Serious Penetrating Craniocerebral Injury Caused by A Nail Gun

online © ML Comm
www.jkns.or.kr http://dx.doi.org/10.3340/jkns.2014.56.6.537 Print ISSN 2005-3711 On-line ISSN 1598-7876
J Korean Neurosurg Soc 56 (6) : 537-539, 2014 Copyright © 2014 The Korean Neurosurgical Society
Case Report
Serious Penetrating Craniocerebral Injury

Caused by a Nail Gun
Yong Hyun Jeon, M.D., Ph.D.,1 Dong Min Kim, M.D., Ph.D.,2 Sung Hoon Kim, M.D., Ph.D.,3 Seok Won Kim, M.D., Ph.D.4
Departments of Anatomy,1 Internal Medicine,2 Neurosurgery,4 College of Medicine, Chosun University, Gwangju, Korea
Department of Rehabilitation Medicine,3 Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
Penetrating cerebral injuries caused by foreign bodies occur rarely due to the substantial mechanical protection offered by the skull. Throughout most
of history, the brain, residing in a “closed box” of bone, has not been vulnerable to external aggression. Recently, we encountered a serious penetrat-
ing craniocerebral injury caused by a nail gun. Total excision of the offending nail via emergency craniotomy was performed, but the patient’s neurologic
status was not improved in spite of aggressive rehabilitative treatment. Here, we report on this troublesome case in light of a review of the relevant
literature.
Key Words : Head · Injury · Penetrating.
INTRODUCTION He showed right side hemiparesis (Grade II/Grade I). Plain skull
radiographs revealed a 5-cm, linear, nail-shaped foreign body
Penetrating cerebral injuries caused by foreign bodies other piercing the brain (Fig. 1).
than bullets are relatively rare due to the substantial mechanical A computed tomography (CT) scan of the brain showed the
protection provided by the skull. In clinical practice, such injuries presence of a metallic foreign body in the left parietal lobe. It
are mostly due to industrial accidents and criminal assaults2,8). reached almost to the pons, and multiple fracture fragments were
Several descriptions of foreign bodies such as wood pencils or met- also seen impacted into the parietal lobe (Fig. 2).
al penetrating the cranium have appeared in the literature5,6). How- Treatment with a combination of ceftriaxone, chlorampheni-
ever, suicide attempts and self-inflicted nail gun injuries are rare- col, and metronidazole was initiated and tetanus immunization
ly reported. A good neurological outcome can be expected if the was administered. The patient was operated immediately and a
free ends of the nails can be seen in the operative field and if the local scalp incision was made at the nail entry site. After a small
brainstem and major vessels are spared12). Here we report on a dif-
ficult case of deep-seated intracranial nail gun injury in which the
free end of the nail was not seen.
CASE REPORT
A 43-year-old man was referred to the emergency room due to

altered mental status subsequent to a self-inflicted nail gun wound.
During a quarrel with a co-worker, he attempted suicide by shoot-
ing himself with a nailing gun at his workplace. On physical ex-
amination, he was found to have an open laceration about 2×1 cm
in the left parietal region. On neurological examination, he was Fig. 1. Preoperative simple radiographs show the nail passing through the
found to be drowsy with a Glasgow coma scale of 14 (E4 V4 M4). left parietal calvarium deep to the proximal brainstem.
• Received : December 16, 2013 • Revised : January 10, 2014 • Accepted : February 1, 2014
• Address for reprints : Seok Won Kim, M.D., Ph.D.
Department of Neurosurgery, School of Medicine, Chosun University, 365 Pilmun-daero, Dong-gu, Gwangju 501-717, Korea
Tel : +82-62-220-3126, Fax : +82-62-227-4575, E-mail : chosunns@chosun.ac.kr
• This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
537
J Korean Neurosurg Soc 56 | December 2014
choose non-surgical management. Simple radiographs are help-

