Penetrating intracranial trauma via nail gun injury is becoming more common and differs significantly from the sequelae of penetrating cranial trauma of gunshot wounds. Safe, effective extraction techniques are therefore necessary and can employ intraoperative angiography (IA). An (IA) Ghost Image Extraction technique for safe removal of an intracranial nail is described here and can be applied to future such situations. A 32-year-old right-handed male with a history of multiple, non-operative closed-head injuries presented complaining of a 3 day history of right retro-orbital headache, blurry vision in his right eye, and C8 distribution parasthesias on the left forearm. CT revealed a 6 cm nail lodged in the right posterior frontal lobe, with the distal tip pointing superior and medially, without evidence of intracranial hemorrhage along the tract. On more pointed questioning, the patient admitted to non-accidental trauma. On arrival to our facility, the patient was afebrile and without meningeal signs. He was neurologically intact with the exception of a subtle left pronator drift and decreased sensation to light-touch distally in the left C8 distribution. The patient went to the angiography suite for pre-operative vascular mapping prior to surgical extraction of the embedded nail. Four vessel cerebral angiography demonstrated the course of the major, distal branches and tributaries of the intracranial vessels and, miraculously, none were injured. Given the proximity of the nail to major intracranial vessels and elegant cortex, the consideration for safe, controlled extraction of the nail involved the use of IA. The five French sheath was left in place. In the operating room after curvilinear incision and appropriate exposure a double concentric craniotomy was performed around the head of the nail. At this point, with the assistance of intra-operative fluoroscopy and angiography, the nail was slowly and carefully removed under direct visualization so as to remove it in the identical course of its entry to avoid further intracranial injury. The subtracted ghost image of the nail (Abstract E-035 figure 1) that appears with IA allows for control of the distal tip of the nail by extraction via the nail's entry path so as to avoid inadvertent laceration of a vessel or further injury to elegant cortex. Periodic angiographic images were obtained during the deliberate extraction to ensure no intracranial vessel injury had occurred. Post-operative CT revealed a small hemorrhage in along the tract of the nail. The patient did well postoperatively.

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Abstract E-035 Figure 1

Competing interests None.