- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
Alim P. Mitha
Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
Department of Clinical Neurosciences, The Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
DOI:10.4103/2152-7806.166168Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Isaacs AM, Yuh S, Hurlbert RJ, Mitha AP. Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair. Surg Neurol Int 28-Sep-2015;6:152
How to cite this URL: Isaacs AM, Yuh S, Hurlbert RJ, Mitha AP. Penetrating intracranial nail-gun injury to the middle cerebral artery: A successful primary repair. Surg Neurol Int 28-Sep-2015;6:152. Available from: http://surgicalneurologyint.com/surgicalint_articles/penetrating-intracranial-nail%e2%80%91gun-injury-to-the-middle-cerebral/
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.
Keywords: Craniotomy, middle cerebral artery, nail-gun, trauma
Intracranial nail-gun injuries are a rare but well-characterized cause of penetrating brain injury. The incidence of these injuries has been rising; the annual rate has almost tripled over the last decade.[
Here, we describe to our knowledge, the first reported case of a penetrating craniocerebral nail-gun injury causing vascular injury to the M1 branch of the middle cerebral artery (MCA). Technical considerations and challenges in the removal of the foreign body and in vascular repair are discussed as well. This report demonstrates that primary repair of a traumatic injury to the arterial vasculature can be associated with good radiographic and clinical outcome.
History and physical examination
A 26-year-old male with no prior medical illnesses presented to hospital after apparently accidentally shooting himself with a nail-gun. He reportedly tripped while helping a friend with work on a deck, triggering the nail-gun during the fall. The patient denied any loss of consciousness, headaches, or seizure-like activity. He was initially assessed in a peripheral hospital Emergency Department where plain skull X-rays revealed a nail traversing the temporal bone [
On presentation to our center, he was alert and oriented (Glasgow Coma Score 15). All cranial nerves were intact. There was no evidence of any motor, sensory or cerebellar dysfunction in his limbs. He was hemodynamically stable. The only abnormal laboratory finding was a mild leukocytosis. Computed tomography (CT) revealed a metallic foreign body is penetrating the right temporal bone. In addition, there was the presence of diffuse subarachnoid hemorrhage (SAH) within the basal cisterns and right sylvian fissure [
Sections of a noncontrast computed tomography head showing scattered subarachnoid hemorrhage in association with an intracranial nail penetrating the right temporal bone and projecting across midline, superior to the sphenoid sinus and anterior to the pituitary fossa, with evidence of obstructive hydrocephalus. Note the beam-hardening artifact
Sections of a computed tomography angiogram are confirming intact internal carotids. The right M1 to the proximal M3 middle cerebral artery and anterior communicating artery regions are not visualized. However, there is normal distal filling of the right middle cerebral artery beyond the beam-hardening artifact, with no obvious vessel perforation, dissection, thrombosis, or branch occlusion
Prior to positioning, the patient received 0.5 mg/kg of 20% IV mannitol. With the head secured in the 3-pin Mayfield fixation system, a curvilinear incision extending from the zygoma, and curving anterior to the ipsilateral hairline was performed. After cutting down to the temporalis fascia and reflecting the myocutaneous flap, a small craniotomy was performed, and the lateral sphenoid wing was drilled flat. The cranium surrounding the nail was left intact, and the dura was opened in a semi-circular fashion. The bone immediately surrounding the nail was then removed with a curved double-action bone rongeur. The nail was then slowly removed with a Leksell rongeur by using slight twist and pull out movements. Immediately after freeing the nail, the brain began to swell. Because of this, maneuvers to decrease the rising intracranial pressure, which included administration of a second dose of 0.5 mg/kg of 20% mannitol and elevation of the head of the operating table, were undertaken with good response. As the sylvian fissure was opened, a small amount of bleeding was noted; however, the bleeding became more brisk as the sylvian fissure was dissected more proximally. As we approached the M1 segment of the MCA vessel, an obvious vessel laceration was identified. Once the MCA was freed and dissected, a temporary clip was placed for proximal control. The laceration was repaired with 10.0 prolene sutures in an interrupted fashion [
Intraoperative images demonstrating the entry point of the nail (double brackets), proposed pterional incision (a) and temporalis reflection (b). A jet of blood (arrow) exsanguinating from the M1 vessel and application of a proximal temporary aneurysm clip (star) (c). Repair of the arteriotomy (d)
Postoperative management and outcome
On postoperative day (POD) 1, a CTA [
With the growing use of pneumatic nail-guns both in the construction industry and by consumers for home use, penetrating craniofacial injuries caused by these devices are on the rise. Most of these injuries are primarily work-related accidents but are also commonly reported as intentionally self-inflicted.[
While the literature is filled with case reports and several series of penetrating intracranial nail-gun injuries, to our knowledge this is the first reported case of a nail-gun injury to the M1 branch of the MCA. In fact, a review of the literature shows few reported cases involving the cerebral vascular system at all. Sani et al. described the successful repair of an intracranial nail-gun injury involving the superior sagittal sinus.[
Posttraumatic pseudoaneurysms are rare but commonly described the occurrence, representing <1% of intracranial aneurysms. They occur when there is the complete disruption of all the three arterial wall layers, and the organizing hematoma or gliotic brain tissue forms the wall of an aneurysm. Posttraumatic pseudoaneurysms occur most commonly in the periphery of the brain where vessels are closely apposed to the dura.[
The significance of a nail-gun associated M1 injury despite a seemingly normal CTA makes several important learning points regarding the management of these patients. Firstly, CTA cannot definitively rule out a vessel injury due to the large amount of metal artifact created by the nail. It can, however, indicate whether the vessel is patent, especially when considered together with the patient's symptomatology. In our case, the patient was neurologically intact and had a CTA suggesting continued patency of the parent vessel. It should, however, be noted that despite the CTA showing no vessel injury, our patient clearly had traumatic disruption of the wall of the M1 vessel from the nail. Nevertheless, because preservation of vessel patency was paramount in our case, we decided to forgo conventional angiography and to be prepared for a surgically corrective action. In hindsight, considering our intraoperative finding of a breached major vessel, we do recommend consideration of conventional angiography if there is any clinical suspicion of potential vascular compromise. If a vascular compromise is detected on angiography, obtaining proximal vascular control prior to the removal of the nail is imperative. In addition, if there is flow compromise within the vessel or an obvious pseudoaneurysm, yet no neurological deficit is present, then a conventional angiography with possible endovascular sacrifice of the vessel or pseudoaneurysm repair prior to surgical removal of the foreign body is strongly recommended. On the other hand, if a neurological deficit is present, and in the absence of a significant infarct, immediate surgical exploration with preparation for intraoperative vessel repair may be warranted in order to perfuse the ischemic brain tissue.
