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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

Right internal carotid AP (left), lateral (middle), and oblique (right) projections of a digital subtraction angiogram obtained on postoperative day 3, showing no evidence of extravasation, stenosis or occlusion after middle cerebral artery repair
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Figure 6: Right internal carotid AP (left), lateral (middle), and oblique (right) projections of a digital subtraction angiogram obtained on postoperative day 3, showing no evidence of extravasation, stenosis or occlusion after middle cerebral artery repair

Mentions: On postoperative day (POD) 1, a CTA [Figure 5] revealed that the major intracranial arteries were patent with no pseudoaneurysm or vessel occlusion noted. A selective 2-vessel conventional digital subtraction angiogram (DSA) was performed on POD 3 that revealed normal cerebral vasculature, with no evidence of extravasation, pseudoaneurysm, and stenosis or thrombosis. There was good flow proximally and distally to the repair site [Figure 6]. The patient received a 7-day course of empiric antibiotic therapy. A psychiatric evaluation proved to be normal. He was discharged on POD 8 with no neurological deficits.


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)

Right internal carotid AP (left), lateral (middle), and oblique (right) projections of a digital subtraction angiogram obtained on postoperative day 3, showing no evidence of extravasation, stenosis or occlusion after middle cerebral artery repair
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 6: Right internal carotid AP (left), lateral (middle), and oblique (right) projections of a digital subtraction angiogram obtained on postoperative day 3, showing no evidence of extravasation, stenosis or occlusion after middle cerebral artery repair
Mentions: On postoperative day (POD) 1, a CTA [Figure 5] revealed that the major intracranial arteries were patent with no pseudoaneurysm or vessel occlusion noted. A selective 2-vessel conventional digital subtraction angiogram (DSA) was performed on POD 3 that revealed normal cerebral vasculature, with no evidence of extravasation, pseudoaneurysm, and stenosis or thrombosis. There was good flow proximally and distally to the repair site [Figure 6]. The patient received a 7-day course of empiric antibiotic therapy. A psychiatric evaluation proved to be normal. He was discharged on POD 8 with no neurological deficits.

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