PMC4596057_01
Anterior-Posterior and lateral skull X-rays showing an 8.7 cm nail projecting over the right temporal region, with apparent intracranial extension. No discrete calvarial fractures are detected
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F1
He was initially assessed in a peripheral hospital Emergency Department where plain skull X-rays revealed a nail traversing the temporal bone [Figure 1].
Sections of a noncontrast computed tomography head showing scattered subarachnoid hemorrhage in association with an intracranial nail penetrating the right temporal bone and projecting across midline, superior to the sphenoid sinus and anterior to the pituitary fossa, with evidence of obstructive hydrocephalus. Note the beam-hardening artifact
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F2
In addition, there was the presence of diffuse subarachnoid hemorrhage (SAH) within the basal cisterns and right sylvian fissure [Figure 2]. CT angiography (CTA) [Figures 2 and 3] revealed the foreign body to be within the vicinity of the circle of Willis.
Sections of a computed tomography angiogram are confirming intact internal carotids. The right M1 to the proximal M3 middle cerebral artery and anterior communicating artery regions are not visualized. However, there is normal distal filling of the right middle cerebral artery beyond the beam-hardening artifact, with no obvious vessel perforation, dissection, thrombosis, or branch occlusion
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F3
CT angiography (CTA) [Figures 2 and 3] revealed the foreign body to be within the vicinity of the circle of Willis.
Intraoperative images demonstrating the entry point of the nail (double brackets), proposed pterional incision (a) and temporalis reflection (b). A jet of blood (arrow) exsanguinating from the M1 vessel and application of a proximal temporary aneurysm clip (star) (c). Repair of the arteriotomy (d)
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F4
The laceration was repaired with 10.0 prolene sutures in an interrupted fashion [Figure 4].
Serial cuts of axial computed tomography angiogram obtained on postoperative day 1 after removal of the nail and closure of a breached middle cerebral artery, showing the visualized intracranial vasculature is normal in appearance
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F5
On postoperative day (POD) 1, a CTA [Figure 5] revealed that the major intracranial arteries were patent with no pseudoaneurysm or vessel occlusion noted.
Right internal carotid AP (left), lateral (middle), and oblique (right) projections of a digital subtraction angiogram obtained on postoperative day 3, showing no evidence of extravasation, stenosis or occlusion after middle cerebral artery repair
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F6
There was good flow proximally and distally to the repair site [Figure 6].