880 Extraction of a Metal Arrow Entering the Skull Base Using a Three-Surgeon Combined Microscopic and Endoscopic Approach

Abstract

INTRODUCTION: Low velocity penetrating brain injuries (PBI) present both a diagnostic and therapeutic challenge in management particularly in operative planning for the extraction of the impaled foreign body. METHODS: A 3-surgeon combined microscopic-endoscopic approach with the use of intraoperative ultrasound, angiogram, and C-arm localization was done. This involved a 5-part procedure: internal carotid angiography; parieto-occipital vertex craniotomy with ultrasound-guided localization; right transciliary cranio-orbito-zygomatic osteotomy transciliary approach; endoscopic guided advancement and extraction of foreign body and endoscopic endonasal transsphenoidal repair of skull base defect. RESULTS: The rationale for the procedures borders on obtaining information on the relationship of the arrow to the major vessels at the base of the brain, visualization of the arrow’s entry into the skull, guidance on the point of exit as the arrow was pushed upwards towards cortex and extracted it from the surface, and the integrated use of a basal approach for actual visualization of the shaft of the arrow. The patient remained clinically and neurologically stable post-operatively and was discharged after 10 days. He was back to pre-morbid functional status during follow-up at the outpatient two weeks after surgery. CONCLUSIONS: Presented is a successfully managed case of low-velocity PBI. The knowledge of surgical anatomy combined with the different concepts and principles of neurosurgery led to the development of combined techniques that can be used and may further be improved in the management of these injuries.