Accepted Manuscript External ventricular drainage preceding the removal of a nail from the intracranial space as a safe management strategy for predicted secondary intraventricular hemorrhage Takumi Morita, MD, Yoshinori Maki, MD, Daisuke Yamada, MD, Ryota Ishibashi, MD, Masaki Chin, MD, Sen Yamagata, MD, PhD PII: S1878-8750(17)31204-4 DOI: 10.1016/j.wneu.2017.07.104 Reference: WNEU 6166 To appear in: World Neurosurgery Received Date: 2 June 2017 Revised Date: 16 July 2017 Accepted Date: 17 July 2017 Please cite this article as: Morita T, Maki Y, Yamada D, Ishibashi R, Chin M, Yamagata S, External ventricular drainage preceding the removal of a nail from the intracranial space as a safe management strategy for predicted secondary intraventricular hemorrhage, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.07.104. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT 1 2 3 4 External ventricular drainage preceding the removal of a nail from the intracranial space as a safe management strategy for predicted secondary intraventricular hemorrhage RI PT 5 6 Takumi Morita, MD, Yoshinori Maki, MD, Daisuke Yamada, MD, Ryota Ishibashi, MD, Masaki Chin, MD, and 7 Sen Yamagata1, MD, PhD 8 9 SC Department of Neurosurgery, Kurashiki Central Hospital 11 Corresponding author: Takumi Morita 12 1-1-1 Miwa Kurashiki, Okayama, Japan 13 Tel: +81-(0)86-422-0210 M AN U 10 Fax: +81-(0)86-421-3424 14 E-mail:kapipara10000@gmail.com 15 Academic degrees for all authors: TM, MD; YM, MD; RI, MD; DY, MD; TM, MD; TM, MD; MC, MD; SY, MD, 16 PhD. TE D 17 18 Key words: nail gun, head injury, intracranial hemorrhage, intraventricular hemorrhage, external ventricular 20 drainage, computed tomographic angiography and venography 21 EP 19 List of abbreviations: 23 ICNGI; intracranial nail gun injury, CT; computed tomography, CTA; computed tomography angiography, CTV; 24 computed tomography venography, IVH; intraventricular hemorrhage 25 AC C 22 26 Conflict of interest: The authors report no conflict of interest concerning the findings specified in this paper. 27 Compliance with ethical standards and informed consent: The authors obtained informed consent from the patient 28 and his family. 29 Funding: The authors received no funds related to this paper. ACCEPTED MANUSCRIPT Abstract 31 Background: Intracranial nail gun injury is a rare traumatic event and can result from a suicide attempt. Cerebral 32 angiography is essential in the evaluation of damage to the intracranial vessels, and surgical removal of nails is 33 generally the optimal treatment. Intraventricular hemorrhage can happen following removal of intracranial nails. 34 Endovascular surgery or intraoperative computed tomography has been reported to be useful for detection and 35 treatment of intraventricular hemorrhage. After the surgical removal of nails, attention should be paid for 36 complications such as pseudoaneurysm and infection. 37 Case description: A-63-year-old man with a history of depression was transferred to our hospital in an unconscious 38 state. Physical examination showed two nails puncturing his left thorax, and computed tomography revealed a nail 39 puncturing the intracranial space. No damage to these intracranial vessels was observed on computed tomography 40 angiography and venography. Following drainage for potential intraventricular hemorrhage, the nails were removed. 41 Postoperatively, prophylactic antibiotic therapy was administrated for secondary infection. Computed tomography 42 angiography did not detect any postoperative pseudoaneurysms. The patient also underwent therapy from a 43 psychiatrist, and was transferred to another hospital. 