PMC6238325_01
3D model showing location of cranial nails
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F1
He was hemodynamically stable [Figures 1 and 2].
Localizer CT image showing location of nails, including in pericardium
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F2
He was hemodynamically stable [Figures 1 and 2].
CT showing pericardial nail
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F3
The nail was removed without incident, with the wound washed out and closed in layers over a pericardial drain [Figure 3].
CT showing hematoma within pons at tip of nail
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F4
The right middle cerebral artery appeared attenuated, and was thought to have an element of vasospasm, but otherwise the arterial vasculature was intact [Figure 4].
Nail through right jugular foramen
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F5
The nail behind his right ear traversed his petrous temporal bone, it was unclear if it had penetrated the carotid artery or internal jugular vein [Figure 5].
Nail involving right internal jugular vein
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F6
There was seen to be sufficient flow through the left transverse sinus to enable sacrifice of the right internal jugular vein if needed [Figure 6].
Nails and their relation to major cerebral arteries
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F7
There was no pseudoaneurysm [Figure 7].
Visualization of nail within cerebellar-pontine angle
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F8
Using a retrosigmoid approach, the nail was seen emerging into the cerebellar-pontine angle, missing the VIIth/VIIIth nerve complex, arteries, and then piercing the anterior brain stem [Figure 8].
Exposure prior to removal of the three skull vault nails
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F9
Bone cement was used for these defects, followed by standard closure [Figures 9 and 10].
Nails after removal from skull. Ruler for reference
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F10
Bone cement was used for these defects, followed by standard closure [Figures 9 and 10].
Angiogram showing M2 truncation defect and absent capillary phase in surrounding area
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F11
The patient was transferred back to intensive care [Figures 11 and 12].
Area of ischemia
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F12
The patient was transferred back to intensive care [Figures 11 and 12].