2026 Volume 13 Pages 333-339
Transorbital penetrating brain injuries are rare and may cause fatal damage depending on their trajectory. We report a case of a man in his 60s with a transorbital injury caused by wooden chopsticks extending to the prepontine region. Imaging demonstrated that the foreign bodies passed through the superior orbital fissure and cavernous sinus, reaching the prepontine region; however, no major vascular injury was identified. Emergency surgery using a frontotemporal craniotomy combined with anterior petrosectomy (Kawase approach) enabled wide exposure of the trajectory at the upper clivus and prepontine space, allowing for the safe removal of fragmented foreign bodies and adhering paper under direct visualization. Postoperatively, no carotid-cavernous fistula was detected; however, brainstem contusion resulted in severe neurological deficits, and the patient died from aspiration-related complications. This approach provides effective exposure for managing transorbital penetrating injuries extending to the upper clivus or prepontine space.
Transorbital penetrating brain injuries (TPBIs) represent a rare subset of craniofacial trauma that can cause devastating neurological damage when critical neurovascular structures are involved. The superior orbital fissure (SOF) is a recognized pathway through which foreign objects may enter the cranial cavity, frequently traversing the cavernous sinus (CS) and, in exceptional cases, reaching the posterior cranial fossa or brainstem. Because of the complex anatomy of the skull base and the proximity of vital structures, surgical management of such injuries remains challenging. We report a rare case of a TPBI into the upper clivus and prepontine cistern, highlighting a surgical strategy using a frontotemporal approach combined with anterior petrosectomy (Kawase approach).
A man in his 60s with a history of schizophrenia had been hospitalized long-term at another institution. He was assaulted by a roommate and sustained bilateral orbital injuries. Upon the patient's admission to our hospital, 2 wooden chopsticks were found to be deeply embedded in the left orbit. The patient developed respiratory distress due to blood aspiration and required immediate endotracheal intubation.
Preoperative imagingComputed tomography (CT) revealed that both chopsticks were fractured within the orbit, with their distal fragments extending into the anterior surface of the pons. A localized subarachnoid hemorrhage was observed in the prepontine cistern (Figure 1A).
Preoperative imaging findings. (A) Axial CT scan demonstrating wooden foreign bodies penetrating the left orbit with localized subarachnoid hemorrhage in the prepontine cistern. (B) The original 3D-CTA in the arterial phase demonstrates the trajectory of the chopsticks (asterisk). The foreign bodies passed laterally to the left ICA within the CS, with the tips reaching the ventral aspect of the brainstem. Notably, the absence of contrast medium extravasation within the CS suggested that the ICA remained intact, providing a critical radiological basis for our preoperative surgical planning. (C) Three-dimensional CT showing the trajectory of the chopsticks through the superior orbital fissure toward the posterior cranial fossa. (D) 3D-CTA demonstrating the relationship between the foreign bodies and surrounding vessels. The chopsticks passed lateral to the left internal carotid artery and reached the ventral brainstem near the left superior cerebellar artery.
3D-CTA: three-dimensional computed tomography angiography; CS: cavernous sinus; CT: computed tomography; CTA: computed tomography angiography; ICA: internal carotid artery
The original 3-dimensional CT (3D-CT) angiography in the arterial phase showed that the chopsticks passed lateral to the internal carotid artery (ICA), with the tips terminating near the left superior cerebellar artery (SCA). The absence of contrast medium extravasation suggested that both the ICA and SCA remained intact. Based on these findings, we determined that the risk of direct major vascular penetration was low; therefore, we opted not to pre-emptively secure the cervical ICA before the extraction. (Figure 1B and D). 3D-CT fusion images combining cranial bone and low-density foreign bodies demonstrated that the objects had passed through the SOF, traversed the lateral aspect of the CS, partially fractured the petrous bone, and reached the prepontine region (Figure 1C).
Surgical techniqueEmergency surgery was performed with the patient in the supine position. The head was elevated 15°, rotated 45° to the right, and secured in a 3-pin head holder. The surgical field included both the frontotemporal region and the ipsilateral orbit. This setup allowed direct visualization of the entry site and ensured that the extraction could be monitored from both intracranial and extracranial perspectives.
