Nail gun injuries to the head with minimal neurological consequences: a case series

Abstract

Background: An estimated 3700 individuals are seen annually in US emergency departments for nail gun-related injuries. Approximately 45 cases have been reported in the literature concerning nail gun injuries penetrating the cranium. These cases pose a challenge for the neurosurgeon because of the uniqueness of each case, the dynamics of high pressure nail gun injuries, and the surgical planning to remove the foreign body without further vascular injury or uncontrolled intracranial hemorrhage.

Case presentation: Here we present four cases of penetrating nail gun injuries with variable presentations. Case 1 is of a 33-year-old white man who sustained 10 nail gunshot injuries to his head. Case 2 is of a 51-year-old white man who sustained bi-temporal nail gun injuries to his head. Cases 3 and 4 are of two white men aged 22 years and 49 years with a single nail gun injury to the head. In the context of these individual cases and a review of similar cases in the literature we present surgical approaches and considerations in the management of nail gun injuries to the cranium. Case 1 presented with cranial nerve deficits, Case 2 required intubation for low Glasgow Coma Scale, while Cases 3 and 4 were neurologically intact on presentation. Three patients underwent angiography for assessment of vascular injury and all patients underwent surgical removal of foreign objects using a vice-grip. No neurological deficits were found in these patients on follow-up.

Conclusions: Nail gun injuries can present with variable clinical status; mortality and morbidity is low for surgically managed isolated nail gun-related injuries to the head. The current case series describes the surgical use of a vice-grip for a good grip of the nail head and controlled extraction, and these patients appear to have a good postoperative prognosis with minimal neurological deficits postoperatively and on follow-up.

Keywords: Brain; Nails; Neurosurgery; Penetrating trauma.

Fig. 1

a Computed tomography scout. b Computed tomography three-dimensional reconstruction. There are ten nails projected over the temporo-parieto-occipital area bilaterally, five on each side, these caused significant artifacts on computed tomography and computed tomography angiogram (not shown here), but no major vessel injury was identified and there was evidence of parietal subarachnoid bleed. c, d Postoperative axial computed tomography. Multiple foci of intraparenchymal hemorrhage and associated subarachnoid hemorrhage seen in the left parietal and right frontal-temporal-parietal regions. Multiple tiny calcified bodies were now noted over the left parietal region; they probably represented small bone fragments introduced at the time of penetrating injury. These were obscured on the prior study due to metallic artifact

Fig. 2

a Case 1. Nine out of the ten nails extracted from the patient; the remaining nail was sent for microbiology testing. b Case 2. Three-inch (7.62 cm) nails extracted after craniectomy

Fig. 3

a Skull X-ray. b Computed tomography head – bone window showing two nails penetrating the calvarium on each side. There was evidence of subarachnoid hemorrhage on computed tomography. c Cerebral angiogram three-dimensional reconstruction. Three-dimensional rotations re-demonstrated the presence of bilateral temporal horizontal metallic nails coursing adjacent to the main proximal intracranial vessels. No definite contrast extravasation, arterial occlusion, stenosis or pseudoaneurysm was identified

Fig. 4

Computed tomography of the patient’s head without contrast. a Brain window. b Bone window. A metallic nail in the right parietal bone and parietal lobe in the preoperative study which is removed in the postoperative study (c) with small air pocket and extra-axial hematoma in the same level

Fig. 5

Cerebral angiogram. a Right internal cerebral artery. b Right vertebral artery. The metallic foreign body transects the superior aspect of the right transverse sinus as it merges into the right sigmoid sinus. There is no active extravasation of contrast or evidence of major arterial compromise. c Preoperative computed tomography of the patient’s head (bone window). d Postoperative computed tomography of his head. Small amount of hemorrhage noted along the track of the removed foreign body from the right posterior fossa and evidence of a small intraventricular hemorrhage