The Role of Intraoperative Cerebral Angiography in Transorbital Intracranial Penetrating Trauma: A Case Report and Literature Review.
BACKGROUND
Transorbital intracranial penetrating trauma with a retained intracranial foreign body is a rare event lacking a widely accepted diagnostic and therapeutic algorithm. Intraoperative catheter angiography (IOA) has been advocated by some authorities to rule out cerebrovascular injury before and/or after removal of the object, but no standard of care currently exists.


METHODS
A 19-year-old man was involved in a construction site accident whereby a framing nail penetrated the left globe, traversed the lateral bony orbit, and terminated in the midtemporal lobe. No hematoma or injury to the middle cerebral arteries (MCAs) was apparent on noncontrast head computed tomography (CT) or CT angiography, respectively. The foreign body was removed in the operating room under direct visualization after a frontotemporal craniotomy without incident. No significant venous or arterial bleeding was encountered. All visualized MCA branches appeared intact. Indocyanine green videoangiography performed immediately after object removal showed adequate filling of the MCA branches. Given these uneventful clinical and radiographic findings, IOA was not performed. Postoperative head CT and CT angiography showed no obvious neurovascular injury. On postoperative day 2, the patient was noted to have an expressive aphasia. Cerebral angiography showed absent antegrade filling of the angular artery with some retrograde perfusion. Magnetic resonance imaging confirmed an ischemic infarction in the midtemporal lobe. The patient's expressive aphasia improved to near baseline during his hospitalization and he made an excellent clinical recovery.


CONCLUSIONS
In transorbital intracranial penetrating trauma with a retained intracranial object, we advocate microsurgical removal of the object under direct visualization followed immediately by IOA. IOA should be strongly considered even in the setting of minimal intraoperative bleeding and normal findings on videoangiography (a course of action that was not followed in the present case). Given that CT angiography and intraoperative videoangiography may miss a potentially treatable traumatic arterial injury, IOA can help determine whether cerebral revascularization may be necessary.
Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
Jonathan P
JP
Riley
Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Andrew B
AB
Boucher
Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.
Denise S
DS
Kim
Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Daniel L
DL
Barrow
Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA. Electronic address: Matthew.Reynolds@jefferson.edu.
Matthew R
MR
Reynolds
D002533:Cerebral Angiography / Q000379:methods*; D002548:Cerebral Revascularization / Q000379:methods; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging / Q000601:surgery; D003399:Craniotomy / Q000379:methods; D005547:Foreign Bodies / Q000000981:diagnostic imaging* / Q000601:surgery; D020197:Head Injuries, Penetrating / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D007208:Indocyanine Green / Q000008:administration & dosage; D064795:Intraoperative Neurophysiological Monitoring / Q000379:methods*; D008297:Male; D055815:Young Adult
D007208:Indocyanine Green
Cerebral angiography; Foreign body; Injury; Intracranial; Penetrating; Transorbital; Trauma