Removal of Intracranial K-Wire through Combined Endoscopic and Pterional Approach

Introduction: Cleft palate is a congenital abnormality that has been treated by numerous strategies. One such method involves a Kirschner wire, also referred to as K-wire, placed through the maxilla and vomer to fixate the cleft palate. The K-wire is typically removed after several months because they can migrate. Here we describe the removal of an intracranially migrated K-wire from the anterior skull base through a combined approach.

Methods: A 17-year-old female with history of a cleft palate and maxillary fixation with a K-wire sometime before turning 1-year-old presented to our clinic. She was being evaluated by oral maxillofacial surgery for further cleft palate repair and computed tomography of the head demonstrated that the K-wire migrated intracranially. She had no neurological findings, but requested that the K-wire be removed. Computed tomography angiography was obtained that suggested the K-wire may be adherent or eroding through the left internal carotid artery. Further migration could prove deleterious and the patient was counseled on the risks and benefits and wished to proceed with surgery. The patient was planned for a simultaneous pterional craniotomy and transnasal endoscopic approach in our hybrid operating room equipped with endovascular capabilities.

Results: Intraoperative findings revealed that the K-wire had migrated through the patient's optic nerve. It pierced the optic nerve without any large vessel involvement. The K-wire was removed transnasally without any significant disruption of surrounding structures. The patient tolerated the procedure well and was discharged home after being monitored for any possible CSF leak. No leak was observed. Patient returned for a follow up visit after 2 weeks and 3 months without any complications.

Conclusion: Removal of foreign objects in the skull base can prove to be challenging and sometimes require a combined approach. This case of a migrating K-wire that was found to pierce the optic nerve demonstrates how a combined approach can provide an optimal and safe outcome. In hindsight, a preoperative Goldmann perimetry or other formal visual field test would have allowed an objective measure of visual field deficits. Fortunately for the patient, she remained at her neurological baseline postoperatively without any reported deficits.

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