44 Conclusion: As for treatment of a case of intracranial nail gun injury, our case shows that preoperative cerebral 45 angiography is not always needed in intracranial nail gun injury when there is no apparent damage to the intracranial 46 vessels and emergent removal of nails is required. External ventricular drainage preceding the removal of a puncture 47 object can be an effective management strategy for secondary intraventricular hemorrhage. TE D M AN U SC RI PT 30 EP 48 Introduction 50 Intracranial nail gun injury (ICNGI) has been reported as a relatively rare trauma injury1-9, and is categorized as 51 low-velocity missile trauma event3,10. ICNGI has a relatively low mortality and morbidity, compared to a 52 high-velocity missile trauma event such as gun shot injury3,10. Complications of ICNGI include vascular injury and 53 intracranial hemorrhage in the acute phase; and pseudoaneurysm, seizure and infection from the subacute phase to 54 the chronic phase1,2,7,10. ICNGI has been reported as an accident and as the result of a suicide attempt4,5,8,10. For cases 55 of the latter, psychological therapy is needed to prevent a suicide reattempt 4,5,10. ICNGI accompanied with other 56 trauma such as an intrathoracic nail injury has been reported, but seems to be uncommon9. We report a case of 57 ICNGI accompanied with intrathoracic nail gun injury resulting from a suspected suicide attempt. AC C 49 ACCEPTED MANUSCRIPT 58 Case report 60 A 63-year-old male carpenter with a past history of depression was transported to our hospital. He was found 61 unconscious lying in the yard of his home with two nails puncturing his left precordium. A contused wound was 62 seen in the right temporal region, but no apparent nail tail was observed. His Glasgow coma scale (GCS) on arrival 63 was E3V2M6. His vitals were stable, but respiratory sounds were not heard in the left precordium. The patient was 64 intubated and two thoracotomy tubes were placed in the left thoracic cavity. Whole-body CT with contrast medium 65 was performed. Computed tomography (CT) revealed two nails in the left thoracic cavity, near the heart and the 66 aorta, respectively (Figure 1A). In addition to the nails in the left thoracic cavity, another nail of 9 cm in length was 67 detected spanning from the right temporal lobe to the left thalamus with traumatic subarachnoid hemorrhage. 68 Intraventricular hemorrhage (IVH) was also seen in the right lateral ventricle (Figure1B and 1C). As CT 69 angiography (CTA) and CT venography (CTV) did not reveal any apparent damage of the major intracranial vessels 70 (Figure 1D and 1E), emergent removal of the nails in the left thoracic cavity and the head was performed. 71 Operation 72 The patient was set in the lateral position and left thoracotomy was performed. After removal of two nails in the left 73 thoracic cavity, laceration of the left pericardium was observed. Apparent bloody pericardium effusion, which might 74 cause cardiac temponade, was not seen, and there was no evidence of injury of the coronal arteries. The pericardium 75 was sutured and the wound was closed. The patient was then set in supine position, and external ventricular drainage 76 was undertaken in consideration of a possible increase in intracranial pressure following IVH with the removal of 77 the nail from the intracranial space. After external ventricular drainage, small craniotomy around the entrance point 78 of the intracranial nail was performed (Figure 2A, 2B and 2C). The intracranial nail was manually removed and 79 secondary bleeding from the removal point or external ventricular drain were not observed. 80 Postoperative clinical course 81 The patient was admitted to the intensive care unit, and tetanobulin and tetanus toxoid were injected. 82 Ceftriaxone of 2g/day and metronidazole of 1.5g/day were also administrated to avoid secondary infection. The 83 postoperative course was uneventful. Postoperative CT and CTA on POD 21 did not show secondary IVH or 84 delayed pseudoaneurysm (Figure 3A and 3B). Considering his medical history of depression, the cause of ICNGI 85 was suspected as a suicide attempt, and we requested a psychiatrist for ongoing examination. Two months after the AC C EP TE D M AN U SC RI PT 59 ACCEPTED MANUSCRIPT 86 operation, the patient was transferred to another hospital for rehabilitation. At the time of writing the patient had not 87 reattempted suicide. 88 RI PT 89 Discussion 91 We presented a case of ICNGI. Several cases of ICNGI have been reported as its use has increased in the 92 workplace or home, as an accident or suicide attempt1-9. 