A large frontotemporal craniotomy was performed, followed by division of the middle meningeal artery. We first identified the arcuate eminence to orient the surgical anatomy, using it as a landmark to define the middle fossa rhomboid. The dura mater of the CS was then meticulously peeled from the lateral wall. During this maneuver, bleeding from the foreign body's entry site lateral to the SOF was controlled via electrocoagulation, allowing clear identification of the chopsticks (Figure 2A). Finally, the mandibular nerve and foramen ovale were definitively confirmed as anatomical anchors (Figure 2B). An anterior petrosectomy was then performed by drilling the petrous apex within the middle fossa rhomboid, which widely exposed the posterior fossa dura (Figure 2C). The tentorium and posterior fossa dura were incised for intradural inspection. This step confirmed the presence of thick subarachnoid hemorrhage, suggesting localized vascular or parenchymal injury, and allowed identification of the trochlear (CN IV) and trigeminal (CN V) nerves (Figure 2D). After evacuating the prepontine hematoma, the abducens nerve (CN VI) was visualized. The distal ends of the chopsticks were confirmed to be extending toward the left SCA, coursing medial to CN V (Figure 2E).
Intraoperative findings. (A) Extradural dissection of the middle cranial fossa floor. Focal destruction of the SOF by the foreign body resulted in the prolapse of orbital fat (arrowhead). The chopsticks (asterisk) are identified near the lateral margin of the SOF. (B) The chopsticks (asterisk) can be identified entering through the lateral margin of the SOF. The mandibular nerve (V3) is visualized emerging from the foramen ovale (FO). The dura propria of the cavernous sinus (double asterisks) is being peeled. The middle fossa rhomboid (area within the dashed circle), defined by the anatomical relationship between V3 and other landmarks, is identified for the subsequent anterior petrosectomy. (C) Exposure of the posterior fossa dura via the anterior petrosectomy (Kawase approach). The petrous apex has been resected, and the posterior fossa dura is widely visualized. (D) Intradural inspection after incision of the tentorium and the posterior fossa dura. Subarachnoid hemorrhage in the prepontine cistern is identified. Both the trochlear nerve (CN IV) and the trigeminal nerve (CN V) are clearly visualized. (E) Exposure after evacuation of the hematoma expanding into the prepontine cistern. The abducens nerve (CN VI) is identified. The chopsticks coursed medial to the CN V and extended to the left SCA, where the distal ends are visualized (double asterisks). (F) Final image after the removal of the chopsticks from the orbital side. A contusion on the surface of the left pons is visible lateral to the basilar trunk (asterisk). Bleeding on the ventral surface of the left pons (double asterisk) caused by the tip of the chopsticks is controlled under direct visualization.
The corresponding surgical procedure is shown in the Supplementary Video.
CN IV: trochlear nerve; CN V: trigeminal nerve; CN VI: abducens nerve; FO: foramen ovale; SOF: superior orbital fissure; SCA: superior cerebellar artery; V3: mandibular nerve
Initially, an attempt at transorbital removal was made; however, it was unsuccessful due to marked resistance at the lateral margin of the SOF. Therefore, the lateral bony margin of the SOF was drilled to release the impaction. Under direct visualization from both the intracranial and extracranial perspectives, the chopsticks were successfully mobilized and removed from the orbital side. Upon extraction of the chopsticks, venous bleeding first occurred from the posterior part of the CS where the foreign body had penetrated. This deep-seated hemorrhage was immediately controlled using gelatin sponge and fibrin glue. Subsequently, as the extraction proceeded, bleeding was encountered at the anterior entry site near the SOF, which was also successfully managed under direct visualization (Figure 2F). The extracted chopsticks were fractured mid-shaft but remained in structural continuity (Figure 3D). The trajectory was thoroughly irrigated, and dural repair with fat grafting was performed. Finally, the conjunctiva was sutured, and intravitreal antibiotics were administered.
Postoperative neuroimaging. (A) Postoperative 3-dimensional computed tomography of the skull base, demonstrating the extent of bone resection via the anterior petrosectomy (area within the dashed circle). (B) Lateral view of a digital subtraction angiogram of the left common carotid artery, showing no evidence of a carotid-cavernous fistula or vascular injury. (C) Sagittal T2-weighted magnetic resonance imaging scans, demonstrating a significant brainstem contusion resulting from the initial penetrating injury. (D) Extracted wooden chopsticks with residual wrapping paper, demonstrating multiple fragmented pieces.
