Unusual Delayed Presentation of a Nail Gun Injury Through the Skull Base

Low-velocity penetrating brain injury: a review of the literature and illustrative case

INTRODUCTION

Low-velocity penetrating brain injury (LVPBI) is a class of brain injury where a foreign object violates the skull and damages the brain. Such injuries are rare and consequently understudied.

CASE

As such, we report an illustrative case of a 29-year-old female with a dense, plastic spike penetrating her right orbit and into her midbrain. After assessment with a CT scan and angiography, the object was removed with careful attention to possible vascular injury. The patient had an uncomplicated post-operative course and received antibiotic and antiepileptic prophylaxis. She was discharged on post-operative day 5, experiencing only mild left-sided weakness.

DISCUSSION

Common concerns regarding LVPBI include infection, post-traumatic epilepsy, and vascular injury. A review of published LVPBI cases over the past 20 years demonstrated that most cases (55.2%) are due to accidents. Of patients undergoing surgery, 43.4% underwent a craniotomy, and 22.8% underwent a craniectomy. Despite the grave nature of LVPBI, only 13.5% of the patients died. Additionally, 6.5% of patients developed an infection over their clinical course.

CONCLUSION

In all, more reported cases further paint a picture of the current state of management and outcomes regarding LVPBI, paving the way for more cohesive guidelines to ensure the best possible patient outcomes.

Craniocerebral nail gun injuries: a definitive review of the literature

AIM

Nail guns are important time saving devices but are associated with morbidity and mortality. Specifically, craniocerebral injuries have been reported in the literature since 1963 and have increased in frequency as the use of these tools has become commonplace. There remains a paucity of literature comprehensively assessing nail gun injuries, as compared with other penetrating craniocerebral injuries like those from firearms.

METHOD

A literature review of PubMed, Medline (Ovid), Cochrane library, and Google Scholar for articles published between 1960 and 2018 reporting craniocerebral nail gun injuries.

RESULTS

In total, 96 individual cases were identified, with 80 meeting inclusion criteria. These were categorized as accidental and intentional injuries. The demographic was overwhelmingly young males (97.5%), and intentional self-inflicted injuries (54%) was the most frequent mechanism of injury. Overall mortality was 10%. Mortality was more common in patients with intentional injuries, but morbidity rates were similar between the accidental and intentional injury cohorts. Post-operative complications rate was 23.8%.

CONCLUSION

Craniocerebral nail gun injuries are associated with lower rates of both mortality and residual neurological deficits than craniocerebral firearms injuries. There is limited data to inform clinical prognostication about long-term neurological impairments and the time to recovery which should be addressed in future studies.

Nail Gun Injury of the Spine: Case Report and Review of the Literature

BACKGROUND

Since the first report about nail gun injuries in 1959, there has been an average of approximately 37,000 patients hurt by nail guns and treated in emergency departments. Carotid arterial injury by nail gun has been reported, but vertebral artery damage is extremely rare.

CASE DESCRIPTION

A 42-year-old man was transported to the emergency department after suffering an accidental self-inflicted nail gun injury to the left lateral aspect of his neck. Radiographic imaging of the cervical spine revealed a 3.1-cm metallic nail in the C5 region. A computed tomography (CT) angiogram revealed the nail passing through the left C5 transverse foramen and compressing the left vertebral artery. He was immediately brought to the operating room for removal of the nail. At 1-month follow-up, the patient did not have any neck complaints and postoperative CT angiogram indicated the patient was asymptomatic with no signs of complication or infection.

CONCLUSIONS

Based on our experience and a review of the literature, in terms of treating a nail gun injury to the cervical spine, we would like emphasize that preoperative CT scan or CT angiogram is necessary to assess the location and shape of the nail, especially nails with barbers or washers. Improving awareness of the risk from accidental nail gun trauma may lead to better prevention of this rare but potentially life-threatening injury.

