Childhood penetrating intracranial injury by non-metallic objects: a case report of three pediatric cases

Introduction

Traumatic brain injury (TBI) results from an external physical force damaging the brain tissue, commonly through a blow, bump, or penetration (1). Within the pediatric neurosurgery department, TBI emerges as a critical concern, representing the primary cause of death and disability in children (2). The incidence of pediatric TBI varies significantly among countries, ranging from 47 to 280 per 100,000 children (3). Penetrating brain injury (PBI) carries the highest risk of fatality among all TBI types, occurring when a foreign object enters the cranial cavity either at low or high velocity due to an external force. While children seldom experience penetrating cranial injuries, TBIs in children are typically caused by unexpected objects and can result in various complications, including brain contusion, cerebral hematoma, cerebrospinal fluid (CSF) rhinorrhea, seizures, cerebral infection, vascular injury, epilepsy, brain abscess, and brain granuloma (4-11). Previous studies have identified a range of foreign objects, including metallic items such as ballpoint pens, screwdrivers, long nails, slim iron rods, as well as non-metallic items such as bamboo chopsticks, pencils, and glass beads (12-17). These foreign bodies can cause severe brain and vascular injuries, often accompanied by minor skin injuries (18). If parents promptly remove the penetrating object without seeking medical assistance, secondary complications such as intracranial hemorrhage, vascular injury, and debris retention may occur (19). Therefore, managing penetrating TBI caused by foreign objects presents a multifaceted and challenging task.

Between November 2014 and February 2018, we treated three children who suffered from penetrating TBI caused by non-metallic objects. Among them, two children were injured by bamboo chopsticks, while the third was injured by a pencil. This study aims to explore therapeutic strategies and clinical management approaches for children experiencing penetrating TBI from non-metal objects. We collected data on the medical background, clinical presentation, surgeries, and follow-up assessments. The overarching goal is to enhance clinical outcomes, prognosis and diminish complications for future patients encountering similar injuries. We present this article in accordance with the CARE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-550/rc).

Case presentation

Case 1

Disease history

A 26-month-old male child experienced a mishap on November 12, 2014. While consuming noodles with bamboo chopsticks, one chopstick penetrated his left nostril, leading to nosebleeds. Within two hours, he exhibited symptoms of vomiting gastric contents, prompting immediate presentation to a nearby hospital. A subsequent head computed tomography (CT) scan at the hospital identified a foreign object entering the cranial cavity through the left nostril and left ethmoid sinus.

Physical examination

Upon assessment, the patient presented with a Glasgow coma scale (GCS) score of 12/15, accompanied by vital signs indicating a body temperature of 37.1 ℃, heart rate of 96 beats per minute, respiratory rate of 33 breaths per minute, and blood pressure measuring 120/70 mmHg. Manifesting drowsiness and a worsening mental state, the patient exhibited normal-sized pupils that reacted appropriately to light. Clinical examination revealed approximately 9 cm of a bamboo chopstick protruding from the patient’s left nostril, accompanied by active foamy, bloody discharge (Figure 1A,1B). Additionally, the patient demonstrated a supple neck and full range of motion in all extremities, with normal muscle strength, tone, and physiological reflexes observed, and no pathological reflexes elicited.

Figure 1 Case 1 with bamboo chopstick shaft. (A,B) Bamboo chopstick shaft (about 9 cm length) and active foamy bloody liquid outside of the left nostril; (C,D) coronal and sagittal section of non-contrast CT; (E,F) 3D-CT imaging. This image is published with the legal participant’s legal guardians’ consent. 3D, three dimensional; CT, computed tomography.

Imaging examination

Upon examination via a non-contrast CT scan and three-dimensional (3D) imaging, it was discovered that the bamboo stick had deeply penetrated the left nostril and into the brain structure. The linear part of chopstick shaft, measuring approximately 6 cm in length, traversed through the nasal and olfactory groove, frontal lobe, and upper portion of the corpus callosum body successively (Figure 1C,1D). Notably, the intracranial part of the bamboo chopstick shaft exhibited burrs and a rough surface, as illustrated in Figure 1E,1F through 3D-CT imaging.

