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It can lead to life-threatening severe neurovascular damage. Surgery is the primary treatment choice; however, there are a number of approaches that can be considered based on the patient's condition in terms of foreign body location and state of the patient. Clinical presentation An 18-year-old male carpenter was hit by a log and sustained transorbital PBI while cutting wood with a machine. Computed tomography (CT) scan showed a wooden spike that was approximately 11 cm from the left medial orbital to the superior part of the posterolateral of the petrous bone, crossing the right side at the base of the skull. CT angiography (CTA), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) revealed no internal carotid artery (ICA) and cavernous sinus lesions, respectively. We had a 3D-printed model for preoperative planning, and surgery was performed using a transorbital approach to extract the wood 14 days after the accident. The impacted wood was removed without any complications. Conclusion There are many surgical approaches for transorbital PBI. We decided to perform the transorbital approach because it is perpendicular to the entry zone. In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal. Surgeons should consistently perform minimally invasive procedures based on the clinical and radiological findings. \" } { \"@context\": \"http://schema.org\", \"@type\": \"BreadcrumbList\", \"itemListElement\": [ { \"@type\": \"ListItem\", \"position\": \"1\", \"item\": { \"@id\": \"https://f1000research.com/\", \"name\": \"Home\" } }, { \"@type\": \"ListItem\", \"position\": \"2\", \"item\": { \"@id\": \"https://f1000research.com/browse/articles\", \"name\": \"Browse\" } }, { \"@type\": \"ListItem\", \"position\": \"3\", \"item\": { \"@id\": \"https://f1000research.com/articles/10-1283/v2\", \"name\": \"Case Report: Transorbital approach for the management of an orbito-temporal...\" } } ] } Home Browse Case Report: Transorbital approach for the management of an orbito-temporal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y. Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.12688/f1000research.74382.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] Tedy Apriawan https://orcid.org/0000-0003-4063-0982 1 * , Abdul Hafid Bajamal 1 * , Ditto Darlan https://orcid.org/0000-0002-8825-5678 1 * , Yusriandi Ramadhan https://orcid.org/0000-0002-7482-6281 1 * Tedy Apriawan https://orcid.org/0000-0003-4063-0982 1 * , Abdul Hafid Bajamal 1 * , Ditto Darlan https://orcid.org/0000-0002-8825-5678 1 * , Yusriandi Ramadhan https://orcid.org/0000-0002-7482-6281 1 * * Equal contributors PUBLISHED 11 Mar 2026 Author details Author details 1 Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, East Java, 60285, Indonesia Tedy Apriawan Roles: Conceptualization, Data Curation, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdul Hafid Bajamal Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Ditto Darlan Roles: Conceptualization, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Yusriandi Ramadhan Roles: Conceptualization, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background and importance Transorbital penetrating brain injury (PBI) due to a non-projectile foreign body is rare. It can lead to life-threatening severe neurovascular damage. Surgery is the primary treatment choice; however, there are a number of approaches that can be considered based on the patient's condition in terms of foreign body location and state of the patient. Clinical presentation An 18-year-old male carpenter was hit by a log and sustained transorbital PBI while cutting wood with a machine. Computed tomography (CT) scan showed a wooden spike that was approximately 11 cm from the left medial orbital to the superior part of the posterolateral of the petrous bone, crossing the right side at the base of the skull. CT angiography (CTA), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) revealed no internal carotid artery (ICA) and cavernous sinus lesions, respectively. We had a 3D-printed model for preoperative planning, and surgery was performed using a transorbital approach to extract the wood 14 days after the accident. The impacted wood was removed without any complications. Conclusion There are many surgical approaches for transorbital PBI. We decided to perform the transorbital approach because it is perpendicular to the entry zone. In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal. Surgeons should consistently perform minimally invasive procedures based on the clinical and radiological findings. READ ALL READ LESS Keywords penetrating brain injury, PBI surgical management, transorbital approach wooden foreign body Corresponding Author(s) Tedy Apriawan ( [email protected] ) Close Corresponding author: Tedy Apriawan Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2026 Apriawan T et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y. Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.12688/f1000research.74382.2 ) First published: 15 Dec 2021, 10 :1283 ( https://doi.org/10.12688/f1000research.74382.1 ) Latest published: 11 Mar 2026, 10 :1283 ( https://doi.org/10.12688/f1000research.74382.2 ) Revised Amendments from Version 1 We added an emphasis on day 14 as the timing of intervention in the abstract, as it represents the main message of the case. We also removed the surgical step table and integrated the steps into the illustrative figure to improve clarity and effectiveness. We added an emphasis on day 14 as the timing of intervention in the abstract, as it represents the main message of the case. We also removed the surgical step table and integrated the steps into the illustrative figure to improve clarity and effectiveness. See the authors' detailed response to the review by Mamoru Murakami See the authors' detailed response to the review by Chi Hoon Choi READ REVIEWER RESPONSES Background and importance Transorbital penetrating brain injury (PBI) secondary to a non-projectile foreign body is rare and potentially life-threatening. The orbital wall is thin; therefore, access to the cranial cavity through this region can be swift. It can cause severe damage to the eye, optic nerves, brain parenchyma, and neurovascular structures. 1 Prevalence studies have reported that transorbital PBI accounts for 45% and 24% of all traumatic brain injury in children and adults, respectively, and accounts for 0.04% of all traumatic brain injury and 4.5% of all orbital pathologies. 2 , 3 Transorbital PBI at the skull base region can cause severe neurovascular damage. Vital structures, such as cranial nerves, arteries, and the cavernous sinus, are of particular concern during preoperative planning for surgery in patients with transorbital PBI in the skull base region. 4 Immediate complications (that can occur within a week of injury) include haemorrhage, vascular damage (such as carotid-cavernous fistula [CCF], traumatic aneurysm, and intravascular thrombosis), ischemic brain injury, brain oedema, and cerebral contusion. 5 Delayed complications (that can occur after more than a week of injury) include infections (meningitis, encephalitis, and orbital cellulitis), foreign body migration, hydrocephalus, and cerebrospinal fluid (CSF) leakage. 