ful for intracranial localization of metallic foreign bodies1,2,5). In
the case of non-metallic bodies, cranium defects or the foreign
body itself can occasionally be seen14). CT scanning of the brain
is now the primary modality used in the neuroradiologic evalu-
ation of patients with penetrating head injury. This is because
CT scanning is quick and provides improved identification of
in-driven bone and missile fragments, characterization of the
missile trajectory, evaluation of the extent of brain injury, and de-
Fig. 2. Preoperative coronal and sagittal computed tomography scans re- tection of intracranial hematomas and mass effects11). In contrast,
veal a penetrating metallic nail. Multiple fracture fragments are also ob- magnetic resonance imaging has limitations that restrict its use
served.
in practice. The strength of the magnetic field poses a danger
when any ferromagnetic metals are present as foreign bodies. For
the same reason, we could not use a three-dimensional navigation
system in our patient. It is recommended that documenting vas-
cular damage should be performed using cerebral angiography
when the foreign body is located just beneath the major arterial
or venous systems1).
In spite of the development of antibiotics, infectious complica-
tions are frequently seen in the penetrating head wound patients.
Prompt surgical exploration is mandatory to reduce the mortal-
ity and complication rate. Despite antibiotic treatment, the mor-
bidity rate is 33% in cases receiving prompt surgical treatment
Fig. 3. Photograph of the metallic nail after removal. and rises to 53% in cases where surgery is delayed9). Small sized
foreign bodies located deep in the brain can be left in place7,10,12).
circumferential craniectomy, the nail was cautiously removed If the foreign body is not in close proximity to major arteries or
under intraoperative C-arm guidance to prevent further vascu- veins and has extracranial components, a blind removal without
lar insult or neurological aggravation (Fig. 3). After washing the craniotomy can be performed. However, deterioration and death
wound with antibiotics, it was closed in layers over a drain. have been described after removal in such cases3,4). Surgery should
The postoperative period was uneventful and the patient ex- be performed for removal of a contaminated foreign body, repair
hibited no further neurological aggravation, evidence of infec- of vascular or dural damage, or drainage of intracranial mass-
tion, or symptoms of raised intracranial pressure. However, in es6,7). Bony fragments should also be excised to prevent compli-
spite of aggressive rehabilitative treatment for 3 months, his right cations. Removed foreign bodies should be cultured for aerobic,
side hemiparesis was not improved and he could not ambulate by anaerobic, or fungal pathogens. In our case, all cultures were neg-
himself. ative. Complications of attempts to treat this kind of injury in-
clude meningitis, cerebral abscess, hematomas, cerebral aneu-
DISCUSSION rysm, hydrocephalus, and focal neurological deficits7).
Although gunshot injury is rare in Korea due to gun control, CONCLUSION

penetrating cranial injuries still occur, mostly from shotguns10).
Other causes are infrequent and include criminal assaults and in- This case demonstrates that a nail gun is a potentially danger-
dustrial accidents9). A few cases of deliberate, self-inflicted, pen- ous tool capable of causing a penetrating brain injury. Emergen-
etrating brain injury from nail guns have been reported12,13). In cy surgical removal should be performed to save the patient’s life
most of these cases, patients survive with a good neurological out- even in cases of deep penetrating injuries caused by a nail gun.
come if the brainstem and major cerebral vessels have been spared
and the offending nail is seen during physical examination. How- References
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2. Bell RS, Vo AH, Roberts R, Wanebo J, Armonda RA : Wartime traumatic
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online © ML Comm

www.jkns.or.kr http://dx.doi.org/10.3340/jkns.2014.56.6.537 Print ISSN 2005-3711 On-line ISSN 1598-7876

Serious Penetrating Craniocerebral Injury

Key Words : Head · Injury · Penetrating.

A 43-year-old man was referred to the emergency room due to

choose non-surgical management. Simple radiographs are help-

Although gunshot injury is rare in Korea due to gun control, CONCLUSION

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