Postoperative 3D-CT confirmed adequate bone removal following the anterior petrosectomy, which provided essential exposure to the upper clivus and prepontine space for the safe management of the foreign bodies (Figure 3A). The surgical procedure is demonstrated in the Supplementary Video.
Postoperative coursePostoperative digital subtraction angiography showed no evidence of a carotid-cavernous fistula, although the left CS was occluded (Figure 3B). Magnetic resonance imaging demonstrated brainstem contusion (Figure 3C). Broad-spectrum antibiotics were administered for 4 weeks, and no infectious complications occurred. Postoperatively, however, the patient's dysphagia, impaired consciousness, and left visual loss remained permanent. He was transferred to another hospital on postoperative day 27. Seventy days later, he died from aspiration-related airway obstruction.
The clinical management of TPBIs is a formidable challenge that demands an uncompromising understanding of skull base anatomy. Although many TPBIs are confined to the anterior or middle cranial fossa and may be amenable to transorbital extraction, our case represents an extreme surgical frontier: a trajectory traversing the SOF and CS to reach the prepontine cistern. The discovery of fragmented wooden chopsticks and adhering packaging paper at such a deep, neurovascularly dense location underscores the limitations of traditional approaches. In this high-stakes scenario, a "blind" transorbital pull is not only insufficient but also potentially catastrophic.
In some previously reported cases, transorbital removal without craniotomy has been successfully performed,1,2) sometimes guided by real-time angiography.3-6) In contrast, the present case was characterized by 2 wooden chopsticks that were fractured along their course, creating a relatively large and irregular wound tract. In addition, the foreign bodies were firmly anchored at the level of the SOF, as evidenced by the marked resistance encountered during attempted removal. These factors made transorbital extraction alone extremely difficult, if not impossible, and significantly increased the risk of catastrophic hemorrhage with blind removal. Therefore, a transcranial approach was considered essential to release the impaction, allow direct visualization of the entire trajectory, and achieve secure hemostatic control.
Wooden foreign bodies also pose a high risk of infection and may be difficult to detect on imaging, further emphasizing the need for careful surgical planning and thorough removal. The presence of the packaging paper added a significant layer of surgical risk. Unlike smooth metallic objects, wooden chopsticks have a high coefficient of friction and a porous surface, which in this case caused the paper wrapper to be dragged deep into the intracranial space. Organic materials—both wood and paper—serve as a nidus for polymicrobial infection or fungal brain abscesses. This finding further justifies the use of a wide, direct-access approach like the anterior petrosectomy; a simple blind pull of the chopsticks would almost certainly have left the paper fragments behind, leading to inevitable infectious complications.
A combined frontotemporal craniotomy with anterior petrosectomy provided sufficient exposure from the SOF to the prepontine cistern, enabling safe removal of all fragments under direct visualization. This approach was particularly useful for confirming the distal ends of the foreign bodies and managing potential bleeding from the CS. Anterior petrosectomy has been widely utilized to access the petroclival region and ventral brainstem, providing a direct surgical corridor to deep-seated lesions.7) Various surgical approaches for transorbital penetrating injuries have been reported, including frontotemporal craniotomy,8-11) fronto-orbitozygomatic craniotomy,12) subtemporal,13,14) and lateral suboccipital15) approaches. However, in the present case, it was necessary to include the orbital side within the operative field while simultaneously securing adequate exposure from the CS to the petroclival region. Therefore, the addition of anterior petrosectomy to a frontotemporal approach was considered a rational and effective strategy.
It is crucial to recognize the limitations of alternative surgical routes in such critical trauma. Although a standard subtemporal approach or a lateral suboccipital approach in the lateral decubitus position might offer access to certain deep areas, these approaches lack the versatility and extensibility required for emergency management. Our choice of the frontotemporal approach with anterior petrosectomy in the supine lateral position was therefore a deliberate strategic decision to ensure a "ready-to-extend" capability, balancing direct visualization with a robust safety net. Should an uncontrollable hemorrhage occur during extraction, this setup ensures immediate access to the neck for cervical ICA control without the need for repositioning. In the lateral decubitus position, the neck is often physically obstructed or outside the sterile field, making rapid proximal control nearly impossible. Our choice was therefore strategic, prioritizing a "fail-safe" for potential vascular crises.