5 Therefore, it is essential to understand the mechanism of injury, reconstruction of preoperative planning surgery, and postoperative care. 4 The timing of surgery also needs to be considered in patients with a wooden transorbital PBI, especially when it involves a rough wooden surface, as it can cause more severe tissue damage. 4 Adequate debridement, administration of antibiotics, and anti-seizure prophylaxis are also required to achieve a satisfactory outcome. 6 Surgery is the primary treatment for most cases of transorbital PBI. Available approaches include the transorbital approach, right or left frontal craniotomy applying the subfrontal approach, right or left frontotemporal craniotomy, bifrontal craniotomy using the anterior interhemispheric approach, lobectomy, and the percutaneous lumbar intrathecal approach. 7 – 12 In our case, we considered using the transorbital approach in view of the clinical and radiological features that are associated with such cases of wooden transorbital PBI. Clinical presentation An 18-year-old male carpenter sustained a wooden PBI at two locations—the right frontoparietal and left orbito-temporal areas, and the base of the skull—while cutting wood with a machine. The wood in the frontoparietal area was extracted, and bone decompression along with evisceration of his left eye were performed six hours after the incident at the district general hospital. Afterwards, the patient was referred to our hospital for further management. He complained of pain and loss of sight in the left eye. He had a Glasgow Coma Scale (GCS) score E 4 V 5 M 6 , trigeminal nerve palsy (V 2 and V 3 ), facial nerve palsy of the peripheral type (House Brackmenn grade IV) and left-sided hemiparesis. There was no sign of CSF leakage. Laboratory examinations revealed leucocytosis and increased C-reactive protein (CRP) and procalcitonin levels. Computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and a 3D-printed model were used preoperatively to plan for surgery ( Figure 1 ). There were no lesions in the internal carotid artery, cavernous sinus, and transverse sinuses ( Figure 2 ). We surgically extracted the wood 14 days after the accident with a minimally invasive surgical step ( Figure 3 ). Empirical antibiotics were administered for six weeks while awaiting definitive antibiotic treatment based on microbiological and antibiotic susceptibility tests. Phenytoin was administered for a week after the accident for post-traumatic seizure prophylaxis. Figure 1. Brain computed tomography (CT) scan without contrast shows a piece of wood about 11 cm (with a low signal density on CT scan). (A) The wood is seen to extend from the left medial orbital region, ethmoid sinus, across the contralateral sphenoid sinus, and reach the superior part of the posterolateral surface of the petrous bone before crossing to the right side. (B) Another piece of wood that extends from the right frontal to the right parietal region (about 10 cm long) is also observed. (D) and (E) show bone window segments. (C) and (F) T1-weighted contrast magnetic resonance imaging (MRI) using gadolinium shows that the foreign body had formed a fibrous capsule. Figure 2. Further radiological evaluation. (A), (B), and (C) computed tomography (CT) angiography and reconstruction of the cerebral arteries shows no rupture in the internal carotid artery (ICA). (D) magnetic resonance angiography (MRA) reveals narrowing of the right ICA that is compressed by the one of the pieces of wood. (E) magnetic resonance venography (MRV) shows no lesion in the cavernous sinus. Figure 3. Surgical step during the extraction of the wooden foreign body. Step 1: The patient was placed in the supine position, facing the right side. Following surgical draping, the operating area around his left eye was disinfected. He was placed perpendicular to the operator's view; Step 2: A linear incision was made on the conjunctiva; Step 3: The superior and inferior palpebrae were gently retracted using the Langenbeck retractor. Blunt dissection of the left orbital soft tissue was then performed; Step 4: The tip of the wooden foreign body was identified on the medial orbital wall; Step 5: Osteotomy was performed using Kerrison punch forceps until the hole at the penetration area became wider; Step 6: The wood was extracted gently using a bone rongeur. Extraction was performed perpendicular to the operator’s view; Step 7: Haemorrhage was evaluated and treated after extracting the wood. Further haemostasis was achieved using Gelfoam and Surgicel; Step 8: Suturing in layers and canthorrhaphy were performed. Postoperative follow-up Postoperative CT scan evaluation revealed gross total extraction without any haemorrhagic lesion along with a GCS of E 4 V 5 M 6 ( Figure 4 ). The patient was discharged six weeks after the pieces of wood were extracted, and no apparent clinical complications and abnormal infectious parameters (leucocyte, CRP, and procalcitonin) were found. Six months postoperatively, there was no feature of trigeminal nor facial palsy. The patient could return to his usual activities, and a customized ocular prosthesis was made for his left eye. Figure 4. Non-contrast head computed tomography (CT) scan showed that the wooden foreign body was removed without any haemorrhage lesion. Discussion The goals of surgery in cases of wooden transorbital PBI include: (1) debridement of non-vital tissues, considering the extensive damage the wood may have caused; (2) evacuation of hematomas, such as extradural, subdural, and intraparenchymal hematoma; (3) removal of as much bone fragments as possible; (4) retrieval of foreign body fragments (larger fragments should be meticulously sought out, as they tend to migrate); (5) securing of adequate haemostasis; and (6) watertight closure of the dura mater, which usually requires the use of grafts. Turbin anatomical criteria refer to zone 3b (medial canthus) as the area where the orbital area exits at the superior orbital fissure and sphenoid wing. 1 The aspects of the central nervous system at risk of damage in that area include the cavernous sinus, temporal lobe, brain stem, or basal cistern. 1 In our case, the patient underwent a two-stage surgery. The first stage of surgery was debridement, surgical extraction of the right frontoparietal wooden object, bone decompression, and left ocular evisceration, which were done six hours after the incident at the district general hospital. The bone flap removed from the injured side was placed on the contralateral subgaleal layer of the injured side. The patient was referred to our hospital because we were more equipped to manage the extraction of the wood from the orbito-temporal part of the base of the skull. In this case we also performed the 3D-printed reconstruction for the surgery plan because 3D-printed model reconstruction can help neurosurgeons for surgical strategies, and it enhances the anatomical visualization of the location and trajectory of the foreign body, which is not completely visible from the outside ( Figure 5 ). 13 Figure 5. 