Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 6 (2016) 65–67

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Case Report & Case Series Combined use of OsiriX™ imaging software and ultrasound to guide surgery in a patient with a needle in the head

Naci Balak, M.D. a,⁎, Emrah Duman, M.D. b, Izzet Durmusalioglu, M.D. a, Ercan Bosnak, M.D. a a Department of Neurosurgery, Göztepe Education and Research Hospital, Kadiköy, Istanbul, Turkey b Department of Radiology, Göztepe Education and Research Hospital, Kadiköy, Istanbul, Turkey article info abstract

Article history: It is essential to use minimally invasive techniques in the surgical removal of the foreign object in asymptomatic Received 22 September 2016 patients. A 39-year old woman with an approximately 3 cm-long thin metallic object adjacent to the left frontal Accepted 1 October 2016 bone is reported. The patient's CT scans were evaluated using OsiriX™ software and by an ultrasound. The object was removed minimally invasively using a local anesthetic, with reduced operative time, less bleeding, quicker Keywords: wound healing and better cosmetic results. Imaging Penetrating injury © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license Minimally invasive surgery (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction patient might have a metallic object in her head. The MRI was stopped. A cranial computed tomography (CT) was performed and revealed an Penetrating head injuries may be diagnosed immediately or with approximately 3 cm-long metallic object in the shape of a sewing needle late symptoms, years after the traumatic event. Late presenting symp- embedded in the external table of the left frontal bone (Fig. 1a, b, c). The toms may include epilepsy, abscess, cognitive decline, frontal lobe syn- patient was suffering severe neck pain and insisted that this foreign ob- drome, and possible trauma-induced glioblastoma multiforme [1,2]. ject should be removed and her cervical MRI study completed so that a However, there is no absolute indication for removing intracranial sew- diagnosis could be made. She was therefore admitted to our hospital for ing needles detected in the later decades of life [3,4]. Epilepsy, infection its removal. The patient could not at first account for how this metallic or abscess, cerebrospinal fluid leaks are among the main surgical indica- object might have entered her head, but later she recalled that when tions [1,5,6]. Chronic headache can also be a reason for removal of the she had given birth to her first child, at the age of twenty, she had needle [3]. In asymptomatic patients, the needle can be left in situ or re- stabbed a sewing needle into her pillow and slept on it. This was be- moved to prevent the possibility of the late symptoms mentioned above cause of a local superstition that a mother and her newborn baby or the migration of the needle associated with subsequent neurological would in this way be protected from evil and harm during the accouche- injury [7]. If the decision is made to operate on a patient with a sewing ment period. needle in the head, it is essential to use minimally invasive techniques. The patient's CT scans were evaluated in three dimensions using This is especially crucial to justify surgical removal in asymptomatic OsiriX™ software (OsiriX™ imaging software, Pixmeo, Geneva, patients. Switzerland). The metallic object was found to be located in the left frontal region, adjacent to the external table of the bone, anterior to the coronal suture, extending approximately from the hair line posteri- 1.1. Case presentation orly parallel to the sagittal plane, 1 cm on the left side of the midline (Fig. 1d, e). The location of the metallic object was also evaluated by ul- A 39-year old woman was seen in the outpatient clinic for severe trasound (Hitachi HI VISION Preirus, Hitachi Medical Corporation Tokyo, neck and shoulder pain. A cervical magnetic resonance imaging (MRI) Japan), which confirmed the same location found by using the OsiriX™ was advised. However, as soon as the MRI study started, the radiology DICOM viewer (Fig. 1f). technician noticed intense artifacts, which made him suspect that the Under local anesthesia, the patient was operated on in the supine position. A linear skin incision of approximately 3 to 4 cm was made, Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging. starting at the frontal hairline and extending posteriorly parallel to the ⁎ Corresponding author at: Department of Neurosurgery, Göztepe Education and sagittal suture, 1 cm on the left side of the midline. The foreign object Research Hospital, Kadiköy, Istanbul 34730, Turkey. was immediately visible under the periost (Fig. 1g). The object was re- E-mail addresses: [email protected], [email protected] (N. Balak), [email protected] (E. Duman), [email protected] moved easily, although some bone drilling was necessary since it was (I. Durmusalioglu), [email protected] (E. Bosnak). partly buried in the external table of the frontal bone (Fig. 1h, i).

http://dx.doi.org/10.1016/j.inat.2016.10.004 2214-7519/© 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 66 N. Balak et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 6 (2016) 65–67

Fig. 1. Cranial computed tomography scans in axial (a), coronal (b), and sagittal planes (c). White arrows indicate the metallic foreign body. OsiriX™ imaging software showed the exact location of the foreignbodyin3Dvolumerenderingview(blackarrows) (d and e). The ultrasound image also shows the foreign body under the skin and adjacent to the bone (the object is between the white arrows) (f). At surgery, the foreign body is seen under the periost (white arrow) (g). After the removal of the object, its bone bed is seen to be clean (h). The foreign object proved to be a sewing needle (i).

2. Discussion used as alternatives to real measurements to within accuracy of 0.3-mm and very high reliability [10,11]. In our case, the patient was suffering complaints in the neck and a The use of ultrasound to locate superficial objects in the soft tissues cervical MRI study was indicated. The needle in her head did not permit under the skin has been reported [12]. However, it cannot reveal a sew- an MRI study to be done, thus necessitating its removal. Since MRI stud- ing needle under the bone in an adult. In pediatric patients, ultrasound- ies are now a common diagnostic tool in all medical specialties, provid- guided needle localization to aid removal may be possible [13].Inthis ing patients with the freedom to have these performed for any reason case, the object was only slightly embedded in the external table of can be another indication of surgery in such cranially asymptomatic pa- the frontal bone and was visible on ultrasound. tients. The anatomical location of the needle is, of course, another issue to take into account in the decision to perform surgery. 3. Conclusions To use minimally invasive techniques is especially crucial to justify surgical removal in asymptomatic patients. Conventional stereotaxy or Combined use of the OsiriX™ imaging software program and an ultra- neuronavigational systems using infra-red optical tracking can be helpful. sound to locate the metallic foreign body in this case resulted in a minimal- On the other hand, neuronavigational systems using electromagnetic ly invasive procedure using a local anesthetic, with reduced operative time, technology are impractical in a patient with a metallic object in the less bleeding, quicker wound healing and better cosmetic results. head. When appropriate neuronavigation is not possible, other devices and techniques are necessary. Intraoperative fluorescence in angiography Funding technologies to guide the removal of the foreign metal body in the vicinity of major vascular structures can be used [8].Inthiscase,wefoundthe This research did not receive any specific grant from funding agen- combined use of the OsiriX™ imaging software program and ultrasound cies in the public, commercial, or not-for-profit sectors. helpful in the minimally invasive and cosmetically better removal. The OsiriX™ imaging software program, an image processing software dedi- Authors' contributions cated to DICOM images, was developed as a stand-alone application for the MacOS X operating system and has been specifically designed for nav- 1. Guarantor of integrity of the entire study NB. igation and visualization of multimodality and multidimensional images 2. Study concepts and design NB. [9]. Length measurements on 3D CT using the OsiriX™ program can be 3. Literature research NB. N. Balak et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 6 (2016) 65–67 67

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