Management of Penetrating Brain Injury Caused by a Nail Gun: Three Case Reports and Literature Review

doi:10.1016/j.wneu.2018.01.127

World Neurosurgery

Volume 112, April 2018, Pages 143-147

https://doi.org/10.1016/j.wneu.2018.01.127 Get rights and content

Highlights

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Three cases of penetrating brain injury caused by nail guns are presented.
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All 3 patients have a good prognosis.
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The relevant literature is reviewed.
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The management of nail gun injuries to the brain is discussed.

Background

Penetrating brain injury (PBI) caused by a nail gun is an extremely rare neurosurgical emergency that poses a challenge for neurosurgeons because of its rarity and complexity.

Case Description

Here we present 3 cases of PBI caused by a nail gun. In the first case, the nail entered through the right parietal bone and lodged in the right parietal lobe and basal ganglia. In the second case, the nail entered through the right occipital bone and lodged in the right occipital lobe. In the third case, the nail entered through the right parietal bone and lodged in the right frontal and parietal lobes. All patients underwent surgical removal of the nail. The first patient presented with reduced left-side strength, whereas the second and third patients were neurologically intact on presentation.

Conclusions

PBI caused by a nail gun can present with differing clinical manifestations, and most cases require immediate surgery. A rational management strategy should provide a good postoperative prognosis with minimal neurologic deficits in these patients.

Introduction

Penetrating brain injury (PBI) is a type of traumatic brain injury (TBI) defined as brain trauma in which a low-velocity sharp object, such as a knife, or a high-velocity projectile, such as a bullet, penetrates the skull but does not exit it.¹ PBIs account for approximately 0.4% of TBI cases.2, 3 Since its introduction in 1959,⁴ the nail gun has become a mainstay in the construction industry and is readily accessible to the public. The incidence of nail gun–induced PBIs has increased with the widespread use of this tool.

Injuries caused by penetrating foreign bodies can include intracranial hemorrhage, cerebral contusion, cerebral vascular injury, infection, seizures, and cerebrospinal fluid fistula. Here we present 3 cases of PBI caused by nail guns. We also review the relevant literature and discuss the management of nail gun injuries to the brain.

Section snippets

Case 1

This 60-year-old Chinese man was admitted to our emergency department approximately 3 hours after sustaining a PBI from a nail gun. After the injury, he was still conscious but had muscle power of only 2/5 in the left upper and lower limbs. Physical examination revealed a small right parietal scalp entrance wound with no visible nail. A skull X-ray showed the presence of a 6- cm nail in the cranial cavity (Figure 1A). Brain computed tomography (CT) showed the presence of an object of metallic

Discussion

PBI caused by a nail gun is an extremely rare neurosurgical emergency. Common causes include work-related accidents, self-harm, suicide, and criminal assault using a nail gun.5, 6 Most nail guns can fire nails at approximately 100–150 m/s,7, 8 which is often sufficient to penetrate the scalp and skull. Because of the its rarity and complexity, nail gun–induced PBI poses a particular challenge for neurosurgeons. Here we discuss several helpful suggestions for the management of PBI caused by nail

Conclusions

PBI caused by a nail gun is a unique form of TBI that may lead to such complications as intracranial hemorrhage, infection, and epilepsy. The main radiologic modalities include X-ray, CT scan, and cerebral angiography. Simple extracranial foreign body removal and craniotomy are the 2 main approaches for removing the nail. Broad-spectrum antibiotic therapy and tetanus prophylaxis should be started as soon as possible. Prophylactic anticonvulsant administration after injury is recommended to

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