Jael syndrome, or the nasty arrow.

The term "Jael syndrome" is a symbolic analogy referring to penetrating craniofacial trauma caused, intentionally or accidentally, by blade or similar weapon in which the foreign body is kept in-situ during initial management. It is rare in clinical and medicolegal practice, but is potentially life-threatening or with neurologic and functional impact. Its name comes from an episode in the Book of Judges in the Hebrew Bible (Old Testament) in which Jael, a woman, kills the Canaanite general Sisera by hammering a tent peg through his temple while he is asleep, thus ensuring the liberation of the people of Israel. Over the centuries, the story had an enduring influence on the European artistic and cultural imagination, with numerous paintings, sculptures, musical and literary compositions memorializing the symbolic power of a unique act of violence. Artists such as Abraham Godyn and Artemisia Gentileschi, baroque sculptors, composers such as Georg Friedrich Haendel and French writers such as Victor Hugo gave the figure of Jael a lasting place in our cultural heritage. In medicine, the first description of a penetrating craniofacial injury with the foreign body in-situ was by Geoffrey Jefferson, a British neurosurgeon, in the mid-20th century, who reported a case of orbitocranial impalement. Subsequently, a few rare cases mainly involved isolated case reports or retrospective series, with consequently low levels of evidence for optimal management. Via a present-day case of penetrating facial trauma involving an arrow, this article reviews diagnostic and therapeutic issues in Jael syndrome. The case illustrates the importance of management in a well-equipped tertiary referral center with specialized medical-surgical multidisciplinary teamwork. Management is based on fundamental principles: systematized initial clinical assessment using the ABCDE (ATLS®) algorithm; not moving or removing the foreign body during the initial stage; early protection of the airway and vascular system; and adapted imaging, ideally by head-and-neck CT angiography. Current strategies favor personalized, selective management based on clinical examination, lesion topography and hemodynamic stability, rather than systematic surgical exploration. However, multicenter prospective studies are needed to refine guidelines, notably by integrating advanced imaging and minimally invasive techniques in order to improve functional prognosis in these rare but high-risk trauma.