Fatal orbital penetrating injury complicated by contralateral internal carotid artery thrombosis and fungal meningitis: A case report

INTRODUCTION

Orbital penetrating injuries with intracranial extension are rare occurrences, accounting for a small subset of penetrating cranial injuries. These injuries are often associated with significant morbidity and mortality due to their proximity to vital neurovascular structures and the risk of secondary infections. The involvement of wooden foreign bodies presents additional challenges, as their porous nature fosters the growth of fungal pathogens, which can lead to severe infections such as meningitis.

Management of such injuries requires a multidisciplinary approach, encompassing neurosurgery, otolaryngology, and infectious disease expertise. While the removal of the foreign body is critical, the risk of complications such as vascular thrombosis, cerebrospinal fluid (CSF) leakage, and intracranial infections necessitates vigilant postoperative care and long-term follow-up.

This report presents the case of a 25-year-old male who sustained a penetrating orbital injury leading to bilateral blindness, contralateral internal carotid artery (ICA) thrombosis, and fungal meningitis. Despite initial successful management, the patient experienced sudden deterioration and death 2 months after discharge. This case underscores the importance of prompt intervention, prophylactic antifungal therapy, and therapeutic drug monitoring to improve outcomes in such complex scenarios.

CASE REPORT

Initial examination

On admission, the patient had Glasgow Coma Scale (GCS) score of E4V5M6. A green-colored wooden stick was visibly protruding from the medial aspect of the left eye [Figure 1a and b]. Both globes appeared intact, but complete ophthalmoplegia was seen in the right eye, and there was no light perception in both the eyes. No signs of meningeal irritation were observed.

Close

Figure 1:

Pre-operative clinical images (a and b) show a green-colored wooden stick protruding from the medial aspect of the left eye. Despite the injury, both globes appear intact, but the patient exhibits complete ophthalmoplegia in the right eye and an absence of light perception in both eyes. A non-contrast computed tomography scan (c) reveals the trajectory of the wooden stick, penetrating the left medial orbit, traversing the right cavernous sinus, and terminating in the prepontine cistern, with an evolving infarct in the right posterior cerebral artery (PCA) territory. Digital subtraction angiography images (d and e) demonstrate thrombosis of the right internal carotid artery (ICA) from the common carotid bifurcation to the intracranial ICA bifurcation, with adequate collateral flow to the right middle cerebral artery via the anterior communicating artery but reduced flow through the posterior communicating artery and PCA. (f) The post-operative view after removal of wooden stick.

Export to PPT

DISCUSSION

Penetrating brain injuries account for only about 0.4% of all head trauma, but their consequences are disproportionately severe due to the risks of intracranial contamination and neurovascular injury.^[1,2] Orbital penetration with wooden foreign objects is particularly rare, but carries unique challenges due to the porous and organic nature of wood, which predisposes to infection.^[3]

These injuries are typically classified into high-velocity (military/firearm) and low-velocity (civilian, household accidents) categories. In low-velocity trauma, penetration commonly occurs at thinner cranial regions such as the orbit and temporal bone.^[1] The trajectory of the penetrating object determines the structures at risk: An upward path through the orbital roof can injure the frontal lobe; a lateral trajectory through the superior orbital fissure may reach the cavernous sinus, temporal lobe, and brainstem; while a medial course through the optic canal can involve the optic chiasm and ICA.^[3] Reported complications include cranial nerve palsies, carotid-cavernous fistula, pseudoaneurysm, and delayed vascular rupture.

Although the GCS at admission guides prognosis, it may provide false reassurance, as patients can deteriorate even months later. Importantly, the globe may remain intact despite extensive intracranial damage. Clinical evaluation of cranial nerve deficits and tract signs must therefore be combined with neuroimaging.

Imaging challenges are significant with wooden foreign bodies. On CT, dry wood may mimic air (appearing hypodense) while hydrated wood can resemble soft tissue, with attenuation values ranging from −649 to +8 HU.^[4] Magnetic resonance imaging (MRI) provides better diagnostic yield: Fresh dry wood is hypointense on T1 and T2, but over time it becomes isointense on T1 and hypointense on T2 as it absorbs water.^[4] Despite these limitations, CT remains essential for detecting orbital or cranial fractures, while MRI clarifies foreign body extent and surrounding parenchymal injury.

Surgical management must be individualized. Pre-operative angiography is crucial when the cavernous sinus or ICA is involved to plan for vascular control. Removal of the foreign body is mandatory, as retained wooden fragments serve as a nidus for infection-even years after injury. Historical series reported brain abscess in 50% of cases before antibiotic use. Surgical options include transorbital extraction, frontal craniotomy, or frontotemporal craniotomy depending on the trajectory and extent of involvement.^[3] The goals are safe removal, neurovascular decompression, debridement, hemostasis, and watertight dural closure to prevent CSF leak.

Antimicrobial coverage must be broad, targeting Staphylococcus aureus, Bacillus, Clostridium species, and fungi such as Aspergillus when live wood is implicated. Tetanus prophylaxis is also essential. Voriconazole has been advocated as prophylaxis against fungal infection, with continuation until imaging shows no residual enhancement.

Post-operative complications include meningitis, abscess, pseudoaneurysm, CSF leak, and carotid-cavernous fistula. CSF leak may initially be managed with lumbar drainage but can require surgical repair. Residual wooden fragments should always be suspected in cases of persistent or recurrent abscess. Long-term follow-up with MRI and angiography is crucial to detect delayed vascular complications.

Recent case reports and reviews emphasize both the heterogeneity and complexity of these injuries. Lei et al. described orbital penetration by a nine-centimeter lead sinker requiring endoscopic extraction after failed blind attempts triggered a severe vagal response.^[5] Rauser et al. reported a delayed presentation of a plastic straw retained for 18 months, highlighting how inert materials may remain occult until infection arises.^[6] Pediatric cases, often involving bamboo chopsticks or pencils, underscore the need for tailored surgical approaches and aggressive infection control.^[7] A systematic review by Shoji et al. of 17 ballpoint-pen injuries found survival to be common but noted persistent neurological or visual deficits in nearly 60% of cases.^[8] The CARE checklist for this case report is available as supplementary file.

CONCLUSION

Orbitocranial penetrating injuries with cavernous sinus involvement remain rare but life-threatening events. Management requires a multidisciplinary approach involving neurosurgeons, ophthalmologists, otolaryngologists, and maxillofacial surgeons. Surgical extraction should always occur in a controlled setting with vascular preparedness. The outcome is determined by the trajectory, extent of neurovascular injury, and timeliness of foreign body removal. Long-term follow-up with contrast MRI and angiography is essential to monitor for infection or delayed vascular sequelae.