

hemiparesis

NK

No

Leftmild

hemiparesis

Park200

65male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

6 BioMed Research International

Table2Clinicoradiologicalfeatureso

fpreviou

slyrepo

rted

caseso

fPSB

I

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Matsumotoet

al1998

3female

Left3c

mPlastic

chop

stick

Falling

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Matsumotoet

al1998

57m

ale

Right2

cmWoo

den

chop

stick

Stickinto

chop

stick

Opticcanal

Blindn

ess

Craniotomy

NK

Blindn

ess

Hebecker2009

32m

ale

Leftno

foreign

body

Wild

deerrsquos

antler

Accident

Leftorbit

floorla

teral

orbit

Com

aBifro

ntalintradural

neurosurgical

approach

No

Free

ofsymptom

Ishikawae

tal

2000

4male

Left6c

mWoo

den

chop

stick

Falling

Preauricular

area

topo

sterio

rfossa

Feverheadache

Subo

ccipita

lcraniectom

yBrainabscess

Ataxiaand

dysm

etria

Matsuyamae

tal2001

1male

Right2

5cm

Woo

den

chop

sticks

Falling

Superio

rorbita

lfissure

Swolleneye

Transcranial

approach

Meningitis

Free

ofsymptom

Maruyae

tal

2002

56fe

male

Left1cm

Bambo

oTu

mbling

Tempo

ral

(lateralorbit)

Drowsin

ess

Left

frontotem

poral

craniotomyand

orbitozygomatic

osteotom

y

No

Lateralgazein

theleft

eye

Hayashi

etal

2003

71fe

male

Rightn

oforeign

body

Bear

claws

Animal

assault

Fron

talsinus

Laceratedface

CSFfistulas

Fron

tal

craniectom

iesto

repairCS

Ffistulas

No

Free

ofsymptom

Nish

ioetal

2004

6female

Right2

5cm

Woo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Feverheadache

neck

stiffn

ess

Craniotomy

Brainabscess

Fre e

ofsymptom

Kim

etal2005

1male

Right2

cmMetallic

chop

stick

Falling

Fron

tal(orbital

roof)

Crying

Craniotomy

No

Free

ofsymptom

Tsao

etal2006

45m

ale

Left25c

mlowast

25c

mPlastic

chair

glide

Beassaulted

Sino

nasalcavity

anterio

rsku

llbase

Ptosis

impaire

dvisio

n

Transnasal

endo

scop

icexplorationand

removalof

the

foreignbo

dy

No

Ano

smiaand

diplop

ia

DeT

ommasiet

al2006

20m

ale

Right10c

mScrewdriver

Falling

Rightm

axilla

Scotom

ainthe

lefteyeCS

Fleakage

Leftpterional

approach

NK

Resto

redvisio

n

Park200

69female

RightN

KWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

No

Free

ofsymptom

Park200

61m

ale

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gleft

hemiparesis

NK

No

Leftmild

hemiparesis

Park200

65male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International 7Ta

ble2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Park200

62male

LeftNK

Metallic

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

NK

No

Free

ofsymptom

Nitsch

etal

2007

22m

ale

Right2

cmNail-g

unAc

cident

Rightu

pper

jaw

totempo

rallob

eIntracerebral

haem

atom

a

Simplee

xtraction

ofthen

ailw

ithou

tac

raniotom

yNK

NK

Hira

ishi2007

5female

Left35c

mPlastic

chop

stick

Falling

Fron

tal(orbital

medial)

Feverheadache

neck

stiffn

ess

Craniotomy

Meningitis

brainabscess

Hyposmia

Kawada2009

5female

Left3c

mWoo

den

chop

stick

Falling

Fron

tal(orbital

roof)

