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

Isaacs AM, Yuh SJ, Hurlbert RJ, Mitha AP - Surg Neurol Int (2015)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus

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
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4596057&req=5

Figure 2: 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

Mentions: 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 [Figure 2]. Evaluation of the surrounding brain parenchyma was limited due to scattered artifact caused by the foreign body. However, there was no clear evidence of intraparenchymal hemorrhage or edema noted. CT angiography (CTA) [Figures 2 and 3] revealed the foreign body to be within the vicinity of the circle of Willis. Artifact from the nail was present on this study too, but the luminal flow could be visualized throughout. Furthermore, there was no clear evidence of vessel perforation, dissection, thrombosis, or branch occlusion. Since there was still a possibility of vessel injury, and because we decided to forgo conventional angiography, we were prepared for a surgically corrective action if an injury to the vessel was encountered. To prepare for this, specialized vascular equipment including aneurysm clips and an operating microscope capable of intraoperative indocyanine green angiography was made available, and the neurovascular team was called. The patient was subsequently taken to the operating room on an emergent basis for removal of the foreign body.


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

Isaacs AM, Yuh SJ, Hurlbert RJ, Mitha AP - Surg Neurol Int (2015)

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
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4596057&req=5

Figure 2: 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
Mentions: 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 [Figure 2]. Evaluation of the surrounding brain parenchyma was limited due to scattered artifact caused by the foreign body. However, there was no clear evidence of intraparenchymal hemorrhage or edema noted. CT angiography (CTA) [Figures 2 and 3] revealed the foreign body to be within the vicinity of the circle of Willis. Artifact from the nail was present on this study too, but the luminal flow could be visualized throughout. Furthermore, there was no clear evidence of vessel perforation, dissection, thrombosis, or branch occlusion. Since there was still a possibility of vessel injury, and because we decided to forgo conventional angiography, we were prepared for a surgically corrective action if an injury to the vessel was encountered. To prepare for this, specialized vascular equipment including aneurysm clips and an operating microscope capable of intraoperative indocyanine green angiography was made available, and the neurovascular team was called. The patient was subsequently taken to the operating room on an emergent basis for removal of the foreign body.

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada.

ABSTRACT

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.

No MeSH data available.


Related in: MedlinePlus