Diagnosis and treatment

Upon confirmation of a penetrating intracranial injury with a lodged foreign body, the child was promptly transported to the operating theatre for urgent intervention. A right frontal craniotomy was performed, involving a coronal skin incision made behind the hairline and employing a modified pterional approach with the patient positioned supine. A carefully measured a 6 cm × 5 cm bone flap was excised, along with the dura. During exploration of the olfactory sulci area subsequent to frontal lobe base elevation, it was discerned that the bamboo chopstick shaft had breached the dura. Employing a retrograde technique from the olfactory sulci, the entire section of the bamboo chopstick within the brain was meticulously removed. Following this, a rongeur was employed under microscopic guidance to extract the chopstick from the nostril. The surgical site underwent thorough irrigation with a saline solution infused with a gentamicin mixture. The dural defect was meticulously repaired using a dura graft and sealed with fibrin glue. The foreign body extraction was successfully completed approximately 6 hours post-penetration.

Postoperative outcomes

During the initial two days following the craniotomy, the child remained alert with intact motor function in all four limbs. Prophylactic administration of intravenous flucloxacillin sodium was initiated to prevent infection, while sodium valproate injection was employed as a preventive measure against epileptic seizures. However, on the third post-operative day, the male child developed a fever, with body temperature peaking at 39 ℃. Analysis of blood parameters revealed an elevated white blood cell (WBC) count of 15.52 g/L. Additionally, the patient experienced hyponatremia, with serum sodium (Na⁺) concentration decreasing to 125 g/L. Consequently, flucloxacillin sodium was substituted with cefazolin on the 7th day after the operation to address intracranial infection (20). Despite fluctuation in body temperature ranging from 37–38.5 ℃, cefazolin was later replaced with ceftriaxone sodium on the 11th day, resulting in normalization of body temperature and blood electrolyte levels by the 14th post-operative day. Remarkably, no occurrences of CSF leakage were observed throughout the two weeks period.

Follow up

Following the operation, the male child underwent semiannual follow-up evaluations for the first 2 years. Throughout these assessments, the child consistently exhibited a normal nervous system presentation, retaining a normal sense of smell. Notably, no complications such as seizures or epilepsy manifested during this follow-up period.

Case 2

Disease history

A 6-year-old female child sustained an injury on February 23, 2018, when she fell while holding a pencil. The tip of the pencil penetrated her right medial orbit, prompting her mother to remove the pencil from the site of injury (Figure 2A,2B). Following this incident, the child was initially treated at a local hospital before being transferred to our department for additional assessment and care.

Figure 2 Case 2 with pencil. (A) The pencil her mother drawn out on the spot; (B) the lead and debris taken out from orbit and cavity; (C) the skin incision of craniotomy and eye-bow laceration and scab; (D) axial section of non-contrast CT of orbit and cavity; (E) coronal section of non-contrast CT of orbit and cavity; (F) sagittal section of non-contrast CT of orbit and cavity. This image is published with the participant’s legal guardians’ consent. CT, computed tomography.

Physical examination

The 6-year-old female child displayed lucidity upon evaluation, boasting a GCS score of 15. Notably, examination findings included swelling of the right eyelid and scab-covered skin lacerations measuring approximately 0.5 cm in length (Figure 2C). However, despite these physical manifestations, the child exhibited normal eye movements, and there were no reports of diplopia.

Imaging examination

Upon admission, the child underwent CT scans of the head and orbit, revealing significant findings. These included a superior orbital wall fracture, intracranial hemorrhage, intracranial pneumatosis, subarachnoid hemorrhage (SAH), and the identification of small foreign bodies that had penetrated and become lodged inside the orbit and cranial cavity (Figure 2D-2F).

Diagnosis and treatment

Upon receiving the diagnosis of a penetrating intracranial injury with a foreign body, orbital damage, and fracture, the patient underwent a craniotomy with a coronal skin incision. Subsequent steps involved careful opening of the right bone flap and repositioning of the dura to the midline. The base of the right frontal lobe was delicately elevated, followed by microscopic exploration of the superior wall of the orbit. During the exploration, a small lead was found embedded in the fractured orbit wall, with the dura pierced by a bone fragment. Further examination revealed the presence of subdural hematoma, intracerebral hematoma, and SAH. Surgical intervention included evacuation of the subdural hematoma and extraction of the lead after partial drilling of the fractured orbit wall. Additionally, meticulous removal of small lead, sawdust, and various miniature oil-painted debris within the medial orbit was performed (Figure 2B). The foreign object was successfully extracted approximately 9 hours after penetrating the area.