Swolleneye

Craniotomy

Brainabscess

Free

ofsymptom

Mitilian

2009

4male

Right11cm

Woo

den

chop

stick

Falling

Superio

rorbita

lfissure

Mild

confusion

vomiting

Craniotomy

Brainabscess

Mild

dysm

etria

ofthea

rm

Wieland

etal

2010

58m

ale

Left-sid

edN

KWoo

denstick

Accident

Maxillofacialto

ethm

oidroof

Feverheadache

nausea

vomiting

mentalstatus

changes

Endo

scop

icrepair

ofthes

kullbase

defect

Intracranial

infection

NK

Hettig

eetal

2010

38fe

male

LeftNK

Plastic

chop

stick

Stum

ble

Poste

riorw

allof

theo

roph

aryn

xto

jugu

lar

foramen

into

the

poste

riorfossa

Nystagm

usleft

9th10thand

12th

cranial

nerves

palsy

qu

adrantanop

ia

Leftoccipital

craniotomy

retro

sigmoid

craniectom

y

No

Left9th10th

and12th

cranial

nerves

palsy

Sweeneyetal

2011

31m

ale

RightN

KKn

ifeSuicidal

attempt

Lower

jawto

anterio

rsku

llbase

Pain

Com

binedrig

htpte rionaland

interhem

ispheric

craniotomies

No

NK

Sweeneyetal

2011

21fe

male

RightN

KKn

ifeHom

icidal

attempt

Leftorbitto

middles

kull

base

Emesis

seizure

Leftcranioor-

bitozygomatic

approach

No

NK

Yonezawa2011

28m

ale

LeftNK

Plastic

chop

stick

Falling

Fron

tal(orbital

medial)

NK

Craniotomy

No

Free

ofsymptom

Arslanetal

2012

13m

ale

Right18c

mIron

bar

Falling

Righto

rbitand

superio

rorbita

lfissure

Com

a(GCS

3)Right

frontop

arietal

craniotomy

No

Died

Shin

etal2012

38m

ale

Left14cm

Plastic

chop

stick

Falling

Superio

rorbita

lfissure

Blindn

ess

swellin

gnu

mbn

ess

arou

ndeye

Removalof

chop

stick

with

out

craniotomy

No

Blindn

ess

Katayamae

tal

2013

18m

ale

Right12c

mMetalrod

Falling

Fron

tal

(sub

zygomatic

bone)

Vomiting

NK

NK

Noneurological

deficit

Wangetal2013

35m

ale

Left18cm

Steel

Falling

Leftmaxillary

sinus

Limited

movem

ento

fneck

Craniotomy

No

Leftfacialpalsy

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

8 BioMed Research International

Table2Con

tinued

Author

andyear

Age

and

gend

erSidesize

Material

Mechanism

ofinjury

Penetrating

pathway

Symptom

Surgicalapproach

Infection

Outcome

Skochetal2

013

35fe

male

MedialN

KElectric

toothb

rush

Accident

Tempo

ral

(lateralorbit)

Blurredvisio

npain

Mod

ified

frontotem

poral

orbitozygomatic

craniotomy

No

Improved

pain

andvisio

n

Deveere

tal

2013

43m

ale

Right5

6cm

Plastic

pen

Falling

Righto

rbit

No

NK

No

Free

ofsymptom

Yamasakietal

2013

4female

Left65c

mplastic

chop

stick

Falling

Fron

tal(orbital

roof)

Swellin

gNK

Meningitis

enceph

alitis

Free

ofsymptom

Williamse

tal

2014

56m

ale

LeftNK

Speargun

Suicidal

attempt

Subm

andibu

lar

region

oral

cavity

Com

aLargec

raniotom

yCerebritis

Died

ACAA

nteriorC

erebralA

rteryCS

FCerebrospinalFluidGCS

Glasgow

Com

aScaleICA

internalcarotid

arteryN

Kno

tkno

wn

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International 9

(a)

(a)

(b)

(b)

(c)

(c)

(d)

lowast

(d)

(e)

(e)

(f)

(f)

(g)

(g)

(h)

(h)

(i)

(i)

Figure 3 Photography showed the entry point (black triangle 998787) of foreign body on face and incision for a frontotemporoorbitozygomaticapproach (a) Short piece of foreign body (simple arrow larr) in the face was exposed and removed by a maxillofacial surgeon (b) Theinfratemporal fossa was opened to expose the long piece of foreign body (c) and it (hollow arrow) was removed in a retrograde fashionDuring the removing process yellowish pus (asterisk lowast) was drained into the infratemporal fossa (d) Photography displayed short piece(simple arrowlarr) and long piece (hollow arrow) of the foreign body (e) Postoperative skull radiography suggested complete removal ofthe foreign body (f) The small bone fragment (hollow arrow head) was left in place due to its close relationship with branch of MCA (g)Three-month follow-up MRI revealed no abscess formation (h) The patient recovered uneventfully (i) MCA middle cerebral artery MRImagnetic resonance imaging

