“Cold Steel”: A Case Report of Endoscopic Trans-Clival Approach for Management of a Blowdart Injury

INTRODUCTION: We report a case of a 7 y/o female sustaining an injury from a metallic blow dart that penetrated the inferior clivus and dura at the craniovertebral junction (CVJ) and was removed with an endoscopic trans-clival approach. CASE PRESENTATION: A 7 year-old female presents to the emergency room after sustaining a penetrating injury from a metallic blow dart to the nose. Patient remained hemodynamically stable with no obvious cerebrovascular injury. Computed tomography (CT) including CT-angiography (CTA) was obtained to confirm the location and proximal structures to the injury, after which patient was taken to the operating room for removal. The blow dart was removed successfully with an endoscopic trans-clival approach without complication. A high flow cerebrospinal fluid (CSF) leak was controlled and repaired with bone wax, abdominal fat graft, and a free mucosal graft. The patient did well post-operatively, with no clinical or radiographic evidence of pneumocephalus, vascular injury, or recurrent CSF leak. She was discharged to home on post-operative day 5 and is now 14 months post-injury with no lasting sequela. CONCLUSION: This case highlights the utilization of described expanded endonasal skull base techniques (i.e. trans-clival and trans-odontoid approaches) for a unique traumatic injury and approach to management in a pediatric patient. Although successful, without acute neurovascular complication and limited patient morbidity, it is difficult to generalize this endonasal approach to all cases of clival trauma with more extensive injuries and/or deficits. Further study is needed to understand the benefits and limitations of an endoscopic endonasal approach to penetrating trauma of the inferior clivus and CVJ.