The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
29. Periago DR, Scarfe WC, Moshiri M, et al. Linear accuracy and reliability of cone beam CT derived 3-dimensional images constructed using an orthodontic volumetric rendering program. Angle Orthod 2008;78:387Y395 30. Jaju PP. Cone beam CT detection of foramen tympanicum or foramen of Huschke. Dentomaxillofac Radiol 2012;41:619 31. Cohlmia JT, Ghosh J, Sinha PK, et al. Tomographic assessment of temporomandibular joints in patients with malocclusion. Angle Orthod 1996;66:27Y35 32. Prabhat KC, Kumar Verma S, Maheshwari S, et al. Computed tomography evaluation of craniomandibular articulation in class II division 1 malocclusion and class I normal occlusion subjects in North Indian population [published online ahead of print August 16, 2012]. ISRN Dent 2012;2012:312031. 33. Perry HT. Relation of occlusion to temporomandibular joint dysfunction: the orthodontic viewpoint. J Am Dent Assoc 1969;79:137Y141 34. Loiselle RJ. Relation of occlusion to temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent Assoc 1969;79:145Y146 35. Stack BC, Funt LA. Temporomandibular joint dysfunction in children. J Pedod 1977;1:240Y247
A Late-Onset Seizure Due to a Retained Intracranial Foreign BodyVPencil Lead: A Case Report and Review Qian Chunhua, MD, Wu Qun, MD Abstract: A 40-year-old man presented with recent recurrent seizures. He was operated on to resect the right temporal mass with a foreign body, a pencil lead. The foreign body had entered the brain parenchyma for an accident in a child without apparent head injury, sustained for 30 years. He was asymptomatic for the intervening 30 years. It is rare that a pencil lead totally penetrated with an inapparent transtemporal closed head injury. The case may caution neurosurgeons to make the complete diagnosis of retained intracranial foreign bodies and thinking of need for early surgical exploration, to avoid chronic and potentially life-threatening neurological complications. Key Words: Penetrating head injury, intracranial foreign body, pencil lead, late-onset seizure, neurosurgical procedure
From the Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China. Received July 17, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Wu Qun, MD, Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Rd, Hangzhou, Zhejiang Province, 310009, People’s Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000439
Brief Clinical Studies
P
enetrating head injuries with foreign body retained are relatively rare and mainly reported in the transorbital penetrating injuries, mostly with wooden as the foreign body, and sometimes needle or bullet.1Y4 The clinical evidence of deep injury may be subtle to lose the diagnosis of intracranial foreign bodies, so the history around injury should be surveyed clear to check if anything can be inserted in skull missing. Computed tomography (CT) and magnetic resonance imaging are essential to provide possible signs of foreign bodies. Severe neurological complications, such as infection, progressive gliosis and granuloma, epilepsy, may occur because of the foreign bodies retained, which harbor bacteria and fragment. Thus, the foreign bodies, whether own bone or wooden or metal, should be removed at the time of injury at all possible.2
CLINICAL REPORT A 40-year-old man presented to the neurosurgery department for recurrent seizures within the recent 4 months, which were displayed as lip smacking, chewing, or swallowing at first, followed by spasm of the limbs expanding from the left to bilateral, foaming at the mouth, obvious left swivel of the head, and unconsciousness, lasting for approximately 3 to 5 minutes and surrounded by a short amnesiac state. The patient had then received an ambulatory electroencephalogram monitoring over 24 hours, showing that the abnormal epileptic electrical activity originated in the right temporal lobe. And then the complex partial seizure diagnosis was made. The patient underwent a nonenhanced CT scan to reveal a slender pointed foreign body of high density in the right temporal lobe and edema surrounding (Fig. 1). Magnetic resonance imaging showed right temporal intraparenchymal mass of less uniform high signal in T1-weighted image, high signal in T2-weighted image, and surrounding T2-hyperintense edema, with some artifact to indicate foreign body embraced (Fig. 2). Laboratory analysis was unremarkable. The patient described a definite traumatic history as a pencil lead being intracranially penetrated in the right temporal lobe 30 years ago when he was a child playing in the classroom. For lack of any clinical manifestations, he requested to be under monitor with the foreign body retained. Surgical excision had performed from the very location approach of the foreign body. We found a graphite-dyed sign of penetrating pathway in the inner side of skull flap (the outside intact), and a complete pencil lead in the temporal lobe, which is capsule in hyperplasic fibro and granuloma, the mass, and some brain parenchyma around, was also dyed by the graphite. The pathologic evaluation of the surgical specimen revealed attenuated fibrous connective tissue with pigmentation surrounding foreign material (Fig. 3). Then, the patient needs to take antiepilepsy drug for a period to judge the treatment effect and then adjust the strategy. Two years’ follow-up showed that the patient had not had epileptic attack any more.
