A case of transorbital penetrating injury with deviated intracranial internal carotid artery by the wooden stick–shaped foreign body surgically removed in the hybrid operating room

Abstract

A penetrating head injury can result in bleeding from damaged blood vessels following removal of the foreign body; therefore, it is desirable to remove the foreign body once hemostasis can be achieved. We report a case of a transorbital penetrating injury with a deviated intracranial internal carotid artery (ICA) by a wooden stick–shaped foreign body, which was surgically removed in a hybrid operating room. A 60–year–old female accidentally fell and presented to the hospital the following day with left eyelid swelling. Her vital signs were stable, and there were no abnormal neurological findings. A head computed tomography (CT) scan showed a low–absorption foreign body penetrating the ethmoid sinus from the left medial orbit extending to the right side of the sella turcica. Cerebral angio­graphy revealed no apparent vascular injury of the right ICA. However, the cavernous and paraclinoid segments of the ICA were compressed and shifted by the foreign body. Considering the risk of vascular injury during removal of the foreign body, a balloon occlusion test was per­formed, which confirmed ischemic tolerance of parent vessel occlusion in case of massive arterial bleeding. Surgery was performed in a hybrid operating room. An otorhinolaryngologist endoscopically ob­served the nasal cavity, and a plastic surgeon removed the foreign body. We successfully confirmed corrected deviation of the ICA and total removal of the foreign body using a hybrid angio–CT system. Head magnetic resonance imaging (MRI) on day 6 showed no traumatic changes in the brain parenchyma. Cerebral angiography on day 8 showed no signs of damage to the ICA, and the patient was discharged home on day 9. Although perforating trauma to the head is relatively rare, it can be fatal. Using a hybrid operating room for foreign body extirpation in the case of perforating head trauma with possible intracranial vascular injury would enhance surgical safety by allowing rapid evaluation and the selection of appropriate treatment for vascular injury.