PMC7536401_01
(A) Pre-op CT scan axial view, (B) Pre-op CTA 3D reconstruction lateral view, (C,D) Pre-op CTA 3D reconstruction oblique views. (E) Axial view from CT scan which was performed after the orbital stage of the surgery. (F) Lateral wall of CS [s.l, superficial layer; d.l, deep layer; Modified from, with permission].
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F1
Non-contrast CT of the head was performed and revealed a linear shaped, segmented into 2 pieces (short superficial part and longer deep part) hypodense, air-mimicking FB, extending from the upper medial part of the left orbit (Zone 3b according to classification of Turbin R. and al), through the SOF (sparing the globe) and into the cranial space (Figures 1A,B). Therefore, head CT scan was performed (Figure 1E) the patient was transferred to the neurosurgical operating theater for the intracranial stage.
Intra-operative images: (A,B) Left CS lateral wall and adjacent non-injured anatomical structures: Lt. ICA:left Internal Carotid Artery, Lt. ON:left Optic Nerve, Lt. PCom:left Posterior Communicating Artery, Lt. NIII:left Oculomotor Nerve. (C) Superficial layer of CS lateral wall. (D) Opening of superficial layer of lateral wall of CS, and (E) Identification and removal of the FB. (F) Sutured superficial layer of CS lateral wall. (G) Photograph of the removed wooden FB fragments. (H) Post-op CT (I) Follow-up MRI scan a year after the injury.
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F2
Adjacent non-injured anatomical structures were recognized, namely, the mesial part of the temporal lobe, the tentorial edge, the left optic nerve, the left ICA and PCom, and the left oculomotor nerve (Figures 2A,B). Careful inspection of CS lateral wall under high magnification allowed visualizing the prominence related to the FB lying beyond the superficial layer of the lateral wall of the CS (Figure 2C). This layer was opened by a linear incision along this prominence (Figure 2D), thereby exposing the FB:a split dry twig (Figure 2E). FB (Figure 2G). Further exploration of the surgical field did not reveal any residual fragments, and complete resection was assumed. After meticulous irrigation, the incision in the superficial layer was closed in a watertight fashion (continuous 7/0 Prolene suture, Figure 2F). Post-operative CT scan demonstrated complete removal of the FB (Figure 2H). Follow-up MRI scan a year after the injury did not demonstrate any pathological findings other than mild gliosis detected at the basal temporal lobe (Figure 2I).