Removal of nail penetrating the basilar artery

Thirty-two nails injected into the head: An operative report and review of the literature

Background:

Self-inflicted nail gun injuries are a rare phenomenon that can result in traumatic damage. The velocity of the nail is generally fast enough to penetrate the skull. However, the extent of damage depends on the exact angle and structures of the brain encountered by the nails.

Case Description:

A 55-year-old male presented with 32 nails in the head and was found down. Initially, the patient presented with localization but had to be intubated soon after due to declining condition. This report describes the operative technique for safe removal of all nails, separated into six categories based on location and structures of the brain encountered. A review of literature revealed potential complications such as hemorrhage and infections and how to protect against these undesired effects.

Conclusion:

Self-inflicted nail gun head injuries are an uncommon form of traumatic head injury. Some important tools that helped prevent our patient from developing major complications included stereotactic navigation, antibiotic prophylaxis, and angiography to carefully monitor for vascular injuries.

Unique Presentation and Novel Surgical Approach to a Transcribriform Penetrating Head Injury Caused by a Nail Gun

A penetrating head injury caused by a nail gun is an infrequent clinically diverse condition that varies in severity by the neurovascular structures involved. The authors present the case of a patient whose frontal lobe was pierced by a nail that entered via a transnasal transcribriform trajectory without causing vascular injury or intracranial hemorrhage; the man was unaware of the nail’s presence and presented with headache five days after the incident. The nail was extracted using a bifrontal craniotomy for direct visualization and for defect repair of the skull base combined with endoscopic endonasal extraction of the nail.

Traumatic intracranial nail-gun injury of the right internal carotid artery causing pseudoaneurysm and caroticocavernous fistula

Penetrating trauma due to nail gun is an uncommon yet important clinical entity. There are numerous case reports describing these injuries, yet few describe those resulting in cerebrovascular injury. Laceration of cerebral blood vessels may result in significant intracranial haemorrhage and cerebral ischaemia, with catastrophic consequences. In the present study, we report a female patient who was shot in the face with a nail gun in a domestic assault. The nail entered her right cavernous sinus and lacerated her right internal carotid artery causing a pseudoaneurysm and a caroticocavernous fistula. This report details the approach to, and pitfalls of, managing a cerebrovascular injury due to penetrating intracranial nail. Catheter cerebral angiography is essential in the diagnosis and treatment of these injuries. Best treatment and outcomes require clinicians with expertise in endovascular and surgical repair strategies.

Penetrating craniocerebral nail gun injury in a child: a case report

Penetrating craniocerebral injuries with a nail gun are extremely rare and even rarer in children. In this case, a 2-year-old boy, who was the youngest patient in the literature with an intracranial nail gun injury involving penetration of the right temporal lobe, was reported. The patient was evaluated by plain radiography and computed tomography. The nail was loosened and pulled gently out by creating a small craniotomy around the nail entrance. Although clinical characteristics and treatment methods of penetrating craniocerebral injuries were similar for reported in literature, the injury mechanism of presented case was different. Penetrating craniocerebral injuries with a nail gun are very dramatic situation, but mortality and morbidity are low. Without major vascular injury, a nail can be removed through a small incision. Penetrating injuries often occur accidentally in the pediatric age group, but the risk of child abuse should always be considered.

Functional muscle strength recovery from nail gun injury to the primary motor cortex

Aim: Functional recovery following injury to the primary motor cortex is an uncommon phenomenon, given the limited ability of neurons of the adult central nervous system to regenerate. Case description: We report on a patient with near complete functional muscle strength recovery from a marked monoparesis due to nail gun injury to the medial primary motor cortex. Besides surgical decision-making, we discuss possible related mechanisms and current challenges in the regenerative processes responsible for the functional recovery. Discussion: To achieve a favorable outcome, surgical decision-making to prevent secondary damage is of upmost importance. Lesion-induced inflammatory response may potentiate endogenous neurogenesis and neuronal plasticity and potentially contribute to the regenerative process involved.

Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note

We report a 45-year-old man who suffered a penetrating nail gun injury resulting in damage to the lateral edge of the superior sagittal sinus. The injury was successfully treated via a parasagittal craniotomy that enabled removal of the nail under direct vision, allowing for rapid suturing of the sagittal sinus. Two neurosurgeons worked together; one carefully withdrew the tip of the nail back into the sinus itself while the second rapidly sutured the hole in the inner superior sagittal sinus leaflet. Postoperatively, the patient made a rapid recovery without neurological deficit.

Diagnosis and treatment of a penetrating brain injury caused by a welding electrode: A case report

RATIONALE

Penetrating brain injury caused by a welding electrode is a rare occurrence. This type of injury requires careful preoperative assessment and timely treatment measures to avoid secondary damage.