Various surgical approaches to removal of these foreign bodies have been proposed. If the calvaria is not penetrated extraction under local anesthetic may be effective and is associated with minimal complications.[
Complications of penetrating head trauma include local wound infection, meningitis, and formation of a brain abscess. Cerebrospinal fluid leaks and air sinus wounds increase the risk of infection.[
Penetrating vascular injuries from nail-gun injuries are exceedingly rare. Despite impressive clinical and radiological presentations, this type of low-velocity trauma usually produces very limited collateral injury. The first step in management involves careful neurological and radiographic assessments. The cornerstone of imaging should be CT with and without angiographic sequences. In the event that vascular compromise is suspected, a formal cerebral angiogram may be considered. However, it is also reasonable to proceed to surgery prepared for vascular disruption. Removal of a penetrating foreign object should be undertaken only with direct visualization and after preparations for vascular control have been made. This case demonstrates that despite a benign-looking preoperative vascular imaging study a high-level of suspicion for vessel injury should be maintained, and preparations for the corrective action undertaken.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Daniel Fok, MD. Division of Neurology, University of Calgary, Calgary, Alberta Roberto Diaz, MD PhD. Division of Neurosurgery, University of Calgary, Calgary, Alberta.
1. . Antibiotic prophylaxis for penetrating brain injury. J Trauma. 2001. 51: S34-40
2. Blankenship BA, Baxter AB, McKahn GM. Delayed cerebral artery pseudoaneurysm after nail gun injury. AJR Am J Roentgenol. 1999. 172: 541-2
3. Bula WI, Loes DJ. Trauma to the cerebrovascular system. Neuroimaging Clin N Am. 1994. 4: 753-72
4. Carey M, Marshall LF, Grady MS.editors. Moderate and severe traumatic brain injury. Youmans Neurological Surgery. Philadelphia: Bullet Wounds to the Brain Among Civilians; 2004. 4:
5. Cemil B, Tun K, Yigenoglu O, Kaptanoglu E. Attempted suicide with screw penetration into the cranium. Ulus Travma Acil Cerrahi Derg. 2009. 15: 624-7
6. du Trevou MD, van Dellen JR. Penetrating stab wounds to the brain: The timing of angiography in patients presenting with the weapon already removed. Neurosurgery. 1992. 31: 905-11
7. Englot DJ, Laurans MS, Abbed K, Bulsara KR. Removal of nail penetrating the basilar artery. Neurosurg Rev. 2010. 33: 501-4
8. Guyot LL, Kazmierczak CD, Diaz FG. Vascular injury in neurotrauma. Neurol Res. 2001. 23: 291-6
9. Hiraishi T, Kawaguchi T, Kobayashi T, Tomikawa M, Ito Y, Fujii Y. Unstable stenosis of the internal carotid artery caused by a craniofacial nail-gun injury-case report. Neurol Med Chir (Tokyo). 2009. 49: 590-3
10. Litvack ZN, Hunt MA, Weinstein JS, West GA. Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma. Case report and review of the literature. J Neurosurg. 2006. 104: 828-34
11. Olumide AA, Adeloye A. Unusual cranio-cerebral injuries: Report of two cases in Nigerians. Surg Neurol. 1976. 6: 306-8
12. Ravelli V, Forli C, Parenti G. Unusual penetrating craniocerebral injuries. Report of three cases. J Neurosurg Sci. 1987. 31: 153-6
13. Reeves DL. Penetrating craniocerebral injuries. Report of two unusual cases. J Neurosurg. 1965. 23: 204-5
14. Sani S, Jobe KW, Byrne RW. Successful repair of an intracranial nail-gun injury involving the parietal region and the superior sagittal sinus. Case report. J Neurosurg. 2005. 103: 567-9
15. Selvanathan S, Goldschlager T, McMillen J, Campbell S. Penetrating craniocerebral injuries from nail-gun use. J Clin Neurosci. 2007. 14: 678-83
16. Shenoy SN, Raja A. Unusual self-inflicted penetrating craniocerebral injury by a nail. Neurol India. 2003. 51: 411-3
17. Son S, Kang DH, Kim BH, Choi NC. Incidentally discovered a self-inflicted a nail in the brain of schizophrenia patient. Psychiatry Investig. 2011. 8: 272-4
18. Spennato P, Bocchetti A, Mirone G, Savarese L, Squillante D, Rotondo M. Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note. Surg Neurol. 2005. 64: 368-71
19. Weil AG, Weill A, Li M, Shédid D. Low-energy penetrating nail injury through the petrous segment of the ICA. Can J Neurol Sci. 2011. 38: 649-51