Presentation
Bike vs tree injury.
Patient Data
Penetrating injury with wooden object (branch?) extending from the right lateral nasal wall, through the nasal septum and the left medial orbital wall. The tip passes through the left orbital roof and has entered the anterior cranial fossa. Multiple small locules of intracranial gas are identified. There is disruption of the medial and superior recti of the left orbit. The optic nerve appears to be spared. Injury to the ophthalmic artery and superior ophthalmic vein cannot be excluded, but there is only minor intraorbital hematoma/stranding.
The penetrating injury abuts the inferior left frontal lobe. No intraparenchymal hemorrhage identified. Extra-axial pneumocephalus noted. Normal grey-white matter insertion is maintained. No evidence of acute ischemia. No hydrocephalus or midline shift.
It is crucial when evaluating a CT with a possible history of penetrating injury, to use a variety of window settings as foreign bodies can be difficult to appreciate on routine brain window (which is very narrow).
Note how the branch in this instance is almost impossible to see on normal window but can be better seen on a variety of other settings.
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