Postoperative outcomes

Following the surgical procedure, a post-operative CT scan revealed the absence of foreign bodies within the orbit and cranial cavity, with no discernible abnormal high-density material present. Intravenous administration of ceftizoxime sodium was commenced as a preventive measure against infection, while sodium valproate was administered to prevent epileptic seizures. However, the child developed a fever on the second day post-surgery, accompanied by an elevated WBC count of 14.84 g/L. Consequently, a 5-day course of meropenem was administered, leading to a gradual normalization of body temperature and WBC count. Notably, swelling of the eyeball subsided, and the child regained normal eye movement and vision, with no complaints of diplopia.

Follow-up

Follow-up examinations were conducted for the child at intervals of 6 months, 1 year, and 3 years following the surgical procedure. Across these evaluations, her eyesight, cognitive function, and nervous system presentation exhibited no abnormalities. Furthermore, there were no instances of epileptic seizures reported during the follow-up assessments.

Case 3

History

The incident occurred on February 3, 2018, when a female child fell while eating, resulting in a bamboo chopstick piercing her face. Without delay, she was taken to a nearby hospital and later transferred to our department for specialized care.

Physical examination

During the examination, it was noted that a chopstick approximately 10 cm in length was visibly protruding from the left side of the child’s face (Figure 3A,3B). Importantly, bilateral pupils exhibited normal size and reactivity to light. Additionally, assessment of motor function revealed unhindered movement of all four limbs, without any indication of prolonged pathological reflexes.

Figure 3 Case 3 with chopstick. (A) The front view of the child with a chopstick pierced into face before craniotomy; (B) the side view of the child with a chopstick pierced into face before craniotomy; (C) the chopstick taken out from nostril after craniotomy; (D) axial section of non-contrast head CT; (E) sagittal section of non-contrast head and maxilloface CT; (F) coronal section of non-contrast head and maxilloface CT. This image is published with the participant’s legal guardians’ consent. CT, computed tomography.

Imaging examination

Following admission, the child promptly underwent a CT scan of the head and facial region. The results indicated penetration of a bamboo chopstick into the cranial cavity through the middle fossa, with the tip of the chopstick extending to the sellar region and lateral fissure. This led to the identification of cerebral contusion, laceration and SAH on the imaging (Figure 3C-3F).

Treatment

Undergoing a left craniotomy with a pterional approach while in the supine position, the child’s surgical intervention commenced. Following the opening of the dura, a thorough dissection and exploration of the lateral fissure cistern was conducted. Subsequent identification of the chopstick’s tip within the brain parenchyma, positioned 3 mm below the lateral fissure, prompted further examination. Upon careful retraction of the temporal lobe, it became apparent that the chopstick had breached the inferior dura of the middle fossa, penetrating into the temporal lobe. Remarkably, no evidence of cerebral hematoma surrounding the intracranial portion of the chopstick shaft was observed. With the aid of a nasal-exposed dissector, the intracranial segment of the chopstick shaft was methodically pushed out of the dura. Following this manoeuver, the resulting dural defect was meticulously addressed by applying a dural patch graft and fibrin glue. Throughout the procedure, the surgical field was repeatedly irrigation with a large volume of normal saline (NS) mixed with gentamicin solution. The entire process, from the moment of penetration to the successful removal of the foreign body, spanned a duration of 7 hours.

Postoperative outcomes

Upon initial inspection, the intracranial part of the chopstick appeared to be intact (Figure 3C), corroborated by post-operative CT scans indicating the absence of the foreign object within the cranial cavity. However, on the first day post-operation, the female child exhibited fever, presenting with a temperature of 39 ℃. A routine blood test revealed an elevated WBC count of 17.27 g/L. In response, meropenem and cefathiamidine sodium were administered intravenously to prevent infection, supplemented by sodium valproate injection to forestall epileptic seizures. Following a five-day course of antibiotic therapy, the child’s body temperature gradually normalized, accompanied by a return to normal WBC count. Additionally, the swelling in the left cheek progressively diminished, facilitating effortless opening and closing of the mouth.

