An 8–year–old girl accidentally fell, and a pencil in her hand punctured the left temporal side of her skull. Her vital signs were normal at the time of transport to the previous hospital. Head computed tomography (CT) showed that the pencil had perforated from the left temporal side of her head to the left caudate nucleus, with hematoma along the perforating path, ventricular hematoma, traumatic subarachnoid hemorrhage, and subdural hematoma. Vascular evaluation using head CT angiography did not reveal any obvious main trunk vessel occlusion or injury. The patient was intubated and sedated to prevent the pencil from pulling out, and craniotomy was immediately performed to remove the pencil. The area of craniotomy was determined assuming right frontotemporal craniotomy, and the skin incision was made to include the pencil insertion site. The pencil was removed, and external decompression was performed to avoid cerebral edema. Postoperatively, the patient was managed in the pediatric intensive care unit. Prophylactic admin­istration of antimicrobials and anticonvulsants was initiated, and the patient did not develop signs of infection or convulsions. Postoperative follow–up imaging showed no traumatic intracranial aneurysm formation. After reduc­tion of brain swelling, cranioplasty was performed on postoperative day 23. Rehabilitation evaluation showed no obvious sequelae, and the patient was discharged to home on postoperative day 35. Although perforating head injuries in the temporal region are relatively rare, they more likely occur in children with soft skulls than in adults. For the treatment of perforating head trauma, it is important not to perform blind removal until surgical treatment. Preoperative assessment of vascular damage should be performed for decision making regarding the appropriate surgical treatment and postoperative management. Subsequently, it is important to confirm that there is no traumatic cerebral aneurysm formation.

Background: We experienced a case of head pene­trating injury caused by a crossbow that was initially treated in the Hybrid Emergency Room (ER).

Case: A 25–year–old male who lost conscious­ness and was collapsed in his room with penetrating crossbow in his head, was transported to our hospital. After routine checkups, the pa­tient was immediately move to the Hybrid ER. A head CT and digital subtraction angio­graphy (DSA) was performed and no obvious injury in the intracranial major vessels was confirmed. The crossbow was safely removed there. The patient was then moved to the central operating room and underwent a relevant sur­gical procedure. Postoperative diffusion–weighted MRI showed a high–signal area in the corpus callosum and disorders of con­sciousness continued for a while. The corpus callosum lesion was determined to be cytotoxic lesion and the patient was followed up. His conscious state gradually improved and the ab­normal signal in the corpus callosum disappeared on the 40th hospital day. On the 91st hospital day, the patient was transferred for additional rehabilitation.

Conclusion: A Hybrid ER is one of a surgical unit installing CT and DSA. The ability of multi­modal medical treatment is useful to traumatic brain injury, especially penetrating head injury for which we often need to carry out flexible surgical procedure.

The patient, a 64–year–old man, was found lying on the bypass road and called emergency medical services. Computed tomography (CT) showed right acute subdural hematoma with midline shift, and we decided to perform craniotomy to remove the hematoma. After removal of the hematoma, micro­scopic examination revealed a small aneurysm in the peripheral portion of the middle cerebral artery running to the cerebral surface of the temporal lobe. The aneurysm was trapped, and the specimen was submitted for pathological examination. Patho­logi­cally, a true aneurysm was suspected. Acute sub­dural hematoma is usually caused by head trauma, but in rare cases, it can be caused by a ruptured aneurysm. In the case of non–traumatic subdural hematoma, not only decompression but also radical treatment is required, which changes the treatment strategy.

Nail gun injuries often occur in the extremities, but im­portant organs such as the heart and brain can be damaged in some cases. Some of them result in several wounds and require urgent surgical interventions. Because injuries of multiple organs are extremely rare, the priority of surgical treatments is not established and should be considered according to each case. Herein, we report a case of penetrating heart and head injuries caused by a nail gun. A 44–year–old man was admitted to our institute after shooting himself using a nail gun the previous day. His conscious­ness was clear without the neurological deficit and his vital signs were stable despite the vital organ injuries. Chest Computed Tomography (CT) scan showed a nail penetrated his heart and head CT revealed the tips of 2 nails reached the right frontal lobe and the right temporal lobe respectively, but they did not indicate cardiac tamponade and intracranial hemorrhage. The other 4 nails around the oc­cipital and cervical portion did not reach the intracranial and stopped in the subcutaneous tissue. After consultation with cardiovascular surgeons, we decided to perform sur­gery on his heart first, because the nail can get deeper and destroy his heart owing to its beat. It was performed using a cardio–pulmonary bypass under heparin administration. After measuring activated clotting time, we confirmed that the effect of heparin had disappeared, and started cranio­tomy. All the nails were successfully removed. The postoperative course was uneventful without neurological defi­cit and complications, and he was discharged on the 16th postoperative day. In the case of multiple organ injuries, rational strategy and earlier surgical interventions are in­dispensable for a good prognosis.

Blunt traumatic carotid artery occlusion (BTCAO) is extremely rare and has been reported in 0.03–0.04% of all cases of blunt trauma to the carotid artery. We report three cases of BTCAO.

Case 1: The patient presented with mild diplopia and significant bruis­ing of his left anterior neck, following a car wreck in which he was injured by the steering wheel. Magnetic resonance imaging (MRI) re­vealed a small brainstem infarct, and MR angiography (MRA) revealed left common carotid artery (CCA) occlusion. Angiography performed on day 3 revealed reappearance of the left internal carotid artery (ICA) from the bifurcation via collateral circulation. The CCA was ligated to avoid further embolic complications, and he was discharged without any neurological deficits.

Case 2: The patient presented with left hemiplegia in a semicomatose state, following a serious head injury after a fall from the rooftop. Initial computed tomography (CT) revealed cerebral contusion and traumatic subarachnoid hemorrhage (SAH) with multiple skull and skull base frac­tures including right sphenoid sinus wall. CT performed on day 2 revealed a large area of cerebral infarction in the right cerebral hemisphere, and we performed decompressive craniotomy. MRA performed on day 14 revealed right ICA occlusion. He was transferred to the rehabilitation hospital with a modified Rankin score of 5.

Case 3: The patient presented in a comatose state with tetraplegia and serious facial and precordial injuries, following a motorcycle accident. CT revealed cerebral contusion, traumatic SAH and pneumocephalus with multiple facial, skull and skull base fractures including left sphenoid sinus wall. MRI performed on day 4 revealed cerebral infarction of the left frontotemporal lobe, and MRA revealed left ICA occlusion. He underwent conservative manage­ment and became independent with mild combined aphasia, 1 year after the accident. Sphenoid sinus wall fracture may indicate the BTCAO. The outcome of BTCAO appears to be largely dependent on the development of each collateral circulation.

Typically, epidural hematomas are seen in young patients and are usually associated with a skull fracture. We report a surgical case of a single inner table fracture caused by a batted baseball. A 14–year–old boy presented to the emergency room with a com­plaint of a subcutaneous hematoma on the right side of his head. A batted ball hit his head while he was pitching. Computed tomo­graphy showed an epidural hematoma, but no fracture was recognized around the subcutaneous hematoma. Intraoperatively, only a small inner table fracture was seen, and there appeared to be a torn middle meningeal artery beneath the fracture; the dura mater was intact. Follow–up MRI showed a cerebral con­tusion at the hematoma site. He was discharged without deficits. Theoretically, the inner table of the skull is easier to fracture than the outer table. This case was an example showing a narrow range of single fracture forces.