Nail–gunによる穿通性頭部外傷で，頭蓋内に残存する３本の釘を急性期に完全除去しえた１例

抄録

The outcome of penetrating head trauma is relatively poor, because some nerves, vascular structures and eloquent brain areas are directly injured and infection rate is very high. There are various penetrating substances, which must be dealt with flexibly. In penetrating head trauma, penetration of the calvaria is rare, because of the existence of hard skull bone. We report a case of transcranial head trauma caused by a nail–gun.

A 53–year–old man attempted suicide using a nail–gun, shooting nails into the temporal and frontal lobes. On admission examina­tion, the patient was found to have impaired consciousness with Japan Coma Scale (JCS) 3 and incomplete right hemiparesis. Computed tomography showed nails in the right frontal, left frontal, and left temporal lobes. The nail in the left temporal lobe penetrated from the forehead to the temporal lobe of the left basal ganglia and was accompanied by intracerebral hemorrhage along the passway. Cerebral angiography confirmed that these nails did not injure any artery nor vein. The right temporal nail was manually removed under local anesthesia. The next day, the nails in the left frontal and left temporal lobes were removed by craniotomy, and the damaged frontal sinus was repaired using a pericranial flap. The left temporal nail had a deep head and was pulled out retrogradely from the tip. We could be safely removed by peeling off the surrounding brain matter. Postoperative bleeding and cerebro­spinal fluid leakage did not occur. Administration of antibacterial agents was started earlier from admission, and a follow–up cranial Magnetic Resonance Imaging confirmed no complications such as abscess formation. In this case, the three nails were surgically re­moved within 48 hours. For penetrating head injuries, removing the foreign body as soon as possible is recommended to avoid infec­tion, but there are no established removal methods. A tailored operation for each case is required considering the foreign body’s position, penetration route, and the damaged part’s location. Although careful follow–up will be required, we examined the acute treatment strat­egy for penetrating head trauma, including a review of literature.