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Paper text:
penetrating brain injury ( pbi ) with low - velocity nonmissile objects is associated with high morbidity and mortality .
pbi has been reported with steel rod , screwdriver , knife , fork , wood stick , scissors , pencil , fence rod , javelin , coat hanger , billiard stick , toothbrush , and chopstick , etc .
, majority of cases have to be dealt with the removal of the penetrating object by a formal craniotomy .
we herein report a case of pbi with a wheel spoke , which was removed from the entry wound without a craniotomy .
a 3.5-year - old girl presented to the surgical emergency with a metal rod intruded to the medial side of the right eye .
the incident occurred while she was playing with a bicycle wheel spoke and accidentally fell over it , resulting in penetrating injury [ figure 1 ] .
the bleeding , however , ceased spontaneously in the meantime when she arrived at us .
she was vitally stable with a glasgow coma scale score of 15/15 with no focal neurological deficit .
skull radiographs in antero - posterior and lateral views revealed angled end of a long wheel spoke penetrating about 10 cm deep into the cranium through the medial aspect of the roof of the right orbit [ figure 2 ] .
the computerized tomography ( ct ) scan with three - dimensional reconstruction showed the spoke lying in the right frontal lobe ( premotor area ) , the internal trajectory being perpendicular to roof of the orbit , away from brain vasculature and vital centers , and a cavitation around the spoke [ figure 3 ] .
the patient was allowed orally on the following day of operation and discharged on the 4 postoperative day on antibiotics for 2 weeks .
the patient has visited us twice ; she is in a good state of health without any signs of local and central nervous system infections and cerebrospinal fluid ( csf ) leakage .
inset showed postremoval image radiographs showing spoke upper slices of computerized tomography ( ct ) scan showed rod in the right frontal region with a cavitation around the rod .
lower slices showed ct with three - dimensional reconstruction ; left lower slice showed intracranial extent
penetrating brain injury to phineas gage , a railway worker , with an iron rod has been a very popular case in the united states .
the prognosis depends on the site of involvement as to damage to major vessels and vital brain centers .
various complications of pbi are sudden death , life - threatening hemorrhage , intracranial hematoma , local trauma to the brain and its vasculature , brain abscesses , meningitis , csf leakage , and neurological deficits .
epilepsy , behavioral , and psychological problems are also encountered in patients , especially with frontal lobe injury .
the mode of injury is accidental in most of the pediatric cases ; however , homicidal intent should be looked out for .
solarino et al . , reported a case where the child got pbi by a coat hanger ; the intent was to hit her mother , but the daughter got the brunt . in our case , the mother had died , and all five siblings had been distributed among various relatives . the index case was living with paternal aunt , and any other intent could not be ruled out .
the objectives of the intervention in case of pbi are to avoid further damage to the brain , remove the offending object , debridement of necrotic brain tissue , and evacuation of the hematoma .
these objectives are , in the majority , accomplished by a formal craniotomy around the wound of entrance . in our case
, we also planned a craniotomy , however , a cavitation phenomenon around the metal rod as divulged on ct scan and a safe trajectory of the wheel spoke led us to alter our strategy .
the rod was an angled , but as it was in the frontal lobe away from the major brain vasculature .
bit by bit retrieval with strict monitoring of the patient led to the successful removal .
postoperative monitoring and follow - up are important as in the immediate postoperative period , brain edema , intracranial hematoma , csf leakage , or meningitis may develop .
a short postoperative course of anti - convulsant is quite useful in preventing immediate convulsions ; however , epilepsy may develop months to years after the trauma .
postoperative course of prophylactic antibiotics is of equal importance for the prevention of infectious sequel .
a perusal of the literature did not reveal any case of transorbital pbi with an angled wheel spoke .
penetrating brain injury ( pbi ) is rare and the severest form of head injury with a high morbidity and mortality . a 3.5-year - old girl presented with pbi with a wheel spoke . 
 computerized tomography scan with three - dimensional skull reconstruction depicted its extent from the medial side of the roof of the right orbit to the right frontal lobe with a cavitation around the spoke . 
 the spoke was removed by manipulation under general anesthesia from the entry site without a formal craniotomy . 
 postoperative outcome was uneventful .