A novel face-level blast mechanism: CT findings of neuro-ocular injury from a mass-casualty event.

BACKGROUND

On September 17, 2024, thousands of handheld communication devices detonated simultaneously across Lebanon, producing a mass-casualty event with an unprecedented close-proximity blast mechanism. Because the devices were held at face level, victims sustained highly localized craniofacial and hands, and to a lesser extent, neck injuries. This article aims to characterize the spectrum, severity, and distribution of intracranial, craniofacial, orbital, and neck injuries among victims presenting to a tertiary trauma center. To our knowledge, this study represents the first radiological characterization of neuro-ocular injury patterns resulting from synchronized handheld device detonations.

METHODS

This retrospective study included all patients presenting to the American University of Beirut Medical Center (AUBMC) within 24 hours of the event who underwent head, neck, and/or orbital imaging. Patients without blast-related injuries or without neuro-ocular imaging were excluded. Computed Tomography (CT) findings were recorded using standardized neuro-ocular trauma categories.

RESULTS

Of 177 patients presenting after the blast, 153 had blast-related injuries, and 103 underwent brain and orbit CT scan. Head injuries were highly prevalent (93.2%). Intracranial hemorrhage (ICH) occurred in 39.8%, most commonly hemorrhagic contusions (22.3%), and subarachnoid hemorrhage (SAH) (21.4%). Skull and facial fractures were present in 65%. Orbital injuries occurred in 82.5%, including orbital wall fractures (54.4%). Ocular trauma was severe, with globe rupture in 56.3% of patients (24.1% bilateral), penetrating globe injuries in 28.2%. Vitreous hemorrhage was the most common posterior segment injury (35.9%). Neck injuries occurred in 13.6% of patients, most commonly retained shrapnel and subcutaneous emphysema, with occasional extension into deep neck spaces and one case of laryngeal injury. Shrapnel was predominantly localized to the face (89.3%) and orbits (74.8%). Incidental intracranial findings were identified in approximately 1-2% of imaged patients.

CONCLUSIONS

The pager detonations produced an extraordinary concentration of craniofacial, orbital, and neck trauma, with rates of ICH, skull fractures, and globe rupture exceeding those reported in previous civilian mass-casualty events. The face-level, close-contact blast mechanism explains the intense neuro-ocular injury burden. Rapid CT imaging proved essential for identifying injury severity, guiding surgical intervention, and supporting coordinated ophthalmologic-neurosurgical management. These findings underscore the need for specialized preparedness in future unconventional blast scenarios.