FIGURE 1. Computed tomography scan revealed a slender pointed foreign body of high density in the right temporal lobe and edema surrounding.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e109
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 2, March 2014
DISCUSSION In symptomatic epilepsy, the central nervous system infections and traumatic brain injury are the 2 most common causes.5 The risk of seizures is increased after traumatic brain injury, but the extent and duration of the increase in risk are unknown. Brain contusion and subdural hematoma are evaluated as the strongest risk factors for the late seizures, which persisted for at least 20 years, whereas skull fracture and prolonged loss of consciousness were significant but weaker predictors.5 It is extraordinary for some of the penetrating head injury cases including our one, slender pointed foreign body to be inserted during a violence or an accident, but there was no apparent craniocerebral injury, without any symptoms immediately after trauma, so it was easily missed in the examinations. Transcranial penetration foreign bodies were relatively rarely reported, most as wooden (branches, chopsticks, or pencils),4 metal (needles or bullets in war),1,2 and also as cotton, stone, or fireworks. In the literatures that reviewed the recent wooden foreign body penetrations, most of the patients were males; the mean age was 22 years, and 43% (10/23) were children 10 years or younger. Tumbling down and falling caused most cases.4 The most common 4 penetrating pathways of foreign bodies were reported as superior orbital walls, superior orbital fissure, lateral orbital wall, and optic canal. Because the bones comprising the orbit are thin, straight external force easily penetrates the bones, and a foreign body will reach the frontal or temporal lobe. Even when the bones are not fractured, a foreign body may reach the cavernous sinus or its proximity via the superior orbital fissure or optic canal and may reach the brainstem in a few cases.4 It is doubtful whether the intraparenchymal foreign body migrated to the terminal position over time attributed to gravity or if it arrived to that position as a result of the initial trauma.6 The risk for late complications increases with organic wooden foreign objects such as tree branches and pencils.6 The wooden foreign bodies not only act as carriers but nidi for infections and delayed complications, ranging from meningitis to abscesses and cerebritis.7 Miller et al8 reported a 64% overall infection rate with a mortality rate of 25%. Brain abscess was the cause of death in 57% and meningitis/cerebritis in 14%. Nishio et al4 documented an infective complication in 70% of patients reviewed, corroborating a very high incidence of complications if undetected. New-onset seizures are a typical manifestation of both recent and remote penetrating trauma.5 Late-onset seizures can be induced secondary to gradual gliosis, and in cases of a retained foreign body, secondary to progressive granulomatous change, delayed abscess formation,5 and metal toxicity.3 So it is thought that retained foreign bodies in the brain should be well examined to make diagnosis and removed at the time of injury if at all possible, or a patient with foreign body should be carefully monitored for life.2
FIGURE 2. Right temporal intraparenchymal mass of less uniform high signal in T1-weighted image, high signal in T2-weighted image, and surrounding T2-hyperintense edema, with some artifact to indicate foreign body embraced.
e110
FIGURE 3. Pathologic evaluation of the surgical specimen revealed attenuated fibrous connective tissue with pigmentation surrounding foreign material.
Our case is unusual, because the foreign body was a pencil lead, graphite material only, which is quite rare; only 1 case besides this was described in the literature by Mikhael and Mattar,9 which had led to granulomatous abscess simulating a brain tumor. In our case, it was unimaginable that the pointed graphite foreign body was penetrated directly from the temporal bone (we can deduce that from the bone appearance) without obvious craniocerebral injury. It lasted a long period between the initial trauma and the presentation of seizures, stunningly resulting in no abscess, granuloma, or even apparent gliosis confirmed in the pathological examination. Can we suppose the graphite toxicity and stimulation for seizures? Different from wooden foreign body, solid graphite one can be well revealed in a CT scan. It is relatively easier to make diagnosis. For the case, it should be surgically treated to remove the foreign body right after the head trauma to avoid the late complications. Spennato et al10 considered the double concentric craniotomy as the only technique that permitted the removal of a foreign body that had penetrated both the skull and the brain to avoid transmitting undue forces to the underlying structures and uncontrollable bleeding, which embraces our case.