3D modeling has been frequently used in the presurgicalplanning of PSBIs in previous studies [8 11 15ndash17 19 2324 28] 3D models can be viewed in 360 degrees rotatedand studied from any perspective [29ndash31] which facilitate thediagnosis and operation to some extent [30 31] 3D Slicer is afree open source software that can be used for segmentation

and 3D modeling with high accuracy and reliability [30 32]It has been used in the management of various diseasesincluding intracranial aneurysms trigeminal neuralgia andintracerebral hematomas [29 30 33] PSBIs in our case serieswere reconstructed using 3D Slicer in which penetratingpoints as well as the surrounding neurovascular structures

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

10 BioMed Research International

were clearly visualized It contributed to the presurgical plan-ning of optimal surgical approach and avoiding unexpectedvascular injury Our findings confirmed the feasibility andreliability of 3D Slicer in the modeling of foreign objects andadjacent neurovascular structures Moreover the segmenta-tion and modeling procedure using 3D Slicer allowed higherquality of visualization better view of objects and richerinformation than workstation reconstruction (Figures 1(g)2(g)ndash2(i) and 3(g)) [30] To our knowledge this is the firststudy to visualize PSBIs with 3D Slicer granting preoperativesurgical plan for proper approaches

43 Treatment of PSBIs Owing to the low incidence ofPSBIs prospective or controlled study is difficult to conducton the limited cases Temporary management of PBSIsconstantly depends on the experience of different institutions[7 15] Despite the availability of some complicated guidelinesfor penetrating brain injury they were mostly based onthe data of scattered cases without systematic summaryfor PSBIs [3 8ndash10] Thus we discussed the treatment ofPSBIs based on related cases we treated and previouslyreported

Operation is themajor strategy for the treatment of PSBIsIndications for surgery are retained objects CSF leakagefracture displacement intracranial hemorrhage and vascularinjury [34ndash38] The purpose of surgery is to remove foreignobjects decompress brain tissue and reconstruct skull baseGenerally operation is suggested in 12 hours after PSBIs [3940] However delayed operation is not recommended untilfull physical and radiological examination are performedsince premature surgery might lead to fatal results Arteryinjury is one of the common concurrent conditions thatshould be identified before surgery the presence of whichwillbe a disaster for emergent operation [16]

In PSBIs with vascular injuries protection of injuredarteries through preoperative endovascular occlusion orintraoperative artery control would be helpful in theremoval of foreign bodies [41] In contrast in PSBIs with-out vascular injuries foreign bodies could be removeddirectly [7] For some typical cases the metal foreign bod-ies or bone fragments are adjacent to important struc-tures and difficult to extract but cause no obvious symp-toms These foreign bodies could be retained in the brain(Case 2)

Surgical approach for skull base injury should be indi-vidualized according to the penetrating trajectory location offoreign body and accompanying vascular and brain injuriesIn current study different modifications of frontotemporoor-bitozygomatic approach were adopted tomanage the anteriorand middle skull base injuries By removing the superiorand lateral bony orbit we could deal with most of foreignbodies penetrating from the orbit into frontal lobe Theremoval of zygomatic arch enables inferior displacement oftemporalis muscle allowing exploration of undersurface oftemporal lobe Generally principles for skull base surgery canalso be applied to PSBIs Proximal vascular control shouldbe first guaranteed to prevent intraoperative hemorrhageAnd direct visualization of foreign object should be achievedbefore its removal Usually it is necessary to drill away the

bone of skull base to expose the foreign bodies Thoroughdebridement along the exposed trajectory as well as carefulreconstruction of the skull base is of great significance toprevent postoperative infection and CSF leakage Howeveraggressive debridement for deep seated debris should beavoided which may be associated with increased disabilityand mortality [20]

Infection is the main complication of PSBIs with areported overall rate of 64ndash70 and mortality rate of 14ndash57[42ndash44] Organic foreign body like wood or bamboo is notonly the carrier but also the best medium for infection suchas brain abscess meningitis and cerebritis [36 45] In thisway organic foreign bodies should be totally retrieved whilesome other deep seated foreign bodies such as small metalor bone fragments could be retained since total extractionwould cause more damage In the absence of sufficient dataand definitive guidelines the type timing and durationof antibiotic use remains uncertain especially when theresult of CSF culture is negative In recent publicationsprophylactic use of broad-spectrum antibiotic was suggestedwithin 7ndash14 days after the injury [16 39] while othersindicated that antibiotic therapy should be administratedaccording to the findings of CSF culture [46] We recom-mended prophylactic use of antibiotics and proper adjust-ment according to CSF culture results especially for woodenobjects

