Transfacial transcranial penetrating fishing arrow injury with intact neurological examination: controlled intraoperative shortening and extraction. Illustrative case.

BACKGROUND

Nonmissile craniofacial penetrating injuries from elongated metallic objects are uncommon and carry significant risks related to concealed vascular injury, hemorrhage, dural violation, and infection. Early CT and selective vascular imaging guide safe management, and blind extraction outside the operating room (OR) should be avoided.

OBSERVATIONS: A 17‑year‑old male presented after transfacial penetration by a "supergun" rod entering inferior to the right zygomatic arch and tracking beneath the temporal squama toward the middle cranial fossa. He arrived with a Glasgow Coma Scale score of 15, an intact airway, and no focal deficits. CT/CT angiograpy (CTA) showed intracranial extension without major vascular injury. In the OR, a right parietotemporal trauma flap incision enabled a targeted temporal craniotomy; the protruding rod was shortened intraoperatively to reduce lever forces and then extracted along the entry trajectory under direct vision with hemostasis. Postoperative CT imaging revealed a right parietotemporal epidural hematoma adjacent to the craniotomy, which was promptly evacuated. Recovery was otherwise uneventful under a 3‑week antibiotic course and 1‑month levetiracetam prophylaxis. Follow‑up CT imaging at approximately 3 weeks showed resolution and satisfactory healing.

LESSONS: For elongated metallic skull penetrating injuries, CTA‑guided planning, avoidance of blind extraction, and controlled OR removal augmented by intraoperative shortening when needed are key to minimizing hemorrhage and neurological injury. https://thejns.org/doi/10.3171/CASE25670.