REFERENCES 1. Abbassioun K, Ameli NO, Morshed AA. Intracranial sewing needles: review of 13 cases. J Neurol Neurosurg Psychiatry 1979;42:1046Y1049 2. Lee JH, Kim DG. Brain abscess related to metal fragments 47 years after head injury. J Neurosurg 2000;93:477Y479 3. Yamakawa H, Takenaka K, Sumi Y, et al. Intracranial bullet retained since the Sino-Japanese war manifesting as hallucinationVcase report. Neurol Med Chir (Tokyo) 1994;34:451Y454 4. Nishio Y, Hayashi N, Hamada H, et al. A case of delayed brain abscess due to a retained intracranial wooden foreign body: a case report and review of the last 20 years. Acta Neurochir (Wien) 2004;146:847Y850 5. Annegers JF, Hauser WA, Coan SP, et al. A population-based study of seizures after traumatic brain injuries. N Engl J Med 1998;338:20Y24 6. Aulino JM, Gyure KA, Morton A, et al. Temporal lobe intraparenchymal retained foreign body from remote orbital trauma. AJNR Am J Neuroradiol 2005;26:1855Y1857 7. Dadlani R, Ghosal1 N, Bagdi N, et al. Chronic brain abscess secondary to a retained wooden foreign body: diagnostic and management dilemmas. Indian J Pediatr 2010;77:575Y576 8. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95Y103 9. Mikhael MA, Mattar AG. Case report: chronic graphite granulomatous abscess simulating a brain tumor. J Comput Assist Tomogr 1977;1:513Y516 10. Spennato P, Bocchetti A, Mirone G, et al. Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note. Surg Neurol 2005;64:368Y371
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 25, Number 2, March 2014
29. Periago DR, Scarfe WC, Moshiri M, et al. Linear accuracy and reliability of cone beam CT derived 3-dimensional images constructed using an orthodontic volumetric rendering program. Angle Orthod 2008;78:387Y395 30. Jaju PP. Cone beam CT detection of foramen tympanicum or foramen of Huschke. Dentomaxillofac Radiol 2012;41:619 31. Cohlmia JT, Ghosh J, Sinha PK, et al. Tomographic assessment of temporomandibular joints in patients with malocclusion. Angle Orthod 1996;66:27Y35 32. Prabhat KC, Kumar Verma S, Maheshwari S, et al. Computed tomography evaluation of craniomandibular articulation in class II division 1 malocclusion and class I normal occlusion subjects in North Indian population [published online ahead of print August 16, 2012]. ISRN Dent 2012;2012:312031. 33. Perry HT. Relation of occlusion to temporomandibular joint dysfunction: the orthodontic viewpoint. J Am Dent Assoc 1969;79:137Y141 34. Loiselle RJ. Relation of occlusion to temporomandibular joint dysfunction: the prosthodontic viewpoint. J Am Dent Assoc 1969;79:145Y146 35. Stack BC, Funt LA. Temporomandibular joint dysfunction in children. J Pedod 1977;1:240Y247
A Late-Onset Seizure Due to a Retained Intracranial Foreign BodyVPencil Lead: A Case Report and Review Qian Chunhua, MD, Wu Qun, MD Abstract: A 40-year-old man presented with recent recurrent seizures. He was operated on to resect the right temporal mass with a foreign body, a pencil lead. The foreign body had entered the brain parenchyma for an accident in a child without apparent head injury, sustained for 30 years. He was asymptomatic for the intervening 30 years. It is rare that a pencil lead totally penetrated with an inapparent transtemporal closed head injury. The case may caution neurosurgeons to make the complete diagnosis of retained intracranial foreign bodies and thinking of need for early surgical exploration, to avoid chronic and potentially life-threatening neurological complications. Key Words: Penetrating head injury, intracranial foreign body, pencil lead, late-onset seizure, neurosurgical procedure
From the Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People’s Republic of China. Received July 17, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Wu Qun, MD, Department of Neurosurgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Rd, Hangzhou, Zhejiang Province, 310009, People’s Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000439
Brief Clinical Studies
P
enetrating head injuries with foreign body retained are relatively rare and mainly reported in the transorbital penetrating injuries, mostly with wooden as the foreign body, and sometimes needle or bullet.1Y4 The clinical evidence of deep injury may be subtle to lose the diagnosis of intracranial foreign bodies, so the history around injury should be surveyed clear to check if anything can be inserted in skull missing. Computed tomography (CT) and magnetic resonance imaging are essential to provide possible signs of foreign bodies. Severe neurological complications, such as infection, progressive gliosis and granuloma, epilepsy, may occur because of the foreign bodies retained, which harbor bacteria and fragment. Thus, the foreign bodies, whether own bone or wooden or metal, should be removed at the time of injury at all possible.2
