Microscopic endonasal transsphenoidal approach for repair of sellar defect from penetrating trauma during wartime: illustrative case

BACKGROUND: Penetrating head trauma caused by blast injuries can result in intracranial foreign bodies (FBs), which pose significant risks, including CSF leaks, pneumocephalus, and infections, particularly when paranasal sinuses are involved. OBSERVATIONS: A 54-year-old male sustained a blast injury in Ukraine, resulting in shrapnel embedded in the sella turcica. The trajectory of the shrapnel traversed the right medial orbital wall into the ethmoid and sphenoid sinuses, ultimately reaching the sella and causing a skull base defect with CSF rhinorrhea. CT imaging revealed subarachnoid hemorrhage and severe pneumocephalus. Because of the FB's proximity to the cavernous sinus and pituitary gland, the decision was made to leave the FB and repair the defect via a microscopic endonasal transseptal transsphenoidal approach with a fascial and muscle graft given that a nasoseptal flap was not possible. The patient experienced no neurological or endocrinological sequelae with complete resolution of the pneumocephalus. LESSONS: The microscopic endonasal transsphenoidal approach is a safe and effective technique for managing skull base defects resulting from penetrating trauma, achieving resolution of pneumocephalus, and preventing meningitis. Decisions regarding FB removal should be individualized, prioritizing patient recovery while minimizing neurovascular risks. https://thejns.org/doi/10.3171/CASE24875.