Follow up

Follow-up examinations were conducted for the child at 0.5, 1, and 3 years post-injury. Across these evaluations, her vision, intelligence and nervous system presentation exhibited no abnormalities, and there were no reports of epilepsy seizures.

This study received approval from the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. 20210098-01). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the legal guardians of all participants for the publication of their medical case and any accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

In pediatric trauma, the likelihood of head impact surpasses that in adults, primarily due to the larger face-to-head area ratio in children. Consequently, this increased ratio corresponds to a greater likelihood of experiencing PBI. Contributing factors include the presence of paranasal sinus arterioles and the thinner, less dense bones in the maxillofacial region and skull base during childhood (21), particularly in cranial channels such as the ethmoidal pore, supraorbital foramen, and superior orbital fissure, combined with the ongoing pneumatization of the paranasal sinuses in children. These factors heighten the vulnerability to cranial penetration by sharp foreign objects, resulting in maxillofacial and head injuries. Remarkably, all three cases examined in this study involved non-metallic foreign objects, specifically two bamboo chopsticks and a pencil. Despite their lower hardness compared to the skull, foreign bodies with low velocity can penetrate the cranial cavity at nearly a vertical angle under sufficient force. Prompt accident management is essential, encompassing both preoperative and postoperative care. Preoperative interventions include trauma management, patient condition assessment, imaging findings verification, infection prevention and surgical preparation. Postoperative care involves craniotomy, wound and incision management, infection control, monitoring of neurological function and rehabilitation. Unlike high-energy mechanisms such as gunshot wounds or blast injuries that typically cause widespread cerebral damage and hemorrhage, low-energy penetrating injuries, such as those observed in our cases, often follow a more linear path with localized damage. However, low-energy mechanisms can still result in severe outcomes due to infection, vascular injury, or CSF leakage, particularly in the pediatric population with thinner skull structures.

In accident scenarios, prompt and precise diagnosis of the foreign body path, brain injury extent, and presence of foreign substances is imperative. However, the utility of magnetic resonance imaging (MRI) is limited in cases of intrusion of wooden objects due to its time-consuming nature and contraindication (22). For cases of PBI, immediate CT scanning is advocated to delineate the exact object location, trajectory and its relationship with surrounding structures like blood vessels and the skull base (23,24). Three-dimensional reconstruction aids in stereographic visualization, enhancing localization accuracy (25,26). In the first case, 3D-CT scans revealed burrs on the chopstick, indicating potential intraoperative extraction challenges. Conversely, in the second case, although the pencil was removed on-site, CT scanning unveiled residual lead fragments in the orbit and cranial cavity, necessitating further examination for debris localization. Similarly, in the third case, CT scanning identified a smaller chopstick shaft portion penetrating the cranial cavity without surface burrs, suggesting feasible extraction. Thus, tailored CT scanning sequences should be employed based on injury site and foreign object morphology. When CT scans reveal penetration near critical structures like the sylvian fissure or circle of Willis, or when vascular injury is suspected, CT angiography (CTA) is strongly recommended for traumatic aneurysm evaluation (25). In Cases 1 and 3, CTA was not performed as initial imaging did not indicate proximity to major vascular structures; however, in retrospect, postoperative CTA could provide additional assurance by ruling out delayed complications such as pseudoaneurysms.