PATIENT CONCERNS

A 55-year-old male patient fell from a height of approximately 5 m during when a welding electrode in his left hand was inadvertently inserted into his brain. The patient had a GCS score of 15 and complaints of dizziness and headache. CT showed an object of metallic density penetrating the skull and entering the brain parenchyma in the frontotemporal region.

DIAGNOSIS

According to the clinical findings and preoperative imaging examination, the diagnosis was open craniocerebral injury with intracranial foreign body and left orbital wall fracture.

INTERVENTION

After definite diagnosis and sufficient preoperative preparation, active surgical treatment was carried out to remove intracranial foreign body. Anti-infection and other symptomatic treatment were given after operation. The signs of infection and changes of vital signs were closely observed.

OUTCOMES

After treatment, no obvious adverse reactions were found and the patient was discharged. No complications such as infection occurred during the follow-up period of 6 months.

LESSONS

In treating patient with a welding electrode penetrating the brain, assessments need to be made preoperatively, the welding electrode needs to be removed in a timely manner, complete hemostasis needs to be achieved during surgery with total repair of the damaged area, and anti-inflammatory treatment needs to be administered postoperatively to achieve good results.

External Ventricular Drainage Preceding the Removal of a Nail from the Intracranial Space as a Safe Management Strategy for Predicted Secondary Intraventricular Hemorrhage

BACKGROUND

Intracranial nail gun injury is a rare traumatic event and can result from a suicide attempt. Cerebral angiography is essential in the evaluation of damage to the intracranial vessels, and surgical removal of nails is generally the optimal treatment. Intraventricular hemorrhage can happen after removal of intracranial nails. Endovascular surgery or intraoperative computed tomography has been reported to be useful for detection and treatment of intraventricular hemorrhage. After the surgical removal of nails, attention should be paid for complications such as pseudoaneurysm and infection.

CASE DESCRIPTION

A 63-year-old man with a history of depression was transferred to our hospital in an unconscious state. Physical examination showed 2 nails puncturing his left thorax, and computed tomography revealed a nail puncturing the intracranial space. No damage to these intracranial vessels was observed on computed tomography angiography and venography. After drainage for potential intraventricular hemorrhage, the nails were removed. Postoperatively, prophylactic antibiotic therapy was administrated for secondary infection. Computed tomography angiography did not detect any postoperative pseudoaneurysms. The patient also underwent therapy from a psychiatrist and was transferred to another hospital.

CONCLUSIONS

As for treatment of a case of intracranial nail gun injury, our case shows that preoperative cerebral angiography is not always needed in intracranial nail gun injury when there is no apparent damage to the intracranial vessels and emergent removal of nails is required. External ventricular drainage preceding the removal of a puncture object can be an effective management strategy for secondary intraventricular hemorrhage.

Ventricular Tract Hemorrhage Following Intracranial Nail Removal: Utility of Real-time Endovascular Assistance

Penetrating brain trauma commonly results in occult neurovascular injury. Detailed cerebrovascular imaging can evaluate the relationship of intracranial foreign bodies to major vascular structures, assess for traumatic pseudoaneurysms, and ensure hemostasis during surgical removal. We report a case of a self-inflicted intracranial nail gun injury causing a communicating ventricular tract hemorrhage upon removal, as well as a delayed pseudoaneurysm. Pre- and post-operative vascular imaging, as well as intra-operative endovascular assistance, was critical to successful foreign body removal in this patient. This report demonstrates the utility of endovascular techniques for the assessment and treatment of occult cerebrovascular injuries from intracranial foreign bodies.

Self-inflicted nail-gun injury with cranial penetration and use of intraoperative computed tomography

BACKGROUND

Management of penetrating cranial trauma remains a high acuity and imaging intense neurosurgical disorder. Imaging of vital structures, including angiography, is typically conducted to understand the proximity of vital structures in comparison to a foreign body and prepare for intraoperative complications such as hemorrhage. Preservation of function following initial injury in cases where minimal neurological deficit exists is essential.

CASE DESCRIPTION

Here, we present a case using intraoperative computed tomography to assist in early detection and resolution of hemorrhage in the surgical management of an intact patient with self-inflicted penetrating cranial trauma.

CONCLUSIONS

This method may aid in early detection of hemorrhage and prevention of consequential neurological deterioration or emergent need for secondary surgery.

Nail gun injuries to the head with minimal neurological consequences: a case series

Background

An estimated 3700 individuals are seen annually in US emergency departments for nail gun-related injuries. Approximately 45 cases have been reported in the literature concerning nail gun injuries penetrating the cranium. These cases pose a challenge for the neurosurgeon because of the uniqueness of each case, the dynamics of high pressure nail gun injuries, and the surgical planning to remove the foreign body without further vascular injury or uncontrolled intracranial hemorrhage.

