Removal of a Penetrating Tree Branch in the Orbitofrontal Region: A Unique Application of an Orbitofrontal Craniotomy through a Supraciliary Brow Approach

Orbitocranial penetrating injury (OPI) including with wooden objects is a well-described mechanism of brain injury. This report describes unique application of an orbitofrontal craniotomy through a supraciliary brow approach to remove a wooden stick penetrating through the orbit into the frontal lobe. A 51-year-old male presented after a traumatic event in which tree branch penetrated his face beneath the left eye, through the left orbit and into his frontal lobes. He did not experience loss of consciousness and was neurologically intact with preserved vision and ocular motility. Computed tomography (CT) and CT angiogram of the head revealed an isodense hollow cylindrical object penetrating though the left orbit through the left frontal lobe extending into the frontal horn of the right lateral ventricle abutting the left anterior cerebral artery with minimal intraventricular hemorrhage and no evidence of arterial injuries.

The patient was treated with broad spectrum antibiotic and antifungal coverage and underwent an orbitofrontal craniotomy through a supraciliary brow approach for extraction of the foreign body, with incisions and positioning as below. The lateral bold curvilinear marking is the position of the supraciliary incision in a prominent forehead skin crease (single arrow). The furthest lateral dotted marking (double arrows) approximates the position of the branch of the left facial nerve to the frontalis muscle. The medial curvilinear marking (white arrowhead) is the estimated lateral limit of frontal sinus which was outlined with the surgical navigation system to avoid entry into the frontal sinus. The lateral curvilinear incision (red arrows) is the planned incision for a larger frontotemporal craniotomy if additional exposure was necessary, a small portion of which was used in this case to harvest temporalis fascia for dural closure.

After placement of a lumbar drain, a left orbitofrontal craniotomy was performed and an extradural, subfrontal dissection of the anterior fossa floor revealed the wooden stick traversing intracranially. In conjunction with the oculoplastics team working extracranially, the wooden stick was removed in two pieces by delivery through the puncture wound inferior to the orbit.

Postoperative 3D CT reconstruction portrays the minimally invasive craniotomy with affixed plating and cranioplasty without significant bony defect.

Postoperatively, the patient had a right frontalis palsy that resolved within 10 weeks. Intraoperative cultures grew Enterococcus casseliflavus, Bacillus cereus, Pseudomonas abietaniphila, and fungal species including Aspergillus niger, Alternaria species, and an unidentified dematiaceous mold. He was treated with an extended course of antimicrobial therapy which included an initial intravenous course of vancomycin, ertapenem, and posaconazole transitioned to oral doxycycline, ciprofloxacin, and isavuconazole after MRI 1 month postoperatively demonstrated source control. At 6 months postoperatively, the patient was prescribed lifelong suppressive isavuconazole. He remains neurologically intact at most recent postoperative visit, approximately 14 months postoperatively.

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Artikel online veröffentlicht:
12. Februar 2021