Penetrating brain injury with a nail gun: technical considerations and the role of cerebral angiography. Illustrative case.

BACKGROUND

Nail gun injuries are rare forms of penetrating brain injuries that can be associated with significant morbidity and mortality. Management strategies differ greatly in previously reported cases.

OBSERVATIONS: A male in his 40s presented with an accidental, work-related nail gun injury to the left parietal lobe with no focal neurological deficits. Noncontrast CT imaging of the head and vessel imaging including CT angiography and venography were performed that demonstrated the retained nail with trace surrounding intraparenchymal hemorrhage but no obvious vascular injury. The patient underwent a preoperative diagnostic cerebral angiography that confirmed no vascular injury. The patient was then taken to a hybrid operating room/angiography suite for a burr hole craniotomy for nail removal. Selective left internal carotid artery intraoperative angiography was performed to confirm there was no contrast extravasation after nail removal. The patient was discharged home on postoperative day 1 on prophylactic antibiotics. Follow-up angiography did not demonstrate pseudoaneurysm formation.

LESSONS: Nail gun injuries require a comprehensive, multidisciplinary approach to minimize the risk of complications, particularly related to vascular injury. Judicious use of preoperative and intraoperative catheter-based angiography can facilitate safe, efficient nail removal and is imperative in assessing immediate and delayed sequelae of penetrating trauma. https://thejns.org/doi/10.3171/CASE25476.