CLINICAL REPORT A 40-year-old man presented to the neurosurgery department for recurrent seizures within the recent 4 months, which were displayed as lip smacking, chewing, or swallowing at first, followed by spasm of the limbs expanding from the left to bilateral, foaming at the mouth, obvious left swivel of the head, and unconsciousness, lasting for approximately 3 to 5 minutes and surrounded by a short amnesiac state. The patient had then received an ambulatory electroencephalogram monitoring over 24 hours, showing that the abnormal epileptic electrical activity originated in the right temporal lobe. And then the complex partial seizure diagnosis was made. The patient underwent a nonenhanced CT scan to reveal a slender pointed foreign body of high density in the right temporal lobe and edema surrounding (Fig. 1). Magnetic resonance imaging showed right temporal intraparenchymal mass of less uniform high signal in T1-weighted image, high signal in T2-weighted image, and surrounding T2-hyperintense edema, with some artifact to indicate foreign body embraced (Fig. 2). Laboratory analysis was unremarkable. The patient described a definite traumatic history as a pencil lead being intracranially penetrated in the right temporal lobe 30 years ago when he was a child playing in the classroom. For lack of any clinical manifestations, he requested to be under monitor with the foreign body retained. Surgical excision had performed from the very location approach of the foreign body. We found a graphite-dyed sign of penetrating pathway in the inner side of skull flap (the outside intact), and a complete pencil lead in the temporal lobe, which is capsule in hyperplasic fibro and granuloma, the mass, and some brain parenchyma around, was also dyed by the graphite. The pathologic evaluation of the surgical specimen revealed attenuated fibrous connective tissue with pigmentation surrounding foreign material (Fig. 3). Then, the patient needs to take antiepilepsy drug for a period to judge the treatment effect and then adjust the strategy. Two years’ follow-up showed that the patient had not had epileptic attack any more.
FIGURE 1. Computed tomography scan revealed a slender pointed foreign body of high density in the right temporal lobe and edema surrounding.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e109
The Journal of Craniofacial Surgery
Brief Clinical Studies
& Volume 25, Number 2, March 2014
DISCUSSION In symptomatic epilepsy, the central nervous system infections and traumatic brain injury are the 2 most common causes.5 The risk of seizures is increased after traumatic brain injury, but the extent and duration of the increase in risk are unknown. Brain contusion and subdural hematoma are evaluated as the strongest risk factors for the late seizures, which persisted for at least 20 years, whereas skull fracture and prolonged loss of consciousness were significant but weaker predictors.5 It is extraordinary for some of the penetrating head injury cases including our one, slender pointed foreign body to be inserted during a violence or an accident, but there was no apparent craniocerebral injury, without any symptoms immediately after trauma, so it was easily missed in the examinations. Transcranial penetration foreign bodies were relatively rarely reported, most as wooden (branches, chopsticks, or pencils),4 metal (needles or bullets in war),1,2 and also as cotton, stone, or fireworks. In the literatures that reviewed the recent wooden foreign body penetrations, most of the patients were males; the mean age was 22 years, and 43% (10/23) were children 10 years or younger. Tumbling down and falling caused most cases.4 The most common 4 penetrating pathways of foreign bodies were reported as superior orbital walls, superior orbital fissure, lateral orbital wall, and optic canal. Because the bones comprising the orbit are thin, straight external force easily penetrates the bones, and a foreign body will reach the frontal or temporal lobe. Even when the bones are not fractured, a foreign body may reach the cavernous sinus or its proximity via the superior orbital fissure or optic canal and may reach the brainstem in a few cases.4 