case_images: PMC8422459_01
case_images: (a) A photograph of the patient with the metal spear (arrow) entering through the oral cavity with contact epistaxis. (b) Lateral view of a plain film of skull showing the spear, flapper tip type, entering through the oral cavity into the posterior fossa.
case_images: SNI-12-391-g001.jpg
case_images: PMC8422459_01_SNI-12-391-g001.jpg
case_images: F1
case_images: In addition, he underwent cranial X-ray [Figure 1] and was later referred to a level I trauma center.
case_images: Cranial computed tomography (CT). Sagittal views (a-c) and axial views (e-g) of bone window showing the spear trajectory - entrance, path, and end of spear tip. Axial views of plain CT, soft-tissue window showing multiple pneumocephali along cerebral sulci and pneumoventricles in the frontal horns of lateral ventricles (d). No cerebellar hemorrhage observed (h).
case_images: SNI-12-391-g002.jpg
case_images: PMC8422459_01_SNI-12-391-g002.jpg
case_images: F2
case_images: The spear's tip was located at the inner cortex of the left side of the occipital bone [Figure 2a-g]. However, no intracerebellar hemorrhage was observed [Figure 2h].
case_images: (a) Cranial 3D computed tomography scan (3D-CT), lateral view, demonstrating the spear direction passing the clivus to the occipital bone. (b) The spear characteristics were revealed after subtracting skull out corresponding with "one-flapper type" of spear's tips. (c and d) Computed tomography angiography reconstruction on AP (c) and lateral (d) views revealing the trajectory of the spear is close to the left vertebral artery with multiple metallic artifacts (head arrows).
case_images: SNI-12-391-g003.jpg
case_images: PMC8422459_01_SNI-12-391-g003.jpg
case_images: F3
case_images: This section was located within the clivus bone, with the end of the flapper having partially penetrated the intracranial cavity [Figure 3a and b]. However, there were multiple metallic artifacts obscuring the surrounding vessels [Figure 3c and d].
case_images: Intraoperative photographs showing (a) the patient position after fiber-optic intubation, and (b) the application of the Dingman mouth retractor to open the patient's mouth and the splitting of the soft palate. The spear is shown entering the posterior oropharyngeal wall. (c) Photograph showing the spear after removal; it had a one flapper (harpoon) tip and was 26 cm in length.
case_images: SNI-12-391-g004.jpg
case_images: PMC8422459_01_SNI-12-391-g004.jpg
case_images: F4
case_images: Therefore, the anesthesiologist performed nasotracheal intubation using the awake fiber-optic technique during which the patient cooperated well [Figure 4].
case_images: Diagnostic digital subtraction angiography (DSA) demonstrating a normal left vertebral artery located just adjacent to the spear on anterior-posterior (AP) (a) and oblique views (b). A 3D DSA was subsequently done and confirm no visualized injuries of the left vertebral artery and surrounding vessels (not shown). The arrow is pointing the spear abutting the left vertebral artery before removal (a and b). The AP (c) and lateral views (d) of a left vertebral angiography after spear removal showing normal vessels without secondary false aneurysms or developed extravasations.
case_images: SNI-12-391-g005.jpg
case_images: PMC8422459_01_SNI-12-391-g005.jpg
case_images: F5
case_images: The other intracranial arteries, including the anterior and posterior circulations near the spear, were unobstructed [Figure 5a and b]. After removing the spear, angiographic findings concerning the intracranial arteries were found to be normal, both immediately [Figure 5c and d] and 2 weeks postoperatively.