3D-printed model reconstruction used for preoperative planning. (A). Tip of the wooden foreign body at the medial orbital wall. (B) and (C) Show that there is no lesion in the internal carotid artery (red) and cavernous sinus (dark blue). Based on details obtained from CT angiography (CTA), magnetic resonance venography (MRV), MRA, and the 3D-printed reconstruction, no serious neurovascular lesions were seen. Therefore, we decided to perform the second stage of surgery in the orbito-temporal part of the base of the skull base. The patient was positioned supine facing to the right for a transorbital approach, perpendicular to the wooden foreign body’s entry zone. The eyelid was retracted gently, and the flap was sutured using silk 3.0. The conjunctiva was incised horizontally from the medial to the lateral canthus. We performed soft-tissue exploration of the orbit using a Langenbeck retractor until the medial wall of the orbit (ethmoid bone) was visible. When performing soft tissue retraction of the orbit using a Langenbeck retractor, it is essential to pay attention to the presence of an oculocardiac reflex due to stretching of the afferent stretch receptors that are transmitted through the ciliary nerve, Gasserian ganglion, and efferent vagal fibres, which are capable of increasing the parasympathetic tone. This could cause bradycardia in the patient. After exploring the soft tissue of the orbit medially, the superficial tip of the wood was revealed in line with its trajectory. Osteotomy of the interlocking bone around the tip of the wooden foreign body was performed using a Kerrison punch, then the bone around the tip of the wood was meticulously removed. The wooden foreign body was gently extracted, perpendicular to the operator’s view, using a bone rongeur . There was no brisk bleeding from the internal carotid artery nor from the cavernous sinus. Adequate debridement (irrigation for dilution) and haemostasis (using Gelfoam and Surgicel) were achieved after the wood was extracted. The wooden foreign body and the fibrous capsule formed were examined for infection via microbiological culture and antibiotic susceptibility testing. Finally, we sutured the skin in layers and performed tarsorrhaphy. The wood was most probably contaminated; therefore, we debrided any easily accessible impacted bone and other extracranial tissues along the track. Regarding the timing of surgery, for our patient surgery was performed 14 days after the accident. The purpose of this was to ensure that a consistently thick fibrous capsule had formed over the entire body of the wood. This is a physiological foreign body reaction that protected the brain from the rough surface of the wood. Ibrahim et al. , in their experimental study in 2017, reported that the immune response to foreign body implantation began on day 14. 14 Mast cells (MC) are mobilized to the site of the wound, where they mature and are activated early in the inflammatory process through chemotactic inflammatory signaling. The activated MC secrete mediators, such as IL-4 and IL-13, attracting macrophages through chemotactic signals. To improve their effectiveness, macrophages fuse to form foreign body massive cells that reside at the tissue interface. 15 Foreign-body giant cells are still incapable of digesting large implants but can secrete cytokines that cause fibroblasts to produce a collagen capsule that embraces the foreign body, and this effectively isolates it from surrounding tissue. 16 On day 14, the thickest fibrous capsule forms, followed by those on days 60, 90, and 180 ( Figure 6 ). 14 Therefore, watchful waiting until day 14 needs to be considered for a hemodynamically stable patient without severe neurovascular complication. Allograft cranioplasty was performed six months after the accident. This was done to reduce the risk of infection. Figure 6. Illustration of the inflammatory and immune response to the foreign body on day 14. Conclusion Many surgical approaches exist for managing transorbital PBIs. In this case, we decided to perform transorbital approach techniques perpendicular to the entry zone, 14 days after the injury. This enabled us to perform a minimally invasive procedure based on the patient’s clinical and radiological features. Data availability All data underlying the results are available as part of the article and no additional source data are required. Acknowledgments The authors would like to thank all those who contributed to the process and completion of this report, including all neurosurgery consultant and fellow residents of the Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Surabaya. References 1. Turbin RE, Levin F, Maxwell DN: Recognition of transorbital intracranial injury. Clin. Ophthalmol. (Auckland, N.Z.). 2007; 1 (1): 85–89. 2. Luerssen TG, Klauber MR, Marshall LF: Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J. Neurosurg. 1988; 68 (3): 409–416. PubMed Abstract | Publisher Full Text 3. Rootman J: Disease of orbit: a multidisciplinary approach. Philadelphia: Lippincot Willian & Wilkins; 1st ed.1988. 4. Xu L, et al. : The Surgical Strategies and Techniques of Transorbital Nonmissile Brain Injury. World Neurosurg. 2020; 144 : e856–e865. PubMed Abstract | Publisher Full Text 5. Vakil MT, Singh AK: A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg. Radiol. 2017; 24 (3): 301–309. PubMed Abstract | Publisher Full Text 6. Asadullah, Apriawan T, Bajamal AH, et al. : Management of penetrating brain injury: A case report. Indones. J. Neurosurg. 2020; 3 (3): 74–79. Publisher Full Text 7. Schreckinger M, et al. : Transorbital penetrating injury: case series, review of the literature, and proposed management algorithm. J. Neurosurg. 2011; 114 (1): 53–61. PubMed Abstract | Publisher Full Text 8. Xu F, et al. : The surgical management of a penetrating orbitocranial injury with a Bakelite foreign body reaching the brain stem. Brain Inj. 2013; 27 (7–8): 951–956. PubMed Abstract | Publisher Full Text 9. Borkar SA, et al. : Transorbital penetrating cerebral injury caused by a wooden stick: Surgical nuances for removal of a foreign body lodged in cavernous sinus. Childs Nerv. Syst. 2014; 30 (8): 1441–1444. PubMed Abstract | Publisher Full Text 10. Mzimbiri JM, et al. : Orbitocranial Low-Velocity Penetrating Injury: A Personal Experience, Case Series, Review of the literature, and Proposed Management Plan. World Neurosurg. 2016; 87 : 26–34. PubMed Abstract | Publisher Full Text 11. Sun G, et al. : Management Strategy of a Transorbital Penetrating Pontine Injury by a Wooden Chopstick. World Neurosurg. 2016; 95 : 622.e7–622.e15. Publisher Full Text 12. Tabibkhooei A, Aslaninia A, Anousha K: Childhood Transorbital Skull Base Penetrating Injury: Report of 2 Cases and Review of Literature. World Neurosurg. 2019; 131 : 213–216. PubMed Abstract | Publisher Full Text 13. Apriawan T, Bajamal AH, Hermawan Y, et al. : Three-dimensional (3D)-printed model reconstruction in pre-operative planning for wooden penetrating brain injury. Bioprinting. Elsevier B.V. 2021; 24 (April): e00168. Publisher Full Text 14. Ibrahim M, et al. : Characterization of the foreign body response to common surgical biomaterials in a murine model. Eur. J. Plast. Surg. 2017; 40 (5): 383–392. PubMed Abstract | Publisher Full Text | Free Full Text 15. Nichols SP, et al. : The effect of nitric oxide surface flux on the foreign body response to subcutaneous implants. Biomaterials. 2012; 33 (27): 6305–6312. PubMed Abstract | Publisher Full Text | Free Full Text 16. Anderson JM, Rodriguez A, Chang DT: Foreign body reaction to biomaterials. Semin. 