A pivotal aspect of our strategy was the inclusion of the ipsilateral orbit within the primary surgical field. While standard skull base procedures typically exclude the orbital region, TPBI demands a comprehensive view of the entire trajectory. By maintaining a single, continuous operative field from the orbit to the prepontine cistern, we transformed a hazardous "blind pull" into a visualized, coordinated extraction. This "one-field" management allowed us to monitor the foreign body's external behavior and orbital tension in real time. Furthermore, it ensured that if the chopsticks remained impacted or fractured during extraction, we could immediately transition to an orbito-zygomatic osteotomy to gain direct lateral access to the SOF. Additionally, peeling the dura mater of the CS was particularly instrumental in this case, as it widened the operative field to sufficiently encompass the trajectory of the foreign bodies. This expanded visibility ensured that the distal ends and the surrounding neurovascular structures were safely managed under direct visualization. The addition of an anterior petrosectomy, combined with the peeling of the CS dura mater, transformed a restricted corridor into a continuous, wide operative field. This thorough exposure allowed us to verify the relationship between the chopsticks and critical neurovascular structures—such as the SCA and CN IV, V, and VI—before and during the removal process.
Troubleshooting: hemostatic strategies for unexpected hemorrhageA critical component of our "ready-to-extend" strategy is preemptive preparation for catastrophic hemorrhage during foreign body extraction. Should profuse venous bleeding occur from the CS and prove refractory to standard packing, we advocate opening the medial wall of Meckel's cave. This maneuver is a vital rescue technique that provides an upward surgical view, allowing for direct visualization and precise hemostasis within the venous channels rather than relying on blind compression. In the event of arterial injury, such as injury to the ICA or its perforators within the CS, the supine lateral position provides a decisive advantage by allowing immediate, unobstructed access to the neck for proximal ICA control without the need for repositioning. Simultaneously, the pre-extraction exposure of the Sylvian fissure ensures distal ICA control, completing a multi-layered safety net. In the event of uncontrolled hemorrhage from the intracavernous ICA, the anatomical flexibility of our approach allows for an immediate proximal control within the skull base. By removing the bone beneath the great superficial petrosal nerve—specifically within Glasscock's triangle—the horizontal segment of the petrous ICA can be exposed. This provides an additional layer of safety beyond cervical ICA control, allowing for definitive management of vascular crises without the need for additional craniotomy or repositioning. By integrating these skull base techniques with strategic patient positioning, we transformed a high-risk extraction into a controlled procedure in which every potential vascular crisis had a dedicated, direct-access recovery plan. In addition, the use of a hybrid operating room should be considered the gold standard for TPBIs with high vascular risk. Pre-positioning a guiding catheter for immediate intraoperative angiography or balloon occlusion provides an ultimate layer of security.
ConclusionTPBIs extending to the petroclival region pose formidable surgical challenges. Our experience demonstrates that a combined frontotemporal craniotomy and anterior petrosectomy provides an optimal surgical corridor for the wide exposure required to safely remove fragmented and firmly impacted foreign bodies. Unlike more restrictive routes, this approach—performed in the supine lateral position—offers a highly versatile and extensible strategy. In particular, incorporating the entry site within the primary surgical field is a critical tactical advantage; it eliminates "blind zones" and allows coordinated extraction under direct visualization of the entire trajectory. Its inherent scalability allows surgeons to rapidly adapt the operative field to the evolving requirements of complex trauma surgery, such as ensuring proximal vascular control or extending the exposure to the orbit. We believe this robust surgical framework serves as a reliable paradigm for managing life-threatening skull base injuries in emergency settings.
All authors have no conflict of interest.
Informed Consent: Written informed consent for the publication of this technical note and any accompanying images was obtained from the patient's court-appointed legal guardian (a judicial scrivener), as the patient had no known next of kin.
Ethical Approval: Institutional Review Board (IRB) approval was not required for this study at Teine Keijinkai Hospital, as it is a retrospective report of a single clinical case and does not involve any experimental interventions or deviation from standard care. The study was conducted in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments.