It is doubtful whether the intraparenchymal foreign body migrated to the terminal position over time attributed to gravity or if it arrived to that position as a result of the initial trauma.6 The risk for late complications increases with organic wooden foreign objects such as tree branches and pencils.6 The wooden foreign bodies not only act as carriers but nidi for infections and delayed complications, ranging from meningitis to abscesses and cerebritis.7 Miller et al8 reported a 64% overall infection rate with a mortality rate of 25%. Brain abscess was the cause of death in 57% and meningitis/cerebritis in 14%. Nishio et al4 documented an infective complication in 70% of patients reviewed, corroborating a very high incidence of complications if undetected. New-onset seizures are a typical manifestation of both recent and remote penetrating trauma.5 Late-onset seizures can be induced secondary to gradual gliosis, and in cases of a retained foreign body, secondary to progressive granulomatous change, delayed abscess formation,5 and metal toxicity.3 So it is thought that retained foreign bodies in the brain should be well examined to make diagnosis and removed at the time of injury if at all possible, or a patient with foreign body should be carefully monitored for life.2
FIGURE 2. Right temporal intraparenchymal mass of less uniform high signal in T1-weighted image, high signal in T2-weighted image, and surrounding T2-hyperintense edema, with some artifact to indicate foreign body embraced.
e110
FIGURE 3. Pathologic evaluation of the surgical specimen revealed attenuated fibrous connective tissue with pigmentation surrounding foreign material.
Our case is unusual, because the foreign body was a pencil lead, graphite material only, which is quite rare; only 1 case besides this was described in the literature by Mikhael and Mattar,9 which had led to granulomatous abscess simulating a brain tumor. In our case, it was unimaginable that the pointed graphite foreign body was penetrated directly from the temporal bone (we can deduce that from the bone appearance) without obvious craniocerebral injury. It lasted a long period between the initial trauma and the presentation of seizures, stunningly resulting in no abscess, granuloma, or even apparent gliosis confirmed in the pathological examination. Can we suppose the graphite toxicity and stimulation for seizures? Different from wooden foreign body, solid graphite one can be well revealed in a CT scan. It is relatively easier to make diagnosis. For the case, it should be surgically treated to remove the foreign body right after the head trauma to avoid the late complications. Spennato et al10 considered the double concentric craniotomy as the only technique that permitted the removal of a foreign body that had penetrated both the skull and the brain to avoid transmitting undue forces to the underlying structures and uncontrollable bleeding, which embraces our case.
REFERENCES 1. Abbassioun K, Ameli NO, Morshed AA. Intracranial sewing needles: review of 13 cases. J Neurol Neurosurg Psychiatry 1979;42:1046Y1049 2. Lee JH, Kim DG. Brain abscess related to metal fragments 47 years after head injury. J Neurosurg 2000;93:477Y479 3. Yamakawa H, Takenaka K, Sumi Y, et al. Intracranial bullet retained since the Sino-Japanese war manifesting as hallucinationVcase report. Neurol Med Chir (Tokyo) 1994;34:451Y454 4. Nishio Y, Hayashi N, Hamada H, et al. A case of delayed brain abscess due to a retained intracranial wooden foreign body: a case report and review of the last 20 years. Acta Neurochir (Wien) 2004;146:847Y850 5. Annegers JF, Hauser WA, Coan SP, et al. A population-based study of seizures after traumatic brain injuries. N Engl J Med 1998;338:20Y24 6. Aulino JM, Gyure KA, Morton A, et al. Temporal lobe intraparenchymal retained foreign body from remote orbital trauma. AJNR Am J Neuroradiol 2005;26:1855Y1857 7. Dadlani R, Ghosal1 N, Bagdi N, et al. Chronic brain abscess secondary to a retained wooden foreign body: diagnostic and management dilemmas. Indian J Pediatr 2010;77:575Y576 8. Miller CF, Brodkey JS, Colombi BJ. The danger of intracranial wood. Surg Neurol 1977;7:95Y103 9. Mikhael MA, Mattar AG. Case report: chronic graphite granulomatous abscess simulating a brain tumor. J Comput Assist Tomogr 1977;1:513Y516 10. Spennato P, Bocchetti A, Mirone G, et al. Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note. Surg Neurol 2005;64:368Y371
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