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PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Dec 2021 ADD YOUR COMMENT Comment Author details Author details 1 Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, East Java, 60285, Indonesia Tedy Apriawan Roles: Conceptualization, Data Curation, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdul Hafid Bajamal Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Ditto Darlan Roles: Conceptualization, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Yusriandi Ramadhan Roles: Conceptualization, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 11 Mar 2026, 10:1283 https://doi.org/10.12688/f1000research.74382.2 version 1 Published: 15 Dec 2021, 10:1283 https://doi.org/10.12688/f1000research.74382.1 Copyright © 2026 Apriawan T et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y. Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.12688/f1000research.74382.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 11 Mar 2026 Revised Views 0 Cite How to cite this report: Murakami M. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r466673 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-466673 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Mar 2026 Mamoru Murakami , Kyoto Tanabe Central Hospital, Kyoto, Japan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.191016.r466673 Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y Wooden foreign bodies are ... Continue reading READ ALL Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y Wooden foreign bodies are prone to cause infection; therefore, early removal by planned surgery is generally recommended once the diagnosis is established, based on the following three studies(1-3). A scheduled operation performed 14 days after injury is highly exceptional, and its indications are limited. Delayed surgery may be complicated by extensive scarring around the foreign body, adherence to the intracranial vessels. The authors should also discuss the potential disadvantages of delayed surgery and clearly state the reason for intentionally adopting a delayed approach. The authors clarified the “Day-14” strategy is not universal and should be considered when: the patient is hemodynamically stable, imaging (CTA/MRA/MRV) excludes vascular injury, there is no CSF leak or intracranial abscess, and laboratory inflammatory markers are stable or decreasing. However, Robaei et al. reported a case of orbitocranial penetration by a fragment of wood, and they insisted because of its porous organic nature and frequent proximity to soil, wood is an ideal reservoir for bacteria and fungi and is likely to provoke inflammation (4).The organic foreign bodies, especially wooden ones, are linked to a high risk for bacterial and fungal infections, inflammatory granuloma formation, and calcification (5). Taking these findings together, wooden foreign bodies are not merely “objects that can cause infection,” but rather “a nidus of infection itself.” If management is delayed, abscess formation can occur, and intracranial extension may be fatal. Therefore, the literature consistently concludes: “Early surgical removal is recommended.” Even if the conditions proposed by the authors are met, it would be difficult to justify considering surgery after a 14-day delay. References - 1 Wahyudi, et al., 2021 - Ref 1 2. Parbatraj Regmi, et al., 2024 - Ref 2 3. He Van Dong, et al., 2024 - Ref 3 4. Dana Robaei, et al., 2004 - Ref 4 5. Bianca Szabo et al., 2019 - Ref 5 References 1. Wahyudi, Zaky A, Islam A, Prihantono, et al.: An extremely rare case: Transorbital penetrating intracranial injury by wooden foreign body. Case report. Annals of Medicine and Surgery . 2021; 71 . Publisher Full Text 2. Regmi P, Dahal A, Bhattrai S, Nandan Khadga S, et al.: Early removal of transorbital penetrating traumatic brain injury by a wooden object: a case report. Annals of Medicine & Surgery . 2024; 86 (11): 6794-6797 Publisher Full Text 3. Dong H, Nguyen A, Dong H, Vu H, et al.: Penetrating brain injury through the cavernous sinus by chopsticks in Vienamese: a case report. Annals of Medicine & Surgery . 2024; 86 (9): 5561-5566 Publisher Full Text 4. Robaei D, Fernando G, MacDonald C, Branley M: Orbitocranial penetration by a fragment of wood. Medical Journal of Australia . 2004; 181 (6): 329-330 Publisher Full Text 5. Szabo B, Pascalau R, Bartoș D, Bartoș A, et al.: Intraorbital penetrating and retained foreign bodies –a neurosurgical case series. Turkish Neurosurgery . 2019. Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: neurosurgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Murakami M. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r466673 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-466673 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Agrawal A. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r467313 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-467313 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Mar 2026 Amit Agrawal , Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.191016.r467313 Dear Author, Although such lesions are reported in literature, but it is always helpful to add further information on penetrating injuries and their spectrum. Please add details for DSA rationale subsection and indications ... Continue reading READ ALL Dear Author, Although such lesions are reported in literature, but it is always helpful to add further information on penetrating injuries and their spectrum. Please add details for DSA rationale subsection and indications for DSA Please add details for culture and antibiotic susceptibility results of the extracted wood and fibrous capsule Please add details for long term follow up Please add CARE checklist as supplementary material Please mention details for oculocardiac reflex or any intraoperative bradycardia Please check the manuscript for grammar and typographical errors Please use standardize terminology like Day-14 versus day 14 throughout Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neurotrauma I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Agrawal A. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r467313 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-467313 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 15 Dec 2021 Views 0 Cite How to cite this report: Choi CH. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r156737 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-156737 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 12 Dec 2022 Chi Hoon Choi , Chungbuk National University Hospital, Cheongju, South Korea Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.78129.r156737 The authors describe a very rare case and its transorbital approach treatment. This article is important in clinical practice showing the diagnostic images and surgical approach. Strength : A very rare case Weakness : It seems necessary to summarize ... Continue reading READ ALL The authors describe a very rare case and its transorbital approach treatment. This article is important in clinical practice showing the diagnostic images and surgical approach. Strength : A very rare case Weakness : It seems necessary to summarize in order according to the flow of time rather than an additional explanation. Title : - Abstract: - Background and importance : - Clinical presentation/ Surgical procedure/ Postoperative FU : Combining the table and figure 3 would be better. Discussion: I would like to divide the paragraphs and categorize them into subheadings. Figure 5: It would be helpful to describe the details of the preoperative plan by 3d printing (the specifications of the printer & ink and the simple usage environment). Figure 6: It is thought to be an inadequate picture to convey the author's intention. It can be omitted and would be better to present pathological pictures of the foreign body or clinical data of patients. