A 20-year-old male was admitted to our emergency department as a referral from a peripheral hospital after a motorcycle accident six hours before admission. He had a tubular foreign body lodged above the suprasternal notch, with a history of torrential bleeding from the site of injury but that had since ceased. His relatives gave a positive history of momentary loss of consciousness followed by mental confusion immediately after the accident but no history of bleeding from the ear, nose and throat.
On primary survey, the airway was patent with regular quiet breathing and there was no cervical spine tenderness. The respiratory rate was 18 breaths per minute with an oxygen saturation of 97–99% on room air. The trachea was central with symmetrical chest expansion, and equal bronchovesicular breath sounds bilaterally. All his peripheries were warm and had a normal radial artery volume pulse with a capillary refill time of less than 3 s in all limbs. His radial pulse rate was 108 beats/minute and he had a blood pressure of 95/59 mmHg. His heart sounds S1 and S2 were heard and normal with no added sounds. The Glasgow Coma Scale was 10/15. His pupils were 3 mm in diameter bilaterally and reacting to light normally. There were no craniopathies or peripheral localizing signs. His random blood sugar was 5.8 mmol/L. There were bruises over the right frontal area but with no active bleeding. No other obvious deformities were evident. The eFAST (Extended Focused Assessment with Sonography in Trauma) was negative.
On secondary survey, he had an edematous right cheek and neck, multiple bruises on the right side of the mouth around the labial commissure, but no wounds visualized in the oral cavity. He had a normal ear, nose and throat examination. A ball-point pen plastic ink chamber (1.5 mm diameter) was firmly lodged in the midline about 1 cm above the suprasternal notch with no active bleeding. There was swelling in zone I and II of the neck and around the area of the point of entry by the pen (See Fig. 1). The rest of the secondary survey was unremarkable.
He had a hemoglobin of 12.6 g/dL. The renal and liver function tests were all normal. The chest radiograph was normal. A non-contrasted brain CT-scan showed deep right basal ganglia and lateral ventricle haemorrhage with right frontal lobe contusion and intracerebral haemorrhage (See Fig. 2). The contrasted CT-angiogram of the chest demonstrated a penetrating foreign body traversing the superior mediastinum and penetrating the lumen of the ascending aorta just distal to the brachiocephalic artery origin but without perforating the posterior wall of the aorta (Fig. 3).
The patient underwent mediastinal exploration via a median sternotomy. We found a ball-point pen traversing the superior mediastinum and the anterior aortic arch wall (Zone 0) with the tip lying in the lumen of the aorta. Only the smaller plastic pen ink chamber was visible externally. The larger diameter and rigid pen barrel had broken within the mediastinum and was plugging the aortic perforation (Fig. 4). There was no obvious active hemorrhage or hematoma in the superior mediastinum and no injury was to the trachea, oesophagus or major aortic arch vessels.
Dissection and mobilization around the aortic injury was done. Under systemic heparinisation, the ball-point pen was explanted and a side biting De Bakey aortic clamp was immediately applied to control haemorrhage (Fig. 5). A 10 mm full thickness injury in the anterior wall of the aortic arch was noted. The defect was debrided and repaired with a polypropylene 4/0 stitch in a double layer (Fig. 6). A 36-Fr mediastinal drain was left in situ. Hemostasis was achieved and the chest wall closed in layers.
The patient was transferred to the ICU for immediate postoperative management. He developed worsening confusion during the first two postoperative days which was treated with antipsychotics. The intracerebral haemorrhage was managed conservatively and no anticoagulation was given postoperatively. On the 4th postoperative day, he was transferred to the ward where recovery continued uneventfully but with residual mental confusion. On the sixth postoperative day the chest drain was removed and the patient was discharged home on antipsychotics, antibiotics and analgesics.
He was reviewed two weeks later and all wounds were noted to be healing well. However, he had residual mental confusion that was considered part of the post-concussion syndrome and for which continued neurosurgical review was sought. His review at 6 weeks revealed complete resolution of his mental confusion with no other neurological deficit and a healed surgical scar.
