Self-inflicted, trans-optic canal, intracranial penetrating injury with a ballpoint pen
A 60-year-old man was admitted to our medical ward due to aspiration pneumonia. He had a medical history of diabetes mellitus, end-stage renal disease; a tuberculosis bacilli-related thoracic spine infection with paraplegia, and a previous coronary artery bypass graft. During his third day at the hospital, he obtained a ballpoint pen and inserted it into his left eye. On physical examination, the patient appeared to be alert with normal vital signs. The ballpoint pen protruded from his left upper eyelid; it was firmly lodged in his left medial orbit between the globe and nose, causing left eye proptosis (Fig. 1).
Neurologic examinations revealed that the patient was neurologically intact except for complete left ophthalmoplegia. Brain CT scanning revealed a tubular foreign body that was located in the anteroposterior plane extending from the orbital apex and directly into the parasellar region (Fig. 2). The metallic portion of the foreign body was entrapped in left optic canal (Fig. 3). There was no evidence of intracranial hemorrhaging or a rupture in the globe (Fig. 4). The patient was treated with high-dose steroids to protect the optic nerve. The plastic ballpoint pen and metallic tip was withdrawn from the orbit smoothly at bedside, and no craniotomy was required. The ballpoint pen had been inserted to an estimated depth of 7 cm through the eyelid and into the orbit. The patient was then transferred to the ICU for close neuro-observation. We initiated intravenous broad-spectrum antimicrobials and vancomycin therapy and continued these medications for three weeks. A psychiatrist was consulted for a complete psychiatric evaluation and suicide prevention. The follow-up CT scan showed no retained foreign bodies or intracranial hemorrhaging (Fig. 5). At the last follow-up examination 2 months after the injury, the patient presented with complete left ophthalmoplegia and blepharoptosis but intact visual function.
Yu-Min Su and Chih-Hsuan Changchien*
Department of Plastic and Reconstructive Surgery, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan*Correspondence address. No.539, Zhongxiao Rd., Chiayi City 600, Taiwan. Tel: +886-5-2765041; Fax: +886-5-2757491; E-mail: moc.liamg@55neihcgnahc
- Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock 2011;4:395–402. [PMC free article] [PubMed] [Google Scholar]
- Matsumoto S, Hasuo K, Mizushima A, Mihara F, Fukui M, Shirouzu T et al. Intracranial penetrating injuries via the optic canal. AJNR Am J Neuroradiol 1998;19:1163–5. [PubMed] [Google Scholar]
- Sharif GRJPS. Transnasal penetrating brain injury with a ball-pen. Br J Neurosurg 2000;14:159–60. [PubMed] [Google Scholar]
- Patton N. Self-inflicted eye injuries: a review. Eye 2004;18:867–72. [PubMed] [Google Scholar]
- Mandat TS, Honey CR, Peters DA, Sharma BR. Artistic assault: an unusual penetrating head injury reported as a trivial facial trauma. Acta Neurochir (Wien) 2005;147:331–3. [PubMed] [Google Scholar]
- Ijaz L, Nadeem MM. Transorbital penetrating brain injury to frontal lobe by a wheel spoke. J Pediatr Neurosci 2014;9:267–9. [PMC free article] [PubMed] [Google Scholar]
- Turbin RE, Maxwell DN, Langer PD, Frohman LP, Hubbi B, Wolansky L et al. Patterns of Transorbital Intracranial Injury: A Review and Comparison of Occult and Non-Occult Cases. Surv Ophthalmol 2006;51:449–60. [PubMed] [Google Scholar]
- Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95–103. [PubMed] [Google Scholar]
- Chen C-T, Wang TY, Tsay P-K, Huang F, Lai J-P, Chen Y-R. Traumatic Superior Orbital Fissure Syndrome: Assessment of Cranial Nerve Recovery in 33 Cases. Plast Reconstr Surg 2010;126:205–12. [PubMed] [Google Scholar]
- Ballard ED, Pao M, Henderson D, Lee LM, Bostwick JM, Rosenstein DL. Suicide in the Medical Setting. Jt Comm J Qual Patient Saf 2008;34:474–81. [PMC free article] [PubMed] [Google Scholar]