93 Prior to surgical removal of nails, preoperative radiological evaluation is indispensable. An intracranial nail was 94 found by secondary CT investigation in our case. Multiple nail injury to the head and the trunk have been also 95 reported9. Whole-body CT for trauma should be performed, especially when the cause of the traumatic event is not 96 clear. To evaluate intracranial vascular resulting from nail puncture, cerebral angiography is essential7. However, 97 when the injury of vital organs is suspected due to nail puncture, emergent surgical removal of nails is desirable, as 98 seen in the left thoracic cavity in our case. Evaluation of major intracranial vessels with CTA has been acceptable 99 when CTA does not show evidence of injury of the major intracranial vessels injury by nail puncture3. Cerebral 100 angiography can be an acceptable replacement for CTA and CTV for the emergent removal of nails in patients 101 without apparent injury of the intracranial vessels. 102 As for the operative management of a penetrating head injury, the following procedures have been proposed such as 103 removal of the penetrating object, removal of bone fragments, debridement, dural repair and endovascular 104 intervention7,11-13. Preceding external ventricular drainage, which we performed prior to the removal of the 105 intracranial nail in our case in order to avoid an increase in intracranial pressure as a result of IVH, seems to be 106 uncommon. 107 In a case described by Rezai et al., external ventricular drainage, prior to removal of a penetrating nail, was 108 performed for acute hydrocephalus with intraventricular and subarachnoid hemorrhage14. The patient in this case 109 died, but the outcome in this case does not suggest that preceding external ventricular drainage is not useful. The 110 cause of the death was a pseudoaneurysm and vasospasm of cerebral arteries . 111 Secondary IVH or ventricular tract hemorrhage after removal of a penetrating object has been reported15. Nathoo et 112 al. reported that IVH was related to poor outcomes in the patients of a penetrating head injury16. Continuous 113 increased intracranial pressure could be a cause for poor outcomes in the patients of penetrating head injury. AC C EP TE D M AN U SC 90 ACCEPTED MANUSCRIPT External ventricular drainage can reduce intracranial pressure after secondary IVH associated to nail removal. 115 Real time endovascular assistance and intraoperative CT have been reported as effective measures for detection 116 and treatment of secondary IVH after removal of penetrating object 6,17. Treatment in the hybrid operation room is 117 now also an option. However, intraoperative CT and the hybrid operation are not available in all institutes, and nor 118 are these suitable for every case of intracranial nail gun injury. Furthermore, real time endovascular assistance can 119 be risky for nails located near the heart or the aorta, which are often an access route for intracranial lesions. When 120 secondary IVH is predicted, in order to avoid increased intracranial pressure with secondary IVH after removal of 121 penetrating objects, preceding external ventricular drainage can be an effective and safe method of management. As 122 for the limitation of our proposition, preceding external ventricular drainage lacks of statistical data based on 123 randomized trials. Second, as external ventricular drainage is a palliative procedure for increasing intracranial 124 pressure, another homeostatic procedure may need if continuous bleeding is observed. Therefore, the indication of 125 preceding IVH should be assessed in each individual case. 126 To optimize the clinical outcomes after surgery, attention must be given for postoperative care such as prevention of 127 secondary infection, detection and treatment for delayed pseudoaneurysm and psychiatric support. Occurrence of 128 infectious complications after penetrating head trauma is high, and the use of broad-spectrum antibiotic prophylaxis 129 is recommended. In our case, ceftriaxone and metronidazole were administrated for 14 days and secondary infection 130 did not occur. As traumatic pseudo aneurysms associated with penetrating brain trauma are reported with a high 