Keywords
penetrating head injury - nails - foreign bodies - craniectomy
Multiple penetrating brain injuries are very common in military practice but not so
common in civilian road traffic accidents. There are various reports of multiple foreign
bodies such as pellets, nails, stones due to blasts, or gunshot injuries.[1] Cases of penetrating nails injuring the skull and brain have been reported earlier.[2] However, cases of multiple penetrating nails to the skull following a road traffic
accident are rare, and here we are presenting one such unusual case of multiple penetrating
nails embedded in right frontal part of calvarium with a very unusual and interesting
mode of injury.
Case Report
A 22-year-old man presented to casualty as a case of multiple penetrating nails in
the right side of the skull after motorcycle accident. He presented to us 4 hour after
the injury. On taking history, he met with an accident on the very first day of his
learning to ride a motorcycle .He could not control the motorcycle and crashed onto
the boundary wall, which was newly constructed with multiple nails embedded over it.
His head stuck to the nails protruding from the wall after collision. As the wall
was constructed 1 day before, the nails easily came out of the wall but stuck to the
skull bone. Following this accident he had no loss of consciousness, convulsion, vomiting
without any history of ear, nasal, or throat (ENT) bleed. On admission, patient was
conscious, oriented, and responding to verbal commands. His vitals were stable: GCS,
E4V5M6; pupils, B/L normal size and equally reactive to light. No clinical signs of
raised intracranial pressure (ICP). No motor or sensory deficit. On local examination,
three iron nails were found on the scalp at right frontal region, which were firmly
fixed to the underlying bone (although no malicious attempts were made to dislodge
them during this local examination). No associated systemic injuries were found including
a cervical spine clearance. All laboratory investigations were within normal limit.
Noncontrast computed tomography (NCCT) of the brain with 3D reconstruction of the
skull bone revealed all three nails penetrated the skull bone with breach of the inner
table and also revealed penetration of dura and underlying brain parenchyma in right
frontal lobe in front of sylvian fissure ([Fig. 1]). No hemorrhagic lesion or associated edema or mass effect was seen. Antibiotics,
anticonvulsants, and tetanus immunoglobulin was administered and patient shifted to
operation theater. Under general anesthesia, in supine position, lateral frontal horse-shoe–shaped
scalp incision was made joining three nails with base toward supraorbital ridge ([Fig. 2]). The purpose of fashioning such an incision was to raise a single flap with access
to all the three nails and the underlying dura simultaneously, maintaining the viability
of the flap. We have joined three nails in horse-shoe manner, keeping the base of
the flap toward supraorbital ridge; that is, the skin between the lower two nails
was not incised and we have started the skin incision from first lower nail and then
progressed to the superior nail and then ended the incision at the second lower nail.
As the nails were stuck firmly to the bone, they did not come out on raising the skin
flap. As all three nails came in the pathway of incision line, flap could easily be
raised without disturbing the nails. Single burr hole was made in between three nails
and it was enlarged to a small craniectomy with Kerrison punch, to accommodate all
the three nails so that all the nails became loosened and came out easily ([Fig. 2]). Following this, thorough irrigation with dilute hydrogen peroxide and normal saline
was done. All nails were removed cautiously to prevent further vascular or parenchymal
damage. As the nails were not penetrated deep into parenchyma, and no hematoma or
contusion discovered in NCCT, the dura was not opened. The wound was again debrided
of any other foreign body with thorough saline irrigation and closed it in layers.
Postoperatively the patient recovered well. There was no wound infection or seizure.
There was no motor or sensory loss and he was able to communicate verbally in a coherent
manner. Post-op scan on fifth day was normal with no hematoma or abscess ([Fig. 2]). Patient was discharged with oral antibiotics and anticonvulsants on seventh day.
He is under regular follow-up and there has been no report of fever, headache, or
seizure till date.