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neroradiology & Neurointervention I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Choi CH. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r156737 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-156737 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 11 Mar 2026 Tedy Apriawan , Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia 11 Mar 2026 Author Response Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion ... Continue reading Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion and clinical course accordingly. Response: We appreciate this suggestion. In this publication, we focused on the patient management choices and the surgical technique performed; therefore, our discussion primarily emphasizes these aspects.” Comment 2: Please merge the table of operative steps with Figure 3, to provide a single comprehensive educational figure. Response: We have merged the stepwise table into Figure 3, so that readers can follow both text and images in one integrated panel. Comment 3: Details of the 3D printing process are lacking. Please specify printer, ink, and resolution so that others can reproduce it. Response: Thank you for pointing this out. This article does not specifically discuss the 3D printing process, as we have addressed that topic in a separate publication. In this paper, we focus on the management decisions made and the surgical technique employed. Comment 4: Figure 6 (schematic of immunological reaction) is not effective. Replace it with more relevant pathological or clinical data. Response: We did not perform histological examination in this patient. Figure 6 is intended to illustrate and summarize the process of fibrous capsule formation that occurred in this case. Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion and clinical course accordingly. Response: We appreciate this suggestion. In this publication, we focused on the patient management choices and the surgical technique performed; therefore, our discussion primarily emphasizes these aspects.” Comment 2: Please merge the table of operative steps with Figure 3, to provide a single comprehensive educational figure. Response: We have merged the stepwise table into Figure 3, so that readers can follow both text and images in one integrated panel. Comment 3: Details of the 3D printing process are lacking. Please specify printer, ink, and resolution so that others can reproduce it. Response: Thank you for pointing this out. This article does not specifically discuss the 3D printing process, as we have addressed that topic in a separate publication. In this paper, we focus on the management decisions made and the surgical technique employed. Comment 4: Figure 6 (schematic of immunological reaction) is not effective. Replace it with more relevant pathological or clinical data. Response: We did not perform histological examination in this patient. Figure 6 is intended to illustrate and summarize the process of fibrous capsule formation that occurred in this case. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 11 Mar 2026 Tedy Apriawan , Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia 11 Mar 2026 Author Response Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion ... Continue reading Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion and clinical course accordingly. Response: We appreciate this suggestion. In this publication, we focused on the patient management choices and the surgical technique performed; therefore, our discussion primarily emphasizes these aspects.” Comment 2: Please merge the table of operative steps with Figure 3, to provide a single comprehensive educational figure. Response: We have merged the stepwise table into Figure 3, so that readers can follow both text and images in one integrated panel. Comment 3: Details of the 3D printing process are lacking. Please specify printer, ink, and resolution so that others can reproduce it. Response: Thank you for pointing this out. This article does not specifically discuss the 3D printing process, as we have addressed that topic in a separate publication. In this paper, we focus on the management decisions made and the surgical technique employed. Comment 4: Figure 6 (schematic of immunological reaction) is not effective. Replace it with more relevant pathological or clinical data. Response: We did not perform histological examination in this patient. Figure 6 is intended to illustrate and summarize the process of fibrous capsule formation that occurred in this case. Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion and clinical course accordingly. Response: We appreciate this suggestion. In this publication, we focused on the patient management choices and the surgical technique performed; therefore, our discussion primarily emphasizes these aspects.” Comment 2: Please merge the table of operative steps with Figure 3, to provide a single comprehensive educational figure. Response: We have merged the stepwise table into Figure 3, so that readers can follow both text and images in one integrated panel. Comment 3: Details of the 3D printing process are lacking. Please specify printer, ink, and resolution so that others can reproduce it. Response: Thank you for pointing this out. This article does not specifically discuss the 3D printing process, as we have addressed that topic in a separate publication. In this paper, we focus on the management decisions made and the surgical technique employed. Comment 4: Figure 6 (schematic of immunological reaction) is not effective. Replace it with more relevant pathological or clinical data. Response: We did not perform histological examination in this patient. Figure 6 is intended to illustrate and summarize the process of fibrous capsule formation that occurred in this case. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Murakami M. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r150802 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-150802 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Sep 2022 Mamoru Murakami , Kyoto Tanabe Central Hospital, Kyoto, Japan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.78129.r150802 Comments to the author Title: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes. The authors describe a very rare case of penetrating injury, treated well via ... Continue reading READ ALL Comments to the author Title: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes. The authors describe a very rare case of penetrating injury, treated well via transorbital approach. The article is well written. They provide suggestions about the surgical approach and the timing of surgery, which are important in clinical practice. Title and abstract: The title is appropriate for the content of the article. The abstract is concise and accurately summarises the essential information of the paper, although it would be better if authors included the comment about the timing of the surgery in conclusion. Case report: The clinical case presentation is well written but some minor points that should be clarified: There is no comment about a conventional angiography. The wooden spike penetrated near the cavernous sinus. In case of suspicion for the injury of internal carotid artery, there are opinions that digital subtraction angiogram (DSA) should be performed to evaluate the lesion which 3DCTA could not clearly demonstrate, such as arterio-venous fistula (AVF). If you did not perform DSA in this case, could you explain that reason? The timing of the second surgery is very important. If the foreign body is wooden, serious infection is often problematic, since the porous nature of wood is a strong growth medium for microorganisms. During waiting for 14 days to the second surgery, there might be possibility of exacerbation of epidural or subdural abscess. Some neurosurgeons might insist the early second-surgery to prevent the serious infections. In case of penetrating brain injury of wooden spikes, do you consistently recommend waiting until 14 days, which the wooden spikes form the fibrous capsule? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: neurosurgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Murakami M. Reviewer Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r150802 ) The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-150802 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 11 Mar 2026 Tedy Apriawan , Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia 11 Mar 2026 Author Response Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We ... Continue reading Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We agree. We have revised the abstract conclusion to explicitly state that in this patient, extraction was performed on Day-14, utilizing the formation of a fibrous capsule to facilitate safer removal. The sentence now reads: “In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal.” Comment 2: Digital subtraction angiography (DSA) was not performed. Please explain why, and clarify the role of DSA in such cases. Response: We appreciate this important point. DSA is indeed the gold standard for detecting vascular lesions such as arteriovenous fistula or pseudoaneurysm. In this case, multiple imaging modalities (CTA, MRA, MRV) showed no vascular injury, the patient was clinically stable, and there were no signs of carotid-cavernous fistula or AV shunt. Based on these, we chose close surveillance instead of immediate DSA. We have now added a sub-section titled “Rationale for not performing DSA” in the Discussion, clarifying that: DSA should be performed when CTA/MRA are inconclusive or when clinical suspicion remains high. In our case, multimodal negative findings and clinical stability justified observation. We emphasize that in other centers or in cases with ambiguous findings, DSA remains recommended. Comment 3: Is the “Day-14” timing universally recommended, or only applicable under specific conditions? Response: Thank you for this critical observation. We have clarified that the “Day-14” strategy is not universal. It should only be considered when: The patient is hemodynamically and neurologically stable. Imaging (CTA/MRA/MRV) excludes vascular injury. There is no CSF leak or intracranial abscess. Laboratory inflammatory markers (WBC, CRP, procalcitonin) are stable or decreasing. We emphasize that immediate extraction is warranted if infection or deterioration occurs. Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We agree. We have revised the abstract conclusion to explicitly state that in this patient, extraction was performed on Day-14, utilizing the formation of a fibrous capsule to facilitate safer removal. The sentence now reads: “In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal.” Comment 2: Digital subtraction angiography (DSA) was not performed. Please explain why, and clarify the role of DSA in such cases. Response: We appreciate this important point. DSA is indeed the gold standard for detecting vascular lesions such as arteriovenous fistula or pseudoaneurysm. In this case, multiple imaging modalities (CTA, MRA, MRV) showed no vascular injury, the patient was clinically stable, and there were no signs of carotid-cavernous fistula or AV shunt. Based on these, we chose close surveillance instead of immediate DSA. We have now added a sub-section titled “Rationale for not performing DSA” in the Discussion, clarifying that: DSA should be performed when CTA/MRA are inconclusive or when clinical suspicion remains high. In our case, multimodal negative findings and clinical stability justified observation. We emphasize that in other centers or in cases with ambiguous findings, DSA remains recommended. Comment 3: Is the “Day-14” timing universally recommended, or only applicable under specific conditions? Response: Thank you for this critical observation. We have clarified that the “Day-14” strategy is not universal. It should only be considered when: The patient is hemodynamically and neurologically stable. Imaging (CTA/MRA/MRV) excludes vascular injury. There is no CSF leak or intracranial abscess. Laboratory inflammatory markers (WBC, CRP, procalcitonin) are stable or decreasing. We emphasize that immediate extraction is warranted if infection or deterioration occurs. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 11 Mar 2026 Tedy Apriawan , Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia 11 Mar 2026 Author Response Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We ... Continue reading Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We agree. We have revised the abstract conclusion to explicitly state that in this patient, extraction was performed on Day-14, utilizing the formation of a fibrous capsule to facilitate safer removal. The sentence now reads: “In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal.” Comment 2: Digital subtraction angiography (DSA) was not performed. Please explain why, and clarify the role of DSA in such cases. Response: We appreciate this important point. DSA is indeed the gold standard for detecting vascular lesions such as arteriovenous fistula or pseudoaneurysm. In this case, multiple imaging modalities (CTA, MRA, MRV) showed no vascular injury, the patient was clinically stable, and there were no signs of carotid-cavernous fistula or AV shunt. Based on these, we chose close surveillance instead of immediate DSA. We have now added a sub-section titled “Rationale for not performing DSA” in the Discussion, clarifying that: DSA should be performed when CTA/MRA are inconclusive or when clinical suspicion remains high. In our case, multimodal negative findings and clinical stability justified observation. We emphasize that in other centers or in cases with ambiguous findings, DSA remains recommended. Comment 3: Is the “Day-14” timing universally recommended, or only applicable under specific conditions? Response: Thank you for this critical observation. We have clarified that the “Day-14” strategy is not universal. It should only be considered when: The patient is hemodynamically and neurologically stable. Imaging (CTA/MRA/MRV) excludes vascular injury. There is no CSF leak or intracranial abscess. Laboratory inflammatory markers (WBC, CRP, procalcitonin) are stable or decreasing. We emphasize that immediate extraction is warranted if infection or deterioration occurs. Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We agree. We have revised the abstract conclusion to explicitly state that in this patient, extraction was performed on Day-14, utilizing the formation of a fibrous capsule to facilitate safer removal. The sentence now reads: “In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal.” Comment 2: Digital subtraction angiography (DSA) was not performed. Please explain why, and clarify the role of DSA in such cases. Response: We appreciate this important point. DSA is indeed the gold standard for detecting vascular lesions such as arteriovenous fistula or pseudoaneurysm. In this case, multiple imaging modalities (CTA, MRA, MRV) showed no vascular injury, the patient was clinically stable, and there were no signs of carotid-cavernous fistula or AV shunt. Based on these, we chose close surveillance instead of immediate DSA. We have now added a sub-section titled “Rationale for not performing DSA” in the Discussion, clarifying that: DSA should be performed when CTA/MRA are inconclusive or when clinical suspicion remains high. In our case, multimodal negative findings and clinical stability justified observation. We emphasize that in other centers or in cases with ambiguous findings, DSA remains recommended. Comment 3: Is the “Day-14” timing universally recommended, or only applicable under specific conditions? Response: Thank you for this critical observation. We have clarified that the “Day-14” strategy is not universal. It should only be considered when: The patient is hemodynamically and neurologically stable. Imaging (CTA/MRA/MRV) excludes vascular injury. There is no CSF leak or intracranial abscess. Laboratory inflammatory markers (WBC, CRP, procalcitonin) are stable or decreasing. We emphasize that immediate extraction is warranted if infection or deterioration occurs. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 15 Dec 2021 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 11 Mar 26 read read Version 1 15 Dec 21 read read Mamoru Murakami , Kyoto Tanabe Central Hospital, Kyoto, Japan Chi Hoon Choi , Chungbuk National University Hospital, Cheongju, South Korea Amit Agrawal , All India Institute of Medical Sciences, Bhopal, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Murakami M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Mar 2026 | for Version 2 Mamoru Murakami , Kyoto Tanabe Central Hospital, Kyoto, Japan 0 Views copyright © 2026 Murakami M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes Apriawan T, Hafid Bajamal A, Darlan D and Ramadhan Y Wooden foreign bodies are prone to cause infection; therefore, early removal by planned surgery is generally recommended once the diagnosis is established, based on the following three studies(1-3). A scheduled operation performed 14 days after injury is highly exceptional, and its indications are limited. Delayed surgery may be complicated by extensive scarring around the foreign body, adherence to the intracranial vessels. The authors should also discuss the potential disadvantages of delayed surgery and clearly state the reason for intentionally adopting a delayed approach. The authors clarified the “Day-14” strategy is not universal and should be considered when: the patient is hemodynamically stable, imaging (CTA/MRA/MRV) excludes vascular injury, there is no CSF leak or intracranial abscess, and laboratory inflammatory markers are stable or decreasing. However, Robaei et al. reported a case of orbitocranial penetration by a fragment of wood, and they insisted because of its porous organic nature and frequent proximity to soil, wood is an ideal reservoir for bacteria and fungi and is likely to provoke inflammation (4).The organic foreign bodies, especially wooden ones, are linked to a high risk for bacterial and fungal infections, inflammatory granuloma formation, and calcification (5). Taking these findings together, wooden foreign bodies are not merely “objects that can cause infection,” but rather “a nidus of infection itself.” If management is delayed, abscess formation can occur, and intracranial extension may be fatal. Therefore, the literature consistently concludes: “Early surgical removal is recommended.” Even if the conditions proposed by the authors are met, it would be difficult to justify considering surgery after a 14-day delay. References - 1 Wahyudi, et al., 2021 - Ref 1 2. Parbatraj Regmi, et al., 2024 - Ref 2 3. He Van Dong, et al., 2024 - Ref 3 4. Dana Robaei, et al., 2004 - Ref 4 5. Bianca Szabo et al., 2019 - Ref 5 References 1. Wahyudi, Zaky A, Islam A, Prihantono, et al.: An extremely rare case: Transorbital penetrating intracranial injury by wooden foreign body. Case report. Annals of Medicine and Surgery . 2021; 71 . Publisher Full Text 2. Regmi P, Dahal A, Bhattrai S, Nandan Khadga S, et al.: Early removal of transorbital penetrating traumatic brain injury by a wooden object: a case report. Annals of Medicine & Surgery . 2024; 86 (11): 6794-6797 Publisher Full Text 3. Dong H, Nguyen A, Dong H, Vu H, et al.: Penetrating brain injury through the cavernous sinus by chopsticks in Vienamese: a case report. Annals of Medicine & Surgery . 2024; 86 (9): 5561-5566 Publisher Full Text 4. Robaei D, Fernando G, MacDonald C, Branley M: Orbitocranial penetration by a fragment of wood. Medical Journal of Australia . 2004; 181 (6): 329-330 Publisher Full Text 5. Szabo B, Pascalau R, Bartoș D, Bartoș A, et al.: Intraorbital penetrating and retained foreign bodies –a neurosurgical case series. Turkish Neurosurgery . 2019. Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise neurosurgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Murakami M. Peer Review Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r466673) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-466673 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Agrawal A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Mar 2026 | for Version 2 Amit Agrawal , Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India 0 Views copyright © 2026 Agrawal A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Dear Author, Although such lesions are reported in literature, but it is always helpful to add further information on penetrating injuries and their spectrum. Please add details for DSA rationale subsection and indications for DSA Please add details for culture and antibiotic susceptibility results of the extracted wood and fibrous capsule Please add details for long term follow up Please add CARE checklist as supplementary material Please mention details for oculocardiac reflex or any intraoperative bradycardia Please check the manuscript for grammar and typographical errors Please use standardize terminology like Day-14 versus day 14 throughout Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Neurotrauma I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Agrawal A. Peer Review Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.191016.r467313) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1283/v2#referee-response-467313 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2022 Choi C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 12 Dec 2022 | for Version 1 Chi Hoon Choi , Chungbuk National University Hospital, Cheongju, South Korea 0 Views copyright © 2022 Choi C. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors describe a very rare case and its transorbital approach treatment. This article is important in clinical practice showing the diagnostic images and surgical approach. Strength : A very rare case Weakness : It seems necessary to summarize in order according to the flow of time rather than an additional explanation. Title : - Abstract: - Background and importance : - Clinical presentation/ Surgical procedure/ Postoperative FU : Combining the table and figure 3 would be better. Discussion: I would like to divide the paragraphs and categorize them into subheadings. Figure 5: It would be helpful to describe the details of the preoperative plan by 3d printing (the specifications of the printer & ink and the simple usage environment). Figure 6: It is thought to be an inadequate picture to convey the author's intention. It can be omitted and would be better to present pathological pictures of the foreign body or clinical data of patients. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Neroradiology & Neurointervention I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 11 Mar 2026 Tedy Apriawan, Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia Reviewer 2 (Chi Hoon Choi, Chungbuk National University Hospital, Cheongju, South Korea) Comment 1: The overall structure would be clearer if written in a chronological, modular style. Please consider restructuring the discussion and clinical course accordingly. Response: We appreciate this suggestion. In this publication, we focused on the patient management choices and the surgical technique performed; therefore, our discussion primarily emphasizes these aspects.” Comment 2: Please merge the table of operative steps with Figure 3, to provide a single comprehensive educational figure. Response: We have merged the stepwise table into Figure 3, so that readers can follow both text and images in one integrated panel. Comment 3: Details of the 3D printing process are lacking. Please specify printer, ink, and resolution so that others can reproduce it. Response: Thank you for pointing this out. This article does not specifically discuss the 3D printing process, as we have addressed that topic in a separate publication. In this paper, we focus on the management decisions made and the surgical technique employed. Comment 4: Figure 6 (schematic of immunological reaction) is not effective. Replace it with more relevant pathological or clinical data. Response: We did not perform histological examination in this patient. Figure 6 is intended to illustrate and summarize the process of fibrous capsule formation that occurred in this case. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Choi CH. Peer Review Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r156737) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-156737 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2022 Murakami M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Sep 2022 | for Version 1 Mamoru Murakami , Kyoto Tanabe Central Hospital, Kyoto, Japan 0 Views copyright © 2022 Murakami M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Comments to the author Title: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes. The authors describe a very rare case of penetrating injury, treated well via transorbital approach. The article is well written. They provide suggestions about the surgical approach and the timing of surgery, which are important in clinical practice. Title and abstract: The title is appropriate for the content of the article. The abstract is concise and accurately summarises the essential information of the paper, although it would be better if authors included the comment about the timing of the surgery in conclusion. Case report: The clinical case presentation is well written but some minor points that should be clarified: There is no comment about a conventional angiography. The wooden spike penetrated near the cavernous sinus. In case of suspicion for the injury of internal carotid artery, there are opinions that digital subtraction angiogram (DSA) should be performed to evaluate the lesion which 3DCTA could not clearly demonstrate, such as arterio-venous fistula (AVF). If you did not perform DSA in this case, could you explain that reason? The timing of the second surgery is very important. If the foreign body is wooden, serious infection is often problematic, since the porous nature of wood is a strong growth medium for microorganisms. During waiting for 14 days to the second surgery, there might be possibility of exacerbation of epidural or subdural abscess. Some neurosurgeons might insist the early second-surgery to prevent the serious infections. In case of penetrating brain injury of wooden spikes, do you consistently recommend waiting until 14 days, which the wooden spikes form the fibrous capsule? Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise neurosurgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 11 Mar 2026 Tedy Apriawan, Department of Neurosurgery, Universitas Airlangga, Faculty of Medicine, Dr. Soetomo Academic General Hospital, Surabaya, 60285, Indonesia Reviewer 1 (Murakami, Neurosurgery) Comment 1: Please add the timing of the second operation (Day-14) into the conclusion of the abstract, as it is the main message of the case. Response: We agree. We have revised the abstract conclusion to explicitly state that in this patient, extraction was performed on Day-14, utilizing the formation of a fibrous capsule to facilitate safer removal. The sentence now reads: “In stable patients without neurovascular injury or uncontrolled infection, we delayed extraction until Day-14 to take advantage of fibrous capsule formation, allowing a safer transorbital removal.” Comment 2: Digital subtraction angiography (DSA) was not performed. Please explain why, and clarify the role of DSA in such cases. Response: We appreciate this important point. DSA is indeed the gold standard for detecting vascular lesions such as arteriovenous fistula or pseudoaneurysm. In this case, multiple imaging modalities (CTA, MRA, MRV) showed no vascular injury, the patient was clinically stable, and there were no signs of carotid-cavernous fistula or AV shunt. Based on these, we chose close surveillance instead of immediate DSA. We have now added a sub-section titled “Rationale for not performing DSA” in the Discussion, clarifying that: DSA should be performed when CTA/MRA are inconclusive or when clinical suspicion remains high. In our case, multimodal negative findings and clinical stability justified observation. We emphasize that in other centers or in cases with ambiguous findings, DSA remains recommended. Comment 3: Is the “Day-14” timing universally recommended, or only applicable under specific conditions? Response: Thank you for this critical observation. We have clarified that the “Day-14” strategy is not universal. It should only be considered when: The patient is hemodynamically and neurologically stable. Imaging (CTA/MRA/MRV) excludes vascular injury. There is no CSF leak or intracranial abscess. Laboratory inflammatory markers (WBC, CRP, procalcitonin) are stable or decreasing. We emphasize that immediate extraction is warranted if infection or deterioration occurs. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Murakami M. Peer Review Report For: Case Report: Transorbital approach for the management of an orbito-temporal penetrating brain injury (skull base region) secondary to wooden spikes [version 2; peer review: 3 approved with reservations] . F1000Research 2026, 10 :1283 ( https://doi.org/10.5256/f1000research.78129.r150802) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/10-1283/v1#referee-response-150802 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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