Case presentation

Here we present four cases of penetrating nail gun injuries with variable presentations. Case 1 is of a 33-year-old white man who sustained 10 nail gunshot injuries to his head. Case 2 is of a 51-year-old white man who sustained bi-temporal nail gun injuries to his head. Cases 3 and 4 are of two white men aged 22 years and 49 years with a single nail gun injury to the head. In the context of these individual cases and a review of similar cases in the literature we present surgical approaches and considerations in the management of nail gun injuries to the cranium. Case 1 presented with cranial nerve deficits, Case 2 required intubation for low Glasgow Coma Scale, while Cases 3 and 4 were neurologically intact on presentation. Three patients underwent angiography for assessment of vascular injury and all patients underwent surgical removal of foreign objects using a vice-grip. No neurological deficits were found in these patients on follow-up.

Conclusions

Nail gun injuries can present with variable clinical status; mortality and morbidity is low for surgically managed isolated nail gun-related injuries to the head. The current case series describes the surgical use of a vice-grip for a good grip of the nail head and controlled extraction, and these patients appear to have a good postoperative prognosis with minimal neurological deficits postoperatively and on follow-up.

Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair

BACKGROUND

Penetrating nail-gun injuries to the head are rare, however, the incidence has been gradually rising over the last decade. While there is a large volume of case reports in the literature, there are only a few incidences of cerebrovascular injury. We present a case of a patient with a nail-gun injury to the brain, which compromised the cerebral vasculature. In this article, we present the case, incidence, pathology, and a brief literature review of penetrating nail-gun injuries to highlight the principles of management pertaining to penetration of cerebrovascular structures.

CASE DESCRIPTION

A 26-year-old male presented with a penetrating nail-gun injury to his head. There were no neurological deficits. Initial imaging revealed that the nail had penetrated the cranium and suggested the vasculature to be intact. However, due to the proximity of the nail to the circle of Willis the operative approach was tailored in anticipation of a vascular injury. Intraoperatively removal of the foreign body demonstrated a laceration to the M1 branch of the middle cerebral artery (MCA), which was successfully repaired.

CONCLUSION

To our knowledge, this is the first reported case of a vascular arterial injury to the MCA from a nail-gun injury. It is imperative to have a high clinical suspicion for cerebrovascular compromise in penetrating nail-gun injuries even when conventional imaging suggests otherwise.

Musculoskeletal concerns do not justify failure to use safer sequential trigger to prevent acute nail gun injuries

BACKGROUND

Acute nail gun injuries can be controlled significantly by using tools with sequential triggers and training. Concern has been raised that sequential triggers, which require that the nose piece of the gun be depressed prior to pulling the trigger, could increase risk of musculoskeletal problems.

METHODS

We conducted active injury surveillance among union carpenter apprentices to monitor acute injuries and musculoskeletal disorders between 2010 and 2013.

RESULTS

Acute injury risk was 70% higher with contact trip rather than sequential triggers. Musculoskeletal risk was comparable (contact trip 0.09/10,000 hr (95% CI, 0.02-0.26); sequential 0.08/ 10,000 hr (95% CI 0.02-0.23)).

CONCLUSIONS

Concern about excess risk of musculoskeletal problems from nail guns with sequential triggers is unwarranted. Both actuation systems carry comparable musculoskeletal risk which is far less than the risk of acute injury; there is clearly no justification for failure to prevent acute injuries through use of the safer sequential trigger.

Nail Gun Induced Open Head Injury: A Case Report

Increasing use of the nail gun has led to higher injury rates from the use of tools with sequential actuation. Nail gun injury can occur to various parts of the body. Very deep penetration in the brain can have fatal results. A 46-year-old male fired shots from a nail gun into his brain in a suicide attempt. This case demonstrated successful surgical management of the resultant open head injury.

Penetrating injury to the superior sagittal sinus by a nail in a 4-year-old child: a case report

Penetrating head injuries are rare in children, with most injuries being accidental as a result of unsupervised use of sharp objects by young children. We present the case of a 4-year-old boy brought to our emergency department with a nail embedded through a wooden board and into his skull. The nail was determined to be entering the superior sagittal sinus through radiographic imaging. Thus, surgical removal of the nail was determined to be necessary. Inspection revealed a likely through-and-through injury to the sinus, and therefore, because sinus reconstruction was not deemed possible, the sinus was occluded with suture ties both in front and behind the nail before nail removal. Postoperatively, the patient did well and remained neurologically intact. Investigation for possible nonaccidental trauma was conducted. Although most commonly accidental in nature, nonaccidental penetrating traumas have been reported in both pediatric and adult populations. This patient did well after occlusion of his superior sagittal sinus at the coronal suture after penetrating injury by a nail. Penetrating injury in the pediatric population is predominantly thought to be accidental, but a high index of suspicion should be maintained for possible nonaccidental etiology.

