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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

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)
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Figure 4: 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)

Mentions: 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 [Figure 4]. Intraoperative Doppler ultrasound was then used to verify that proximal and distal flow in the vessel was maintained.


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)

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

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

Figure 4: 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)
Mentions: 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 [Figure 4]. Intraoperative Doppler ultrasound was then used to verify that proximal and distal flow in the vessel was maintained.

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