Elsevier

World Neurosurgery

Volume 106, October 2017, Pages 1056.e9-1056.e13
World Neurosurgery

Case Report
External Ventricular Drainage Preceding the Removal of a Nail from the Intracranial Space as a Safe Management Strategy for Predicted Secondary Intraventricular Hemorrhage

https://doi.org/10.1016/j.wneu.2017.07.104Get rights and content

Background

Intracranial nail gun injury is a rare traumatic event and can result from a suicide attempt. Cerebral angiography is essential in the evaluation of damage to the intracranial vessels, and surgical removal of nails is generally the optimal treatment. Intraventricular hemorrhage can happen after removal of intracranial nails. Endovascular surgery or intraoperative computed tomography has been reported to be useful for detection and treatment of intraventricular hemorrhage. After the surgical removal of nails, attention should be paid for complications such as pseudoaneurysm and infection.

Case Description

A 63-year-old man with a history of depression was transferred to our hospital in an unconscious state. Physical examination showed 2 nails puncturing his left thorax, and computed tomography revealed a nail puncturing the intracranial space. No damage to these intracranial vessels was observed on computed tomography angiography and venography. After drainage for potential intraventricular hemorrhage, the nails were removed. Postoperatively, prophylactic antibiotic therapy was administrated for secondary infection. Computed tomography angiography did not detect any postoperative pseudoaneurysms. The patient also underwent therapy from a psychiatrist and was transferred to another hospital.

Conclusions

As for treatment of a case of intracranial nail gun injury, our case shows that preoperative cerebral angiography is not always needed in intracranial nail gun injury when there is no apparent damage to the intracranial vessels and emergent removal of nails is required. External ventricular drainage preceding the removal of a puncture object can be an effective management strategy for secondary intraventricular hemorrhage.

Introduction

Intracranial nail gun injury (ICNGI) has been reported as a relatively rare trauma injury1, 2, 3, 4, 5, 6, 7, 8, 9 and is categorized as low-velocity missile trauma event.3, 10 ICNGI has a relatively low mortality and morbidity compared with a high-velocity missile trauma event such as gunshot injury.3, 10 Complications of ICNGI include vascular injury and intracranial hemorrhage in the acute phase and pseudoaneurysm, seizure, and infection from the subacute phase to the chronic phase.1, 2, 7, 10 ICNGI has been reported as an accident and as the result of a suicide attempt.4, 5, 8, 10 For cases of the latter, psychological therapy is needed to prevent a suicide reattempt.4, 5, 10 ICNGI accompanied with other trauma such as an intrathoracic nail injury has been reported but seems to be uncommon.9 We report a case of ICNGI accompanied with intrathoracic nail gun injury resulting from a suspected suicide attempt.

Section snippets

Case Report

The authors obtained informed consent from the patient and his family for this report. A 63-year-old male carpenter with a history of depression was transported to our hospital. He was found lying unconscious in the yard of his home with 2 nails puncturing his left precordium. A contused wound was seen in the right temporal region, but no apparent nail tail was observed. His Glasgow Coma Scale on arrival was E3V2M6. His vitals were stable, but respiratory sounds were not heard in the left

Discussion

We presented a case of ICNGI. Several cases of ICNGI have been reported as its use has increased in the workplace or home, as an accident or suicide attempt.1, 2, 3, 4, 5, 6, 7, 8, 9 Before surgical removal of nails, preoperative radiologic evaluation is indispensable. An intracranial nail was found by secondary CT investigation in our case. Multiple nail injury to the head and the trunk have been also reported.9 Whole-body CT for trauma should be performed, especially when the cause of the

Conclusions

We reported a case of ICNGI related to possible suicide attempt. CTA and CTV can be sufficient as preoperative intracranial evaluation when no apparent damage of intracranial vessels is observed and emergent removal of nails is required. External ventricular drainage preceding nail removal from the intracranial space may be an effective and safe management strategy when secondary IVH is predicted. Psychiatric support is also mandatory to avoid a suicide reattempt.

Acknowledgments

We appreciate Drs. Mizuki Sato, Youichirou Tamura, and Hayato Uchino for their collaboration on this study.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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