Fig. 1 (A) Clinical photograph of the patient showing the three nails in situ. (B) 3D reconstruction
of the skull showing the entry of the nails and the breach of the inner table. (C)
Bone window showing the entry of the nail in to the skull. (D, E) NCCT brain showing
scattering artifacts in coronal and axial sequence and some evidence of parenchymal
injury shown by red ring. (F) Cartoon showing mechanism of injury.
Fig. 2 (A, B) Intraoperative image of curvilinear incision joining the three nails. (C)
NCCT brain showing a post-op craniectomy defect in the right frontal region with minimal
edema of underlying brain without any mass effect. (D) 3D bone reconstruction showing
craniectomy defect. (E) Post-op clinical photograph.
Discussion
Multiple penetrating brain injuries are very common in war and military injuries but
very rare in civilian head injuries. Penetrating brain injuries can be due to industrial
accidents, suicide attempts, and criminal assult.[1] Various objects such as knife, nails, screw drivers, metal rods, and chopsticks
are seen in penetrating head injuries. Low-velocity injuries, such as in our case,
differ from gunshot and missile injuries in the way that they do not cause concentric
cones of cavitations and necrosis. Instead, the damage is predominantly restricted
to hemorrhagic infarction and contusion in the line of wound tract.[3] Low-velocity wounds such as ours are very unlikely to have counter coup or diffuse
axonal injury (DAI). Thus, in absence of damage to vital canters and large vessels,
the prognosis is usually favorable. Hence, early treatment is necessary in these cases
to avoid delayed vascular complications, infections, and epilepsy. Neuroimaging such
as NCCT of the brain with coronal, sagittal, axial scans and 3D reconstruction of
the skull is essential for decision making regarding surgical intervention.[4] Cerebral angiography is recommended for patients with penetrating head injuries
with increased risk for vascular damage such as wound trajectory passing near the
sylvian fissure, supraclinoid carotid, major dural venous sinus, etc.[5]
[6] Angiography is also recommended in delayed subarachnoid hemorrhage (SAH) and intracranial
hemorrhage (ICH).[5]
[6] In our case, no hemorrhage was seen in NCCT and patient had no neurologic deficits;
thus, we did not proceed for angiography. Surgical decision varies from center to
center. We proceeded with craniectomy rather than circumferential craniotomy for all
foreign bodies same time. Generally debridement should be done, but we avoided durotomy
as very little part of nail was penetrated into the brain and no hematoma was seen
in NCCT. All foreign bodies should be removed under direct vision to avoid further
damage to the brain. There is a risk of local wound infection, meningitis, ventriculitis,
and cerebral abscess in penetrating brain injuries, with Staphylococcus epidermidis being the most frequently associated organism.[7] Ideally surgical intervention should be performed within 12 hours of the injury
to prevent the risk of infection.[8] In our case, we operated the case within 10 hours of injury. We followed the recommendations
by “The Infection in Neurosurgery Working Party of British Society for Antimicrobial
Therapy” and the patient was given inj co-amoxiclav (1.2 g) IV 8 hourly with inj metronidazole
(500 mg) IV 8 hourly for 5 days.[9] The risk of posttraumatic epilepsy for penetrating head injuries is approximately
30 to 50% and it is due to direct traumatic injury to cerebral cortex with subsequent
scarring.[10] Ten percent of patients present with seizure within 7 days of trauma, 80% during
the first 2 years. Recent studies recommend anticonvulsants in first week after penetrating
brain injury.[10] In this case, we have continued prophylactic anticonvulsants and antibiotics for
1 week and there is no seizure or infection till now.
Conclusion
The rarity of the mechanism of injury and the resulting penetration of multiple nails
in the skull make this case an interesting read. A complete radiologic evaluation,
careful surgical removal of embedded nails by craniectomy, use of antibiotics and
antiepileptic drugs, and close postoperative neurologic evaluation may be lifesaving,
even in cases of multiple penetrating craniocerebral injuries caused by nails.
