PMC4083241_01
3-dimensional computed tomography reconstruction of the spear's tract through the oropharynx and skull.
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F1
Using the images obtained, the course of the foreign object was determined to proceed through the left submandibular region, oral cavity, retropharyngeal soft tissues, left petrous apex, left carotid canal, left temporal horn of the left lateral ventricle, posterior aspect of the left frontal lobe, left temporal lobe, and its partial exit through and out of the left temporoparietal region (Figures 1-4).
View of the cut tail of the spear protruding from the patient's neck before removal.
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F2
Using the images obtained, the course of the foreign object was determined to proceed through the left submandibular region, oral cavity, retropharyngeal soft tissues, left petrous apex, left carotid canal, left temporal horn of the left lateral ventricle, posterior aspect of the left frontal lobe, left temporal lobe, and its partial exit through and out of the left temporoparietal region (Figures 1-4).
View of the spear tip protruding through the skin overlying the left parietal bone.
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F3
Using the images obtained, the course of the foreign object was determined to proceed through the left submandibular region, oral cavity, retropharyngeal soft tissues, left petrous apex, left carotid canal, left temporal horn of the left lateral ventricle, posterior aspect of the left frontal lobe, left temporal lobe, and its partial exit through and out of the left temporoparietal region (Figures 1-4).
View of the large craniotomy through a left-sided question-mark-shaped trauma flap exposing the foreign object in the posterior parietal region and allowing for a pterional-type approach to the ICA within the intracranial cavity.
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F4
Computerized tomography (CT) scan of the brain, cervical spine, and face were obtained after cutting the foreign body to allow entry into the CT gantry (Figure 4). Using the images obtained, the course of the foreign object was determined to proceed through the left submandibular region, oral cavity, retropharyngeal soft tissues, left petrous apex, left carotid canal, left temporal horn of the left lateral ventricle, posterior aspect of the left frontal lobe, left temporal lobe, and its partial exit through and out of the left temporoparietal region (Figures 1-4).
View of the second, smaller craniotomy was formed directly surrounding the tip of the harpoon, allowing the bone to be removed by sliding it upward and posteriorly along the path of the projectile.
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F5
Therefore, the craniotomy was performed in two pieces: a large piece of bone was removed anteriorly providing pterional access and a second, smaller craniotomy was formed directly surrounding the tip of the harpoon, allowing the bone to be removed by sliding it upward and posteriorly along the path of the projectile (Figure 5).
The embedded portion of the spear after removal.
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F6
Once the ENT surgical team signaled proximal exposure and preparation of the ICA for proximal control was complete, the harpoon was gently extracted anterograde along the original trajectory in order to avoid damage from its barb-like fins with a grain against the retrograde direction at approximately 17:30, 7.5 h after the initial event (Figure 6).
Pre-operative CT scan showing complete transection of the petrous portion of the left internal carotid artery.
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F7
When it was fully removed, the patient was observed for bleeding, and, remarkably, there was none noted from the cortical exit site, the entry site in the neck, or the oropharynx (Figures 7 and 8).
Post-operative follow up CT scan showing lack of flow through the left ICA.
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F8
When it was fully removed, the patient was observed for bleeding, and, remarkably, there was none noted from the cortical exit site, the entry site in the neck, or the oropharynx (Figures 7 and 8).