5 Conclusions

PSBI is a rare disease with various injury mechanismsand complicated traumatic conditions Lots of difficultiesregarding the diagnosis and management of PSBIs remain tobe solved Based on our experience and review of previousstudies we suggest full physical examination and radio-logical evaluation before surgery Preoperative 3D model-ing with 3D Slicer could help visualize penetrating path-way and surrounding neurovascular structures in detailgranting free view from any angle and selection of opti-mal approach However caution is needed in interpretingour findings because of the limited cases Further largescale prospective studies are required to identify the effectof preoperative 3D reconstruction on the prognosis ofPSBIs as well as the guideline for the management ofPSBIs

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this article

Authorsrsquo Contributions

Danfeng Zhang performed data collection data analysis andwriting of the article Jigang Chen collaborated in literaturesearch and study design Kaiwei Han collaborated in figuregeneration and study design Mingkun Yu collaborated instudy design data analysis and editing of the article LijunHou collaborated in literature research figure generation andediting of the article

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International 11

References

[1] T A Gennarelli H R Champion W J Sacco W S Copesand W M Alves ldquoMortality of patients with head injuryand extracranial injury treated in trauma centersrdquo Journal ofTrauma vol 29 no 9 pp 1193ndash1201 1989

[2] Y Hayashi H Fujisawa Y Tohma J Yamashita and H InabaldquoPenetrating head injury caused by bear claws case reportrdquoJournal of Trauma - Injury Infection and Critical Care vol 55no 6 pp 1178ndash1180 2003

[3] J Maruya et al ldquoBrain abscess following transorbital penetrat-ing injury due to bamboo fragmentsmdashcase reportrdquo Neurol MedChir (Tokyo) vol 42 no 3 pp 143ndash146 2002

[4] M S Walid J C Yelverton and J S Robinson Jr ldquoPenetratingorbital trauma with internal carotid injuryrdquo Southern MedicalJournal vol 102 no 1 pp 116-117 2009

[5] A Agrawal A Pratap C S Agrawal A Kumar and SRupakheti ldquoTransorbital orbitocranial penetrating injury dueto bicycle brake handle in a childrdquo Pediatric Neurosurgery vol43 no 6 pp 498ndash500 2007

[6] F H Chowdhury M R Haque Z Hossain N K ChowdhurySMAlam andMH Sarker ldquoNonmissile Penetrating Injury tothe Head Experience with 17 Casesrdquo World Neurosurgery vol94 pp 529ndash543 2016

[7] M Schreckinger DOrringer B GThompson F LaMarca andO Sagher ldquoTransorbital penetrating injury Case series reviewof the literature and proposed management algorithm Reportof 4 casesrdquo Journal ofNeurosurgery vol 114 no 1 pp 53ndash61 2011

[8] M Deveer F Imamoglu C Imamoglu and S Okten ldquoAnincidental case of asymptomatic intracranial foreign body onCTrdquo BMJ case reports vol 2013 2013

[9] S Hettige K Kok P Epaliyanage and N W M ThomasldquoChopstick injury penetrating the skull base A case reportrdquoSkull Base vol 20 no 3 pp 219ndash222 2010

[10] A De Tommasi P Cascardi C De Tommasi S Luzzi and PCiappetta ldquoEmergency surgery in a severe penetrating skullbase injury by a screwdriver Case report and literature reviewrdquoWorld Journal of Emergency Surgery vol 1 no 1 article 36 2006

[11] J Skoch T L Ansay and G M Lemole ldquoInjury to the temporallobe via medial transorbital entry of a toothbrushrdquo Journal ofNeurological Surgery Reports vol 74 no 1 pp 23ndash28 2013

[12] E Ishikawa K Meguro K Yanaka et al ldquoIntracerebellar pene-trating injury and abscess due to a wooden foreign bodymdashcasereportrdquo Neurologia Medico-Chirurgica vol 40 no 9 pp 458ndash462 2000

[13] S Matsumoto K Hasuo A Mizushima et al ldquoIntracranialpenetrating injuries via the optic canalrdquo AJNR AmericanJournal of Neuroradiology vol 19 no 6 pp 1163ndash1165 1998

[14] A MWielandW T Curry M L Durand and E H HolbrookldquoManagement of a long-standing organic intracranial foreignbodyrdquo Skull Base vol 20 no 6 pp 487ndash490 2010

