INTRODUCTION

Penetrating injuries that cause orbital roof fractures and frontal lobe lesions present significant surgical challenges, particularly when an intracranial foreign body is retained. Typically, a traditional surgical approach would involve a frontotemporal craniotomy with subsequent retraction of the frontal lobe, especially if the foreign body is located posteriorly. Although a large craniotomy is necessary in cases of extensive hematoma or severe cerebral edema [1], it is generally preferable to minimize brain retraction to avoid potential permanent neurological deficits [2]. In instances of low-velocity impacts with no significant associated cerebral injury, minimally invasive procedures should be considered. Techniques such as supraorbital eyebrow craniotomy and endoscopic endonasal approach are commonly employed for minimally invasive access to the anterior skull base [3,4]. However, the angle of approach with supraorbital eyebrow craniotomy is suboptimal for removing a foreign body that has entered perpendicularly through the orbital roof into the frontal lobe. Similarly, endoscopic endonasal approach does not provide favorable access to areas lateral to the lamina papyracea, where most related traumas occur. We propose that transorbital neuroendoscopic surgery (TONES) [5] is ideally suited for this specific clinical scenario. We report on the use of an endoscopic transorbital approach via the superior eyelid crease (SLC) for treating an orbital roof trauma that involved a frontal lobe injury and necessitated the removal of an intracranial foreign body.

CASE REPORT

A 55-year-old man presented to the emergency department after an assault involving an umbrella, which resulted in a laceration at the medial canthus. An ophthalmologist sutured the laceration and subsequently ordered an outpatient computed tomography (CT) scan. Conducted 2 weeks later, the scan revealed a 2×2-cm retained foreign body in the left frontal lobe, which had fractured the orbital roof (Fig. 1). The scan also showed significant cerebral edema, notable given the time elapsed since the initial injury.

Clinically, the patient exhibited a Glasgow Coma Scale score of 15 and showed no neurological deficits. His vision was unaffected, and extraocular movements were normal.

The patient was informed about the situation, and a TONES procedure (SLC) was recommended as it is less invasive for removing the foreign body. This approach involves minimal brain retraction and provides direct access to the orbital roof fracture. An alternative approach via a pterional craniotomy was also discussed.

After the patient consented, he was taken to the operating room for a combined neurosurgical and ophthalmologic procedure. He was placed under general anesthesia, and the initial incision was made on the superior eyelid. The superior orbital septum was identified, and dissection continued in a preseptal plane until the orbital roof was reached. The orbital roof was accessed using electrocautery, extending from the supraorbital nerve to the frontozygomatic suture. Dissection then proceeded bluntly in a subperiosteal plane, exposing the orbital roof and lateral wall. This provided sufficient access for medial and inferior retraction of the orbit, allowing for the introduction of the endoscope. The dissection continued posteriorly until the fracture and foreign body were located. Necrotic brain tissue extruding from the fracture was debrided to fully expose the foreign body. To ensure safe removal, an orbitectomy was performed around the bony deficit using a Kerrison rongeur, and the dural opening was enlarged to fully expose the base of the foreign body. The foreign body, identified as the plastic tip of an umbrella (Fig. 2), was then completely removed using Mosquito forceps. It was intact, with no fragments remaining. No signs of infection were observed. The dural defect was closed with an inlay of DuraGen matrix (Integra) and sealed with Tisseel fibrin sealant (Baxter). The periorbita was then released from retraction, which helped to tamponade the defect. The ophthalmology team subsequently closed the incision. Pupil function was monitored throughout the procedure to ensure that no excessive pressure was placed on the orbit.

A postoperative assessment indicated that the patient tolerated the intervention exceptionally well, with no cerebrospinal fluid leakage, preserved normal eye structure and function, and 50 mL of blood loss. Fig. 3 depicts the patient's postoperative CT scan.

Six days postoperatively, the patient exhibited increased cerebral edema and a ring-enhancing lesion measuring 4×4×4 cm, indicative of an abscess in the left frontal lobe (Fig. 4). The patient underwent re-exploration through the same approach to drain the abscess and obtain a culture. The culture results suggested a polymicrobial abscess, containing both Finegoldia magna and Propionibacterium acnes. He received 6 weeks of intravenous ceftriaxone/metronidazole treatment. The patient was discharged 6 days following the second operation, free of cognitive deficits and without further complications.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from the patient.

DISCUSSION

As presented in this case report, the endoscopic transorbital approach offers significant benefits over the classic frontotemporal craniotomy for managing anterior skull base and frontal lobe injuries resulting from orbital trauma. Notably, the approach aligns with the vector of the penetrating injury, facilitating the removal of foreign bodies without exacerbating trauma to the surrounding brain tissue. This method also enables the extension of the orbital roof entry wound and the evacuation of frontal lobe hematomas without necessitating brain retraction or corticectomy, which are typically required in a frontotemporal approach. Additionally, the minimally disruptive nature of this procedure results in less morbidity to the soft tissue, particularly the temporalis muscle, and yields a cosmetically favorable incision that heals with minimal scarring [5]. The SLC approach is particularly advantageous as it can be extended laterally to access the middle fossa and cavernous sinus, making it a versatile option for addressing most orbital traumas that cause intracranial injury. However, there are some disadvantages when compared to traditional frontotemporal craniotomy. The learning curve is steep, requiring surgeons to become familiar with the anatomy and endoscopic techniques. Surgeons experienced in endoscopic endonasal surgery will likely find this technique more intuitive and easier to master. The working corridor is narrower, which can be problematic in cases of severe orbital trauma and swelling. Additionally, collaboration with an oculoplastic surgeon is essential to avoid ocular damage or functional impairment, though organizing such collaboration can be challenging in emergency settings. Patient selection for this approach must be conducted with caution. In cases of severe brain hemorrhage and edema, a traditional frontotemporal craniotomy may be more appropriate. For extensive intraparenchymal hemorrhages that extend beyond the wound entry point or in cases of severe orbital trauma with increased intraocular pressure, management is ideally performed via craniotomy or a combined approach. Although rare, specific complications associated with this approach should be monitored and avoided whenever possible. These include transorbital cerebrospinal fluid leak, levator muscle dysfunction leading to long-term ptosis, orbital hematoma, and proptosis [6]. Vision loss and cranial nerve dysfunction have also been reported, albeit very rarely [7].

In conclusion, we advocate for the endoscopic transorbital approach as an alternative to frontotemporal craniotomy for selected cases of intracranial injury caused by penetrating injuries through the orbit.

ARTICLE INFORMATION

Author contributions

Conceptualization: PL; Methodology: PL; Investigation: all authors; Project administration: CP, ML, PL; Writing–original draft: CG, PL; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Computed tomography scan of the patient’s brain before the procedure, clearly showing the foreign body. (A) Sagittal view. (B) Coronal view. (C) Axial view.

Fig. 2.

Surgical technique. (A) The surgeons are removing the intracranial foreign body. (B) The small incision through which the procedure was done is now closed and will heal into a subtle scar. (C) The foreign body, which was an umbrella tip more than 2 cm long. The patient provided informed consent for publication of the clinical images.

Fig. 3.

Postoperative computed tomography scan following the transorbital procedure. (A–C) Multiple axial slices.

Fig. 4.

Brain magnetic resonance imaging of the abscess that formed 6 days after the first operation. (A) Sagittal view. (B) Coronal view. (C) Axial view.

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