The cornerstone of surgical intervention for penetrating intracranial injuries lies in swiftly removing the foreign body while mitigating secondary brain injury (6). Selection of the surgical approach hinges upon factors such as injury location and the characteristics of the foreign object involved. In the first case, locating the chopstick part within the gyrus proved challenging, contrasting with the easily identifiable penetrated dura fissure. Hence, a modified pterional approach was chosen, with the foreign object divided into two parts at the dura defect site using high-speed drilling. Extraction of the extranasal portion was straightforward, while the intracranial portion required meticulous microscopic guidance. Collaboration with an ophthalmologist in the second case aimed to explore endoscopic surgery feasibility through the wound funnel, yet local wound swelling and restricted space challenged this approach. Consequently, a subfrontal approach craniotomy was selected to access the orbital wall and frontal lobe, minimizing facial disfigurement, optimizing manipulation space, and reducing the risk of residual foreign body debris. In the third case, the chopstick shaft’s positioning in the sylvian fissure prompted a pterional approach craniotomy, facilitating comprehensive exploration of both the sylvian fissure and middle fossa. With the intracranial portion lacing burrs and the shaft extracranial, removal was straightforward using a nasal septum dissector. To forestall postoperative CSF fistula, the cranial fissure was meticulously sealed with bone wax or gelatin sponge, and the dura defect was meticulously covered with a dural patch graft. Postoperatively, none of the patients experienced CSF leakage, and there were no discernible neurological or cognitive changes. Case 1 retained olfactory function, while cases 2 and 3 preserved visual acuity. Over a 3-year period, their neurological, cognitive, intellectual statuses remained unaltered, attesting to a successful rehabilitation case without notable neurological deficits. Furthermore, variances in cranial nerve maturation and development across age groups may influence PBI outcomes and management strategies. Nonetheless, the brain’s developmental plasticity suggests a greater potential for recovery. Case 1, with a smaller brain and relatively soft skull, exhibits heightened susceptibility to penetrating trauma compared to cases 2 and 3, necessitating more vigilant follow-up. Despite these disparities, all three children seamlessly integrated into normal life, akin to their peers’ experiences.

All three patients were initially treated at other hospitals and then transferred to our center for specialized neurosurgical management. During transport, stabilizing the penetrating object is critical to avoid further injury. In both direct and transferred cases, the object was immobilized to prevent movement en route. In comparison with previous reports, the favorable outcomes in our cases, including the absence of neurological deficits and long-term complications, may be attributed to prompt surgical intervention, individualized surgical planning based on 3D imaging, and intensive postoperative care. For instance, Mitilian et al. reported residual deficits following transorbital penetration (26), while in our case 2, precise orbital wall reconstruction avoided any visual impairment. Likewise, prior studies involving retained foreign bodies have shown higher risks of abscess formation and late-onset seizures (4,8,10), which were not observed in our cases due to complete debridement and prolonged antibiotic coverage.

Pediatric PBI carries a significantly higher risk of infection, estimated at over 40% in children, leading to increased morbidity and mortality (27). Infections could originate from the penetrating foreign objects themselves or from the normal flora in the nasal cavity and sinuses. The rough surface of foreign objects harbors numerous bacteria, increasing the risk of infection with prolonged residence in the cranial cavity. Following foreign object removal, thorough irrigation of the surgical field with NS and gentamicin NS (80,000 units in 250 mL NS solution) is crucial. Debris from broken foreign objects should be meticulously explored to prevent retention in the surgical field, and necrotic tissue should be evacuated to prevent complication such as cerebral infection, brain abscesses, and inflammatory granuloma (8,28-30). A retrospective study revealed postoperative abscesses or infections in patients with penetrating head injuries, with Staphylococcus aureus being the most common causative agent (28). Additionally, non-anthrax Bacillus species, previously considered contaminants, are now recognized as opportunistic pathogens (29,31). leading to Bacillus central nervous system infections post-PBI (32,33). Therefore, broad-spectrum antibiotic prophylaxis post-operatively is essential, starting early in all PBI cases and continuing for at least 6 weeks (34,35). This regimen should cover both gram-positive cocci and gram-negative bacillus, and penetrate blood brain barrier (BBB) effectively. Based on our experience, we recommend the administration of penicillin and cephalosporins. Close monitoring of body temperature and peripheral blood WBC count is essential. If fever and elevated WBC count persist after 3–5 days of antibiotics treatment, alternative antibiotics should be considered, or simultaneous administration should be initiated to expedite intracranial infection. Antibiotics should be continued for an additional week after normalization of body temperature.

