Management of Nonmissile Penetrating Brain Injuries


A 21-year-old woman presented to our emergency room (ER) in transfer, following a love triangle dispute that resulted in a steak knife being inserted into the patient’s left eye (Fig. 2A and 2B). The patient was initially unresponsive with emesis and questionable seizure activity. She was intubated and treated with antibiotics and mannitol. On neurological examination, the patient’s pupils were equal and reactive to light. She had minimal movement to noxious stimuli. A skull X-ray showed the blade of the knife extending from the orbit along the middle fossa floor posteromedially (Fig. 2B). A noncontrast CT scan of the head did not show any significant hemorrhage and confirmed the location of the retained knife extending into the left cavernous sinus and perimesencephalic cistern (Fig. 2C). Reconstructed CT angiography showed the knife blade adjacent to the petrous carotid and posterior cerebral arteries with no large-vessel vascular occlusion (Fig. 2D). A 3-D reconstructed digitally subtracted cerebral angiogram confirmed there were no large-vessel abnormalities.

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(A) Preoperative photograph of a patient with retained transorbital knife. (B) Preoperative lateral X-ray showing the retained knife. (C) Noncontrast head computed tomography (CT) showing the trajectory of the knife through the superior orbital fissure. The knife ends within the perimesencephalic cistern. (D) 3-D reconstructed CT angiogram shows the relationship of the knife edge to the left cavernous internal carotid artery and perimesencephalic vasculature.


The patient was taken to the operating room and underwent a left cranio-orbito-zygomatic approach for knife extraction with direct visualization of the adjacent neurovasculature. Proximal vascular control was obtained through exposure of the cervical carotid. Additionally, a lumbar drain was placed to maximize intraoperative brain relaxation. The proximal knife blade was directly visualized transversing the superior orbital fissure extradurally during initial exposure. Dissection proceeded through a transsylvian approach with exposure and protection of the proximal vasculature with cottonoids. The distal knife blade was clearly visualized exiting the cavernous sinus and lying lateral to the brain stem within the perimesencephalic cistern, consistent with preoperative imaging. The knife was removed along its initial trajectory under direct vision without significant hemorrhage. Intraoperative Doppler confirmed filling along the vascular tree left internal carotid artery (ICA), M1, and A1. At the time of closure, the brain appeared edematous, requiring CSF diversion and posterior extension of the craniectomy. An intraparenchymal intracranial pressure monitor was placed, and closure proceeded with an onlay duraplasty substitute (Duragen, Integra, Plainsboro, NJ). Our ophthalmology team explored the globe and closed the entry wound primarily, with the globe intact.


The patient was managed postoperatively in the ICU and required tracheostomy and gastrostomy placement. A follow-up CT scan showed minimal hemorrhage along the knife tract and a hypodensity in the left midbrain felt to be related to initial injury. A 2-week postoperative angiogram showed complete filling of the vascular tree without pseudoaneurysm formation. She was discharged to a skilled nursing facility and at 1-year follow-up has since undergone tracheostomy and gastrostomy removal as wells as a cranioplasty. Her follow-up CT angiogram shows no abnormalities.