Removal of a nail from bone after nail gun injury: a case report and utility of a classic technique

Nail gun injuries are common, work-related injuries that typically involve bony impalement of an extremity with the nail. Treatment recommendations are well established, although suggestions for removing the nail itself have been lacking. In our hands, removal using typical operating room equipment has been challenging, usually resulting in nail head deformity and breakage, which makes completing the procedure even more difficult. As a result, we have revisited the tool designed solely for the purpose of nail removal, that is, a claw hammer: this tool is readily available from materials management at most hospitals, can be easily autoclaved, and is effectively used with a block or surgical pan lid to gain leverage and protect the soft tissues. We have found this method to be simple and extremely useful for nail removal for the nail-impaled patient.

Penetrating brain injury caused by nail guns: two case reports and a review of the literature

BACKGROUND

To the best of the authors' knowledge, there are few case reports of penetrating brain injuries (PBI) caused by nail guns and these have usually involved incomplete penetration of the skull. Complete penetration of a nail into the intracranial cavity is extremely rare.

CASE STUDY

Here, two such cases are presented. In the first, the nail entered through the right temporal bone, lodged in the right temporal lobe and was removed via craniotomy with intra-operative ultrasound guidance. In the second, the nail destroyed the left parietal bone, damaged the left internal capsule and lodged in the left temporal lobe near the left petrous apex and the brain stem. According to the latest literature retrieval, this is the first reported case of nail-gun injury to the internal capsule. The position of the nail precluded removal without further neurologic damage. Treatment strategies designed to optimize outcome, with or without surgery, and possible complications are discussed in this report.

Nail projectiles propelled by a mason's lacing cord: an experimental approach

The recent clinical observation of two unintentional penetrating ocular and cerebral injuries due to 90-mm construction nails gave occasion to an experimental study to check the alleged trauma mechanism for plausibility. Both casualties reported that they had attached a mason's lacing cord to the masonry using a nail as anchoring when suddenly the nail was yanked from its moorings and propelled like a missile by the overstretched lacing cord. As to the best of the authors' knowledge, this mechanism of injury has not yet been reported in any of the literature; it was the aim to find an experimental approach to review the plausibility of the alleged sequence of events leading to the accidents. The tensile strength at break and strain at break of different mason's lacing cords (diameter of 1 and 2 mm) were measured according to DIN EN ISO 2062 by using a tensile testing machine. Based on the maximum spring energy of the lacing cords, which was determined 174.9 J for the 1-mm cord (length 10 m) and 747.4 J for the 2-mm cord (length 10 m), the maximum possible velocity of the nails as projectiles was calculated to be 243.5 m/s for the 1-mm cord and 503.4 m/s for the 2-mm cord. The critical elongation a cord of a certain length has to be stretched to deliver enough kinetic energy to a 90-mm nail to surpass the threshold velocity for skin penetration, which was investigated by Sellier (1977) to be approximately 18 m/s, was also calculated. To conclude, the energy delivered by the cords is high enough to surpass the rather low threshold velocity of nails. The details of how these accidents occurred, which seemed questionable at first, can be reasonably explained by trauma biomechanics.

Nail-gun injury of the cervical spine: simple technique for removal of a barbed nail

Although nail-gun injuries are a common form of penetrating low-velocity injury, impalement with barbed nails has been underreported to date. Barbed nails are designed to resist dislodgment once embedded, and any attempt at removal may splay open the barbs along the path of entry, with the potential for significant soft-tissue and neurovascular injury. A 25-year-old man sustained a nail impalement of the cervical spine from accidental discharge of a nail gun. The patient was noted to be fully conscious with no neurological deficits. Cervical Zone 2 impalement was noted, with only the head of the nail visible. Angiography revealed the nail lying just anterior to the right vertebral artery (VA), with compression of the vessel. Preoperatively, analysis of a similar nail revealed that orientation of the head determined position of the barbs. A deep neck dissection was then performed to the lateral aspect of the C-3 body, using the nail as a guide. Prior to removal, the nail was turned 180° to change the position of the barbs, to prevent injury to the VA. Nail removal was uneventful. The authors present a simple technique for treatment of a nail-gun injury with a barbed nail. Prior to removal, radiographic analysis of the impaled nail must be performed to determine the presence of barbs. If possible, the surgeon should request a similar nail for analysis prior to surgery. Last, the treating surgeon must have knowledge of the barbs' position at all times during nail removal, to prevent damage to critical structures.