131 mortality, follow-up radiological imaging is essential. Traumatic pseudoaneurysm can be detected on average within 132 2 to 3 weeks after injury, but can occur months after the injury1,7,18. In our patient, delayed pseudoaneurysm was not 133 apparent on CTA. However, if an intracranial psuedoaneurysm is suspected on CTA, cerebral angiography should 134 be performed and direct clipping or endovascular treatment considered18. ICNGI have been reported in patients with 135 a history of mental disorders5,8,10. If ICNGI is suspected as result of a suicide attempt like our case, postoperative 136 psychiatric assessment and treatment is required to prevent a suicide reattempt. 137 Conclusion 138 We reported a case of ICNGI related to possible suicide attempt. CTA and CTV can be sufficient as preoperative 139 intracranial evaluation when no apparent damage of intracranial vessels is observed and emergent removal of nails is 140 required. External ventricular drainage preceding nail removal from the intracranial space may be an effective and AC C EP TE D M AN U SC RI PT 114 ACCEPTED MANUSCRIPT 141 safe management strategy when secondary IVH is predicted. Psychiatric support is also mandatory to avoid a suicide 142 reattempt. 143 Acknowledgement 145 We appreciate Drs. Mizuki Sato, Youichirou Tamura and Hayato Uchino for their collaboration on this study. RI PT 144 146 Highlights 148 ・A case of intracranial nail gun injury accompanied to intrathoracic nail gun injury was reported. 149 ・Computed tomography angiography can be replaceable for cerebral angiography if surgical removal of nails is 150 considered to be emergent. 151 ・Preceding external ventricular drainage can be an option before removal of intracranial nail, especially without 152 support of endovascular treatment or intraoperative computed tomography. M AN U SC 147 153 154 Figure legends TE D 155 Figure 1. 157 A) Preoperative CT revealed two nails in the left thoracic cavity, near the heart and the aorta. B) Head CT revealed 158 another nail of 9 cm spanning from the right temporal lobe to the left thalamus with traumatic subarachnoid 159 hemorrhage. C) IVH was confirmed in the right lateral ventricle (black arrow). D), E) CTA and CTV did not reveal 160 apparent damage of major intracranial vessels. EP 156 AC C 161 162 Figure 2. Intraoperative images. 163 A) Small craniotomy around the entrance point of the intracranial nail was performed. B) The intracranial nail was 164 manually removed. C) Secondary hemorrhagic event was not apparently observed from the removal point. 165 166 Figure 3. Postoperative radiological images. 167 A) IVH was not increased on postoperative CT. B) Delayed pseudoaneurysm was not evident on CTA performed on 168 postoperative day 21. ACCEPTED MANUSCRIPT 169 AC C EP TE D M AN U SC RI PT 170 ACCEPTED MANUSCRIPT 171 Reference 172 1. 173 injury. AJR Am J Roentgenol. 1999;172:541-542. 175 Rev. 2010;33:501-504. 3. 177 gun: a unique mechanism of injury. Ear Nose Throat J. 2002;81:779-783. 179 nail gun: an unsuccessful attempt of suicide. Clin Neurol Neurosurg. 2006;108:490-492. 5. 181 182 2015;20:267-270. 6. 183 184 7. 8. 9. Jithoo R, Govender ST, Nathoo N. Penetrating nail gun injury of the head and chest with incidental pericallosal artery aneurysm. 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AC C EP TE D 211 AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN U SC RI PT ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT Highlights RI PT ・A case of intracranial nail gun injury accompanied to intrathoracic nail gun injury was reported. ・Computed tomography angiography can be replaceable for cerebral angiography if surgical removal of nails is considered to be emergent. SC ・Preceding external ventricular drainage can be an option before removal of intracranial nail, especially AC C EP TE D M AN U without support of endovascular treatment or intraoperative computed tomography. ACCEPTED MANUSCRIPT List of abbreviations: RI PT ICNGI; intracranial nail gun injury, CT; computed tomography, CTA; computed tomography AC C EP TE D M AN U SC angiography, CTV; computed tomography venography, IVH; intraventricular hemorrhage