[15] J M Sweeney J J Lebovitz J L Eller J R Coppens RD Bucholz and S I Abdulrauf ldquoManagement of nonmissilepenetrating brain injuries a description of three cases andreview of the literaturerdquo Skull Base vol 1 no 1 pp 39ndash46 2011

[16] J R Williams D M Aghion C E Doberstein R G CosgroveandW F Asaad ldquoPenetrating brain injury after suicide attemptwith speargun case study and review of literaturerdquo Frontiers inNeurology vol 5 article 113 2014

[17] A Nitsch R Verheggen and H-A Merten ldquoPenetratingpneumatic nail-gun injury to skull baserdquo British Journal of Oraland Maxillofacial Surgery vol 45 no 8 p 692 2007

[18] Y Wang L Pan and H Xu ldquoThe surgical treatment of rein-forced steel bar injury penetrating the skull base and maxilla-mandibular areardquo Journal of Craniofacial Surgery vol 25 no 6pp e521ndashe523 2014

[19] K Katayama N Shimamura Y Ogasawara M Naraoka andH Ohkuma ldquoTranslucent three-dimensional CT is useful inconsidering the treatment strategy for the penetrating skullbase injury with a metal rod Case reportrdquo Neurologia Medico-Chirurgica vol 53 no 9 pp 613ndash615 2013

[20] M Arslan M Eseoglu B O Gudu and I Demir ldquoTransorbitalorbitocranial penetrating injury caused by a metal barrdquo Journalof Neurosciences in Rural Practice vol 3 no 2 pp 178ndash181 2012

[21] T Matsuyama et al ldquoTransorbital penetrating injury by achopstickmdashcase reportrdquo Neurol Med Chir (Tokyo) vol 41 no7 pp 345ndash348 2001

[22] Y-H Tsao C-H Kao H-W Wang S-C Chin and K SMoe ldquoTransorbital penetrating injury of paranasal sinusesand anterior skull base by a plastic chair glide Managementoptions of a foreign body in multiple anatomic compartmentsrdquoOtolaryngology - Head and Neck Surgery vol 134 no 1 pp 177ndash179 2006

[23] F Yamasaki H Ohge R Tsumura et al ldquoTransorbital penetrat-ing intracranial injury by a chopstick a case report and reviewof the literaturerdquo No Shinkei Geka vol 41 no 11 pp 1001ndash10092013

[24] S Kim J Y Lee J S Song and J Oh ldquoTransorbital-intracranialinjury by a chopstick Three-dimensional computed tomogra-phyrdquoActaOphthalmologica Scandinavica vol 83 no 5 pp 609-610 2005

[25] H Imokawa T Tazawa N Sugiura D Oyake and K YosinoldquoPenetrating neck injuries involvingwooden foreign bodies therole of MRI and the misinterpretation of CT imagesrdquo AurisNasus Larynx vol 30 pp S145ndashS147 2003

[26] A Carothers ldquoOrbitofacial Wounds and Cerebral ArteryInjuries Caused by Umbrella Tipsrdquo JAMA The Journal of theAmerican Medical Association vol 239 no 12 pp 1151-11521978

[27] R Eidsness D J Coupal M E B Kelly and S HattinghldquoTraumatic orbital injuryrdquo Journal of TraumamdashInjury Infectionand Critical Care vol 62 no 5 pp 1286-1287 2007

[28] T-H Shin J-H Kim K-WKwak and S-H Kim ldquoTransorbitalpenetrating intracranial injury by a chopstickrdquo Journal ofKorean Neurosurgical Society vol 52 no 4 pp 414ndash416 2012

[29] X Xu X Chen J Zhang et al ldquoComparison of the tada formulawith software slicer Precise and low-cost method for volumeassessment of intracerebral hematomardquo Stroke vol 45 no 11pp 3433ndash3435 2014

[30] K-W Han D-F Zhang J-G Chen and L-J Hou ldquoPresurgicalvisualization of the neurovascular relationship in trigeminalneuralgia with 3D modeling using free Slicer softwarerdquo ActaNeurochirurgica vol 158 no 11 pp 2195ndash2201 2016

[31] B You Y Cheng J Zhang et al ldquoApplication of contrast-enhanced T1-weighted MRI-based 3D reconstruction of thedural tail sign in meningioma resectionrdquo Journal of Neuro-surgery vol 125 no 1 pp 46ndash52 2016

