Figure 1
Brain CT examination
Foreign body-wood traveled from the orbit through the cavernous sinus to the brain stem
SectionNeuroradiology
Case TypeClinical Cases
AuthorsPalladas P., Voultsinou D., Fidanis Th., Zervidis I., Grigoriadis Ch., Kalpakidis V.
Connected authors
53 years, male
Clinical History
A 53 years old male with an occupational accident evaluated with CT, substraction angiography and treated with left carotid artery embolization and surgery.
Imaging Findings
CT examination revealed the presence of a foreign body at the left orbital cavity with entrance point at the inferolateral part of the orbit which was displaced supero-mediallly (Figure 1a). At the site of the attachment of the foreign body with the bulb a hyperdence convex area at the bulb wall was observed (Figure 1a).The imaging findings were indicative of either hematoma or retinal detachment. The left superior ophthalmic vein (Figure 1c), was dilated compared to the right one. The optic nerve was viewed intact. A small sphenoidal bone fracture was observed. (Figure 1d).
The foreign body route continued through the superior orbital fissure and the ipsilateral cavernous sinous to the brain stem-MPR view (Figure 2a, b, 3). The cavernous sinus depicted asymmetrical and the foreign body observed at a close proximity to the adjacent bone with restriction of the cavernous sinus space. This finding in combination with the dilated left superior ophthalmic vein was suspicious for traumatic carotid-cavernous communication.
At lower levels the left cerebellar cisterna was dilated compared to the right one finding indicative of hygroma (Figure 3b).
At substraction angiography the left carotid artery, at the cavernous part depicted externally compressed -diminished size, with irregular margin- signs of injury. No contrast medium extravasion or direct carotid-canernous communication visualized at arterial and venous phase (Figure 4). The preoperative embolization of carotid artery part was necessary (Figure 5) before surgery. The patient operated and the foreign body removed (Figure 6).
The foreign body route continued through the superior orbital fissure and the ipsilateral cavernous sinous to the brain stem-MPR view (Figure 2a, b, 3). The cavernous sinus depicted asymmetrical and the foreign body observed at a close proximity to the adjacent bone with restriction of the cavernous sinus space. This finding in combination with the dilated left superior ophthalmic vein was suspicious for traumatic carotid-cavernous communication.
At lower levels the left cerebellar cisterna was dilated compared to the right one finding indicative of hygroma (Figure 3b).
At substraction angiography the left carotid artery, at the cavernous part depicted externally compressed -diminished size, with irregular margin- signs of injury. No contrast medium extravasion or direct carotid-canernous communication visualized at arterial and venous phase (Figure 4). The preoperative embolization of carotid artery part was necessary (Figure 5) before surgery. The patient operated and the foreign body removed (Figure 6).
Discussion
Most foreign body injuries to the extremities or other parts of the body involve common daily activities, but occupational accidents probably account for the majority of the cases.
Most metallic materials are opaque on radiographs, except aluminium. Most animal bones and all glass foreign bodies are as well opaque on radiographs. However, plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are usually not sufficiently opaque to be visualized. The diagnosis of a nonopaque object may be difficult. In selected cases, CT and US may show the suspected foreign object in the superficial tissues of the body. At US, foreign objects frequently give a localized, reproducible hyperechoic signal. Needle localization techniques similar to those used for mammographic needle localization of nonpalpable breast lesions before surgical breast biopsy may occasionally aid. Plain radiographs typically are used in patients who have a foreign body insertion. CT scanning is the imaging modality of choice in these cases. Surgical extraction is needed in most cases.
Most metallic materials are opaque on radiographs, except aluminium. Most animal bones and all glass foreign bodies are as well opaque on radiographs. However, plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are usually not sufficiently opaque to be visualized. The diagnosis of a nonopaque object may be difficult. In selected cases, CT and US may show the suspected foreign object in the superficial tissues of the body. At US, foreign objects frequently give a localized, reproducible hyperechoic signal. Needle localization techniques similar to those used for mammographic needle localization of nonpalpable breast lesions before surgical breast biopsy may occasionally aid. Plain radiographs typically are used in patients who have a foreign body insertion. CT scanning is the imaging modality of choice in these cases. Surgical extraction is needed in most cases.
Differential Diagnosis List
Foreign body-wood at the orbit, cavernous sinus and brain stem.
Final Diagnosis
Foreign body-wood at the orbit, cavernous sinus and brain stem.
Case information
| URL: | https://www.eurorad.org/case/6731 |
| DOI: | 10.1594/EURORAD/CASE.6731 |
| ISSN: | 1563-4086 |
Figure 2
Brain CT examination Multiplanar Imaging Reconstruction
Figure 2a. Sagital view. The foreign body route continued through the superior orbital fissure and the ipsilateral cavernous sinous to the brain stem.
Figure 2 b. Coronal view. The cavernous sinus depicted asymmetrical compared to the right site and the foreign body observed at a close proximity to the adjacent bone with restriction of the cavernous sinus space.
Figure 4
Substraction angiography
Figure 4a. Sagital view
The cavernous carotid part visualized externally compressed (diminished size ), with irregular margin at the site of contact with the foreign body. Findings indicating carotid artery injury.No contrast medium extravasion or direct carotid-canernous communication visualized at arterial and venous phase at the angiography.
Figure 4b. Coronal view.
Figure 4c. Zoomed view.
Figure 5
Photograph of the patient.
Figure 6
Substraction angiography after embolization.
Figure 5. Embolization particles demostrated at the left carotid lumen.
Brain CT examination
Brain CT examination Multiplanar Imaging Reconstruction
Figure 2a. Sagital view. The foreign body route continued through the superior orbital fissure and the ipsilateral cavernous sinous to the brain stem.
Figure 2 b. Coronal view. The cavernous sinus depicted asymmetrical compared to the right site and the foreign body observed at a close proximity to the adjacent bone with restriction of the cavernous sinus space.
Substraction angiography
Figure 4a. Sagital view
The cavernous carotid part visualized externally compressed (diminished size ), with irregular margin at the site of contact with the foreign body. Findings indicating carotid artery injury.No contrast medium extravasion or direct carotid-canernous communication visualized at arterial and venous phase at the angiography.
Figure 4b. Coronal view.
Figure 4c. Zoomed view.
Photograph of the patient.
Substraction angiography after embolization.
Figure 5. Embolization particles demostrated at the left carotid lumen.