Ventricular Tract Hemorrhage Following Intracranial Nail Removal: Utility of Real-time Endovascular Assistance

Abstract

Penetrating brain trauma commonly results in occult neurovascular injury. Detailed cerebrovascular imaging can evaluate the relationship of intracranial foreign bodies to major vascular structures, assess for traumatic pseudoaneurysms, and ensure hemostasis during surgical removal. We report a case of a self-inflicted intracranial nail gun injury causing a communicating ventricular tract hemorrhage upon removal, as well as a delayed pseudoaneurysm. Pre- and post-operative vascular imaging, as well as intra-operative endovascular assistance, was critical to successful foreign body removal in this patient. This report demonstrates the utility of endovascular techniques for the assessment and treatment of occult cerebrovascular injuries from intracranial foreign bodies.

Keywords: cerebral embolization; nail gun; penetrating brain trauma.

Figure 1

Assessment of initial injury from intracranial nail. (A) AP skull plain radiograph demonstrating nail penetration depth. (B) Axial image from head CT demonstrating basilar traumatic subarachnoid hemorrhage. (C) Lateral projection of a left internal carotid angiogram demonstrating nail positioning in the vicinity of a left M3 branch (nail head highlighted by black arrow), with no aneurysms, vessel occlusions/transections, or active extravasation.

Figure 2

Ventricular tract hemorrhage following intracranial nail removal. (A–D) Serial oblique projections of a left internal carotid angiogram immediately after nail removal, demonstrating active hemorrhage (white arrows) from a small left M3 branch extending down the puncture tract into the lateral ventricle. (E) Lateral left internal carotid angiogram confirming resolution of hemorrhage after no active extravasation was seen on serial M3 microcatheterizations. No aneurysmal dilatation or flow-limiting stenosis is seen. (F) Axial T2-weighted flair brain MRI demonstrating only mild local inflammation 5 days after nail removal.

Figure 3

Delayed pseudoaneurysm formation. (A) Left internal carotid angiogram demonstrating a left anterior parietal MCA branch pseudoaneurysm (white arrow), successfully treated via proximal branch embolization [(B); black arrow highlighting area of branch sacrifice].