Management of Penetrating Brain Injury Caused by a Nail Gun: Three Case Reports and Literature Review

BACKGROUND

Penetrating brain injury (PBI) caused by a nail gun is an extremely rare neurosurgical emergency that poses a challenge for neurosurgeons because of its rarity and complexity.

CASE DESCRIPTION

Here we present 3 cases of PBI caused by a nail gun. In the first case, the nail entered through the right parietal bone and lodged in the right parietal lobe and basal ganglia. In the second case, the nail entered through the right occipital bone and lodged in the right occipital lobe. In the third case, the nail entered through the right parietal bone and lodged in the right frontal and parietal lobes. All patients underwent surgical removal of the nail. The first patient presented with reduced left-side strength, whereas the second and third patients were neurologically intact on presentation.

CONCLUSIONS

PBI caused by a nail gun can present with differing clinical manifestations, and most cases require immediate surgery. A rational management strategy should provide a good postoperative prognosis with minimal neurologic deficits in these patients.

Penetrating Craniomaxillofacial Injury Caused by a Pneumatic Nail Gun

Craniomaxillofacial injuries can be complex, requiring a multidisciplinary approach. The primary survey is always the first step in trauma management prior to proceeding with further evaluation and treatment. A 26-year-old man presented with a penetrating nail gun injury through the oral and nasal cavities. He did not present in extremis but required elective endotracheal intubation for intraoperative assessment and treatment. Airway management was enhanced by the use of lingual nerve and inferior alveolar nerve blocks via the Vazirani-Akinosi technique to maintain spontaneous respiration while the tongue was distracted from the palate. The nail was removed and rapid sequence induction initiated for orotracheal intubation. Local nerve blocks can be an effective tool in the armamentarium of the craniomaxillofacial trauma surgeon in managing blunt and penetrating injuries. We demonstrate its utility in airway management when a penetrating foreign body in the upper airway precludes orotracheal or nasotracheal intubation.

Intraoral approach for surgical removal of a nail in penetrating maxillofacial injury

An unusual case of penetrating maxillofacial injury caused by a nail gun is presented. In this case, the foreign body was shot into the left infratemporal fossa and maxillary sinus through the left cheek. We used an intraoral approach that allowed precise localization of the point of the infratemporal surface of the maxilla through which the nail penetrated the maxillary sinus. The nail was successfully removed and the patient was discharged with complete recovery. The details of the surgical approach as well as localization techniques are described. Different approaches to remove the nail as well as the advantages and disadvantages of each approach are discussed.

CT angiography evaluation of unusual transorbital penetrating injury: a toothbrush

Orbital penetrating injuries may cause significant harm to optic nerves and eyeball as well as to the brain and cerebral vasculature. Defining surrounding neurovascular structures by CT angiography (CTA) is important for surgical removal. We present an uncommon case of a 3-year-old child with a penetrating orbital injury caused by a toothbrush. To the best of our knowledge, there is no report orbital injury with a toothbrush so far.

Neglected foreign body infratemporal fossa, a typical presentation: a case report

A 25 year old male presented to our ENT OPD with the history of hyperemic swelling left zygomatic area with a pointed pustule in the centre resembling a furuncle,which progressed into a discharging sinus, complicated by trismus. The patient had a past history of trauma in the vicinity of the left zygomatic area 4-months back with a pointed stick the tip of the stick which had got lodged in the wound at that time was removed. The diagnostic dilemma was solved as neglected foreign body infratemporal fossa.

Toward failure analyses in systems biology

Parallels between designed and biological systems with respect to formal failure analyses have been presented. Failure analysis in designed systems depends on an identified, limited set of parameters or operation variables with high predictive value. In contrast, the biological systems pose problems in identification of operation variables and the identified variables may not be accurate predictors of failure. The difficulty in parameter identification is because of large numbers of components and the inability to envelope variables at each compartment or contour level. Contour level maps for biological systems are currently non-existent, and most failure models are based on very limited, unilateral operation variables (a mutant gene). Operation variable identification within each contour level will enhance failure analyses of complex biological systems.