case_images: PMC6238325_01
case_images: 3D model showing location of cranial nails
case_images: SNI-9-221-g001.jpg
case_images: PMC6238325_01_SNI-9-221-g001.jpg
case_images: F1
case_images: He was hemodynamically stable [Figures 1 and 2].
case_images: Localizer CT image showing location of nails, including in pericardium
case_images: SNI-9-221-g002.jpg
case_images: PMC6238325_01_SNI-9-221-g002.jpg
case_images: F2
case_images: He was hemodynamically stable [Figures 1 and 2].
case_images: CT showing pericardial nail
case_images: SNI-9-221-g003.jpg
case_images: PMC6238325_01_SNI-9-221-g003.jpg
case_images: F3
case_images: The nail was removed without incident, with the wound washed out and closed in layers over a pericardial drain [Figure 3].
case_images: CT showing hematoma within pons at tip of nail
case_images: SNI-9-221-g004.jpg
case_images: PMC6238325_01_SNI-9-221-g004.jpg
case_images: F4
case_images: The right middle cerebral artery appeared attenuated, and was thought to have an element of vasospasm, but otherwise the arterial vasculature was intact [Figure 4].
case_images: Nail through right jugular foramen
case_images: SNI-9-221-g005.jpg
case_images: PMC6238325_01_SNI-9-221-g005.jpg
case_images: F5
case_images: The nail behind his right ear traversed his petrous temporal bone, it was unclear if it had penetrated the carotid artery or internal jugular vein [Figure 5].
case_images: Nail involving right internal jugular vein
case_images: SNI-9-221-g006.jpg
case_images: PMC6238325_01_SNI-9-221-g006.jpg
case_images: F6
case_images: There was seen to be sufficient flow through the left transverse sinus to enable sacrifice of the right internal jugular vein if needed [Figure 6].
case_images: Nails and their relation to major cerebral arteries
case_images: SNI-9-221-g007.jpg
case_images: PMC6238325_01_SNI-9-221-g007.jpg
case_images: F7
case_images: There was no pseudoaneurysm [Figure 7].
case_images: Visualization of nail within cerebellar-pontine angle
case_images: SNI-9-221-g008.jpg
case_images: PMC6238325_01_SNI-9-221-g008.jpg
case_images: F8
case_images: Using a retrosigmoid approach, the nail was seen emerging into the cerebellar-pontine angle, missing the VIIth/VIIIth nerve complex, arteries, and then piercing the anterior brain stem [Figure 8].
case_images: Exposure prior to removal of the three skull vault nails
case_images: SNI-9-221-g009.jpg
case_images: PMC6238325_01_SNI-9-221-g009.jpg
case_images: F9
case_images: Bone cement was used for these defects, followed by standard closure [Figures 9 and 10].
case_images: Nails after removal from skull. Ruler for reference
case_images: SNI-9-221-g010.jpg
case_images: PMC6238325_01_SNI-9-221-g010.jpg
case_images: F10
case_images: Bone cement was used for these defects, followed by standard closure [Figures 9 and 10].
case_images: Angiogram showing M2 truncation defect and absent capillary phase in surrounding area
case_images: SNI-9-221-g011.jpg
case_images: PMC6238325_01_SNI-9-221-g011.jpg
case_images: F11
case_images: The patient was transferred back to intensive care [Figures 11 and 12].
case_images: Area of ischemia
case_images: SNI-9-221-g012.jpg
case_images: PMC6238325_01_SNI-9-221-g012.jpg
case_images: F12
case_images: The patient was transferred back to intensive care [Figures 11 and 12].