The Role of Intraoperative Cerebral Angiography in Transorbital Intracranial Penetrating Trauma: A Case Report and Literature Review

• Published in: World neurosurgery 2017-01, Vol.97, p.761.e5-761.e10
• Main Authors: Riley, Jonathan P., M.D, Boucher, Andrew B., M.D, Kim, Denise S., M.D, Barrow, Daniel L., M.D, Reynolds, Matthew R., M.D., Ph.D
• Format: Article
• Language: English
• Subjects: Cerebral angiography; Cerebral Angiography - methods; Cerebral Revascularization - methods; Craniocerebral Trauma - diagnostic imaging; Craniocerebral Trauma - surgery; Craniotomy - methods; Foreign Bodies - diagnostic imaging; Foreign Bodies - surgery; Foreign body; Head Injuries, Penetrating - diagnostic imaging; Head Injuries, Penetrating - surgery; Humans; Indocyanine Green - administration & dosage; Injury; Intracranial; Intraoperative Neurophysiological Monitoring - methods; Male; Neurosurgery; Penetrating; Transorbital; Trauma; Young Adult
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2016.09.083

Abstract Background Transorbital intracranial penetrating trauma (TIPT) 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 prior and/or subsequent to removal of the object, but no standard of care currently exists. Case Description A 19-year-old male was involved in a construction site accident whereby a framing nail penetrated the left globe, traversed the lateral bony orbit, and terminated in the mid-temporal lobe. No hematoma or injury to the middle cerebral arteries (MCA) was apparent on non-contrast head computed tomography (CT) or CT angiography, respectively. The foreign body was removed in the operating room under direct visualization following a frontotemporal craniotomy without incident. No significant venous or arterial bleeding was encountered. All visualized MCA branches appeared intact. Indocyanine green (ICG) videoangiography performed immediately following object removal showed adequate filling of the MCA branches. Given these uneventful clinical and radiographic findings, IOA was not performed. Post-operative head CT and CT angiogram showed no obvious neurovascular injury. On post-operative day two, he was noted to have an expressive aphasia. Cerebral angiography demonstrated absent antegrade filling of the angular artery with some retrograde perfusion. Magnetic resonance imaging (MRI) confirmed an ischemic infarction in mid-temporal lobe. His expressive aphasia improved to near-baseline during his hospitalization and he made an excellent clinical recovery. Conclusions In TIPT with a retained intracranial object, the authors 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 which was not performed 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.