This study delves deeper into antibiotic utilisation compared to previously reported cases in the literature (4-9). The decision to change antibiotics in case 1 was prompted by the patient’s presentation of elevated temperature and leukocyte count on the third day post-craniotomy, suggestive of a potential intracranial infection. Consequently, the antibiotic regimen was adjusted to provide broader coverage against possible infectious agents. Cefazolin is administrated for intracranial infections management, with ceftriaxone sodium available as an alternative should resistance develop or symptoms persist. By postoperative day 14, stabilization of the child's blood electrolytes and temperature indicated the efficacy of antibiotic therapy and additional therapeutic interventions in managing and facilitating recovery from the infection. Although antibiotic regimens varied across the three cases, all were directed towards infection prevention. In case 2, infection diagnosis was based on a fever and elevated WBC count the day after surgery, leading to a transition from ceftizoxime sodium to meropenem for infection control. In case 3, meropenem and cefathiamidine sodium were administered as prophylactic antibiotics against infection, complemented by ceftizoxime sodium, a broad-spectrum antibiotic effective against gram-positive and gram-negative microorganisms. Meropenem, exhibiting broad-spectrum activity, inhibits the growth of diverse bacterial species, while cefathiamidine sodium, a cephalosporin antibiotic, demonstrates antibacterial efficacy against both gram-positive and gram-negative bacteria. Despite different antibiotic protocols, all three cases received individualized antibiotic therapy aimed at preventing infection.

In cases of pediatric PBI caused by non-metallic foreign objects, swift and accurate diagnosis is essential to evaluate brain injury severity and foreign object integrity. Utilizing CT scans to examine the head and maxillofacial region aids in precisely locating the foreign object. Employing an appropriate craniotomy approach is crucial for the removal of foreign object. Repairing any penetrating cranial fissure and dura defect is necessary to prevent postoperative CSF fistula. Meticulous attention to cerebral tissue and vital structures is imperative to prevent secondary injury. Despite potential attempts by non-professionals to extract the foreign object, such actions increase the risk of irreparable dural tears and subsequent CSF fistula formation. Seeking prompt professional assistance is recommended to minimize damage and prevent secondary brain injury (36). Additionally, post-operative broad-spectrum antibiotic prophylaxis is advised to prevent intracranial infection.

Recent preclinical models have significantly enhanced our understanding of pediatric TBI pathophysiology, especially regarding injury-induced neuroinflammation, blood-brain barrier disruption, and changes in brain connectivity and metabolism (37). These models also provide insight into shared biological mechanisms between TBI and autism spectrum disorder (ASD), such as persistent microglial activation, oxidative stress, and gut-brain axis dysfunction. Notably, both conditions may manifest similar clinical features, including sensory processing deficits, seizures, gastrointestinal symptoms, and impaired social interaction (38). These overlaps underscore the importance of comprehensive long-term monitoring in pediatric TBI patients, not only for physical and cognitive recovery, but also for early identification of potential neurodevelopmental sequelae. Incorporating biomarkers, neuroimaging, and behavioral assessments—paralleling protocols used in ASD research—could be beneficial in predicting and managing outcomes. Future preclinical studies that integrate neurodevelopmental endpoints are crucial for establishing early interventions and improving pediatric care pathways.

The study’s strength lies in its clinical applicability and novelty, documenting three cases of intracranial injury in children caused by non-metallic objects. It emphasizes the pivotal role of timely surgical intervention and precise diagnosis in preventing secondary brain damage, infection, or hemorrhage. Nonetheless, the study’s small sample size, encompassing only three cases, may limit the comprehensiveness of insight into this injury type. Future multi-center studies with long-term follow-up are essential to validate and broaden these findings. The establishment of evidence-based clinical guidelines informed by such research endeavors has the potential to substantially enhance patient outcomes and long-term prognosis.

Conclusions

This study documented three instances of intracranial PBI among pediatric individuals. The study underscores the paramount significance of expeditious surgical intervention and precise diagnostic measures in mitigating secondary brain damage, as well as diminishing the risk of infection or hemorrhage.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-550/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2024-550/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2024-550/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study received approval from the Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. 20210098-01). All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the legal guardians of all participants for the publication of their medical case and any accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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