[32] A Fedorov R Beichel J Kalpathy-Cramer et al ldquo3D sliceras an image computing platform for the quantitative imagingnetworkrdquoMagnetic Resonance Imaging vol 30 no 9 pp 1323ndash1341 2012

[33] A Can A Mouminah A L Ho and R Du ldquoEffect of vascularanatomy on the formation of basilar tip aneurysmsrdquo Neuro-surgery vol 76 no 1 pp 62ndash66 2015

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

12 BioMed Research International

[34] J Fezza and R Wesley ldquoThe Importance of CT Scans inPlanning the Removal of Orbital-Frontal Lobe Foreign BodiesrdquoOphthalmic Plastic amp Reconstructive Surgery vol 15 no 5 pp366ndash368 1999

[35] K A Greene C A Dickman K A Smith E J Kinder and JMZabramski ldquoSelf-inflicted orbital and intracranial injury witha retained foreign body associated with psychotic depressionCase report and reviewrdquo Surgical Neurology vol 40 no 6 pp499ndash503 1993

[36] S A Sadiq and G Thurairajan ldquoA case of transorbital intracra-nial damage underlying a seemingly innocuous injuryrdquo Injuryvol 26 no 4 pp 279-280 1995

[37] K A Szabo S H Cheshier M Y S Kalani J W Kim andR Guzman ldquoSupraorbital approach for repair of open anteriorskull base fracture case reportrdquo Journal of Neurosurgery Pedi-atrics vol 2 no 6 pp 420ndash423 2008

[38] T Yamashita T Mikami T Baba et al ldquoTransorbital intracra-nial penetrating injury from impaling on an earpickrdquo Journal ofNeuro-Ophthalmology vol 27 no 1 pp 48-49 2007

[39] S F Kazim M S Shamim M Z Tahir S A Enam and SWaheed ldquoManagement of penetrating brain injuryrdquo Journal ofEmergencies Trauma and Shock vol 4 no 3 pp 395ndash402 2011

[40] T S Helling W Kendall McNabney C Keith Whittaker CC Schultz and M Watkins ldquoThe role of early surgical inter-vention in civilian gunshot wounds to the headrdquo Journal ofTraumamdashInjury Infection and Critical Care vol 32 no 3 pp398ndash400 1992

[41] E J Cunningham B Albani T J Masaryk et al ldquoTemporaryballoon occlusion of the cavernous carotid artery for removal ofan orbital and intracranial foreign body technical case reportrdquoNeurosurgery vol 55 no 5 p 1225 2004

[42] Y Nishio N Hayashi H Hamada Y Hirashima and S EndoldquoA case of delayed brain abscess due to a retained intracranialwooden foreign body a case report and review of the last 20yearsrdquoActa Neurochir (Wien) vol 146 no 8 pp 847ndash850 2004

[43] C F Miller J S Brodkey and B J Colombi ldquoThe danger ofintracranial woodrdquo Surg Neurol vol 7 no 2 pp 95ndash103 1977

[44] Q Chunhua andW Qun ldquoA late-onset seizure due to a retainedintracranial foreign body-pencil lead a case report and reviewrdquoJournal of Craniofacial Surgery vol 25 no 2 pp e109ndashe1102014

[45] I F Dunn D H Kim P A Rubin R Blinder J Gates and A JGolby ldquoOrbitocranial wooden foreign body a pre- intra- andpostoperative chronicle case reportrdquo Neurosurgery vol 65 no2 pp E383ndashE384 2009

[46] R Gutierrez-Gonzalez G R Boto M Rivero-Garvıa A Perez-Zamarron andGGomez ldquoPenetrating brain injury by drill bitrdquoClinical Neurology andNeurosurgery vol 110 no 2 pp 207ndash2102008

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Submit your manuscripts athttpswwwhindawicom

Neurology Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Alzheimerrsquos DiseaseHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

International Journal of

ScientificaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

BioMed Research International

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentSchizophrenia

The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neural Plasticity

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Parkinsonrsquos Disease

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Research and TreatmentAutism

Sleep DisordersHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neuroscience Journal

Epilepsy Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Psychiatry Journal

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Computational and Mathematical Methods in Medicine

Depression Research and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Brain ScienceInternational Journal of

StrokeResearch and TreatmentHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Neurodegenerative Diseases

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

Cardiovascular Psychiatry and NeurologyHindawi Publishing Corporationhttpwwwhindawicom Volume 2014