Acta Neurochir (2009) 151:685–687
DOI 10.1007/s00701-009-0221-9

BRIEF REPORT OF A SPECIAL CASE

Transorbital penetrating head injury by a toilet brush handle
M. R. Farhadi & M. Becker & C. Stippich &
A. W. Unterberg & K. L. Kiening

Received: 26 June 2008 / Accepted: 11 February 2009 / Published online: 4 March 2009
# Springer-Verlag 2009

Abstract
Background Transorbital penetrating brain injuries are rare
lesions without defined therapy standards.
Clinical presentation and intervention A male patient
presented at our institution with a toilet brush handle in
the right cerebral hemisphere. CT imaging identified the
object entering the right orbit and having crossed the right
hemisphere in the ventricular plane. After performing a
medium-sized craniotomy, the object was removed step-bystep under monitoring with an intraoperative CT scan to
ensure no involving major hemorrhage.
Conclusion Transorbital penetrating brain injuries are treated best by utilizing all up-to-date technical developments
such as intraoperative CT-scanning to increase the safety in
the management of such exceptional lesions with increased
risk of immediate life-threatening intracranial bleeding.
Keywords Traumatic brain injury . Foreign body .
Intraoperative CT

M. R. Farhadi (*) : A. W. Unterberg : K. L. Kiening
Department of Neurosurgery, University of Heidelberg,
Im Neuenheimer Feld 400,
69120 Heidelberg, Germany
e-mail: mohammad.farhadi@med.uni-heidelberg.de
M. Becker
Department of Ophthalmology, University Hospital Heidelberg,
Heidelberg, Germany
C. Stippich
Department of Neuroradiology, University Hospital Heidelberg,
Heidelberg, Germany

Introduction
Orbital injuries are commonly seen in the emergency
department but they seldomly involve the intracranial
compartment. Non-projectile penetrating traumatic brain
injuries due to unusual foreign bodies entering the brain
via the orbit do not occur very frequently [1]. This is
the first report describing a transorbital craniocerebral
injury caused by a toilet brush handle as well as the
removal of the foreign body under control of an
intraoperative CT-scan.

Case report
A 55-year-old man experienced a severe open head injury
as result of a generalized seizure while sitting on the toilet.
He lost consciousness and fell facedown onto an upright
standing toilet brush, which entered the right orbit (Fig. 1a–
b). CT-scanning substantiated these findings showing that
the object destroyed the orbital roof and crossed the right
hemisphere in the ventricular plane at a depth of 9 cm. CTangiography showed no interference with larger cerebral
vessels (Fig. 1c–d). After performing a right-sided frontotemporo-parietal craniotomy the object was removed stepby-step under direct vision from the entry point, guided by
an intraoperative CT-scan. No evidence of ongoing bleeding or brain contusion hemorrhage was noted intraoperatively (Fig. 1e). Follow-up CT detected a brain abscess
within the area of the former trajectory, which resolved
after neuronavigated puncture and prolonged systemic
antibiotic therapy (Fig. 1f). Microbiological cultures of
abscess material as well as the subsequent polymerase
chain reaction DNA sequencing remained sterile. After
discharging the patient 49 days later to a rehabilitation

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M.R. Farhadi et al.

Fig. 1 a The plastic toilet brush
handle entered the right orbit
(lateral view). b Toilet brush
handle after removal. c Contrastenhanced CT-angiography
(coronal section) shows the
relationship between toilet brush
handle and vascular structures
on the right. d Axial CT-scan
demonstrates intraparenchymal
tract of the toilet brush handle
(hypodense, “air-like” signal).
Arrows indicate displaced
orbital roof bone fragments.
Concomitant contusions,
ventricular bleeding and midline
displacement can be seen.
e Axial, native CT-scan obtained
intraoperatively immediately
after removal of the foreign
object demonstrates a hemorrhagic contusion along the
trajectory without the need for
immediate evacuation. f Consecutive axial contrast-enhanced
cranial CT (day 12 post-trauma)
reveals a hypodense mass
occupying the right frontal lobe,
with a hyperdense ring and
cerebral edema around the
lesion suggesting cerebral
abscess

facility, he remained in a “severely disabled” state according to the Glasgow Outcome Scale.

Discussion
Penetrating craniocerebral damages are among the most
fatal injuries of the head and usually have a poor outcome.
Surgical treatment is still the mainstay of management in
these patients. In the absence of evidence-based studies, a
surgical treatment standard for e.g. craniotomy before
removal of the object has not yet been determined.
However, in some reported patients craniotomy seemed to
promote survival patients with an extensive transorbital
brain injury [3]. A rational treatment strategy should focus
on preventing further brain damage. The aim of primary
surgical management is prompt craniotomy for decompression in extended transorbital brain injuries and removal of
the foreign object. Early follow-up cranial CT-scans are
strongly recommended to detect residual or delayed

hematomas with mass effect and/or increased intracranial
pressure, which may need re-operation. However, severe
bleeding and brain swelling may occur during the removal
of the object and cause rapid serious deterioration of the
patient. Intraoperative CT may help in recognizing and
treating this event. Complications such as a brain abscess or
meningitis occur in 48% and 64% of patients with
craniocerebral injuries, respectively [4]. In approximately
20% of the patients, microbiological cultures of abscess
material remain sterile [2]. Polymerase chain reaction is
described as an alternative, especially in the identification
of slow-growing and fastidious organisms [2]. However, in
our patient,, we were not able to demonstrate a causative
pathogens despite the use of both bacterial cultures and
PCR techniques.
Transorbital penetrating brain injuries are treated best
utilizing all up-to-date technical developments including
intraoperative CT-scanning to increase the safety if there
is a risk of immediate life-threatening intracranial
bleeding.

Transorbital penetrating head injury by a toilet brush handle

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