Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand.
Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
Oper Neurosurg (Hagerstown). 2023 Mar 1;24(3):e223-e227. doi: 10.1227/ons.0000000000000509. Epub 2022 Nov 18.
We report a case of nail gun-related penetrating brain injury, puncturing through the anterior third of superior sagittal sinus, which remained patent and was associated with an arteriovenous (AV) shunt revealed on catheter angiogram.
A previously well 35-year-old male patient presented with a self-inflicted pneumatic nail gun injury. Neurological examination was unremarkable. Computed tomography (CT) of the brain demonstrated the nail had penetrated through the skull, traversed the anterior third of the superior sagittal sinus (SSS), right frontal lobe parenchyma, frontal horn of right lateral ventricle, caudate, and right cerebral peduncle. CT angiogram showed no associated vascular injury, with CT venogram showing a short segment of filling defect within SSS adjacent to nail penetration. However, digital subtraction angiography revealed an associated arteriovenous shunt 8 mm anterior to the dural penetration site, which filled the SSS in arterial phase. Removal of the nail was performed using a double concentric craniotomy around the nail entry site. Before removal of the nail, the SSS anterior to the nail penetration site was tied off and divided along with coagulation and division of the falx, while the SSS posterior to the nail penetration site was also tied off to isolate the penetrated SSS segment. The patient recovered well with repeat digital subtraction angiography demonstrating no residual AV shunting.
This case report aims to highlight the importance of performing a catheter angiogram and describe our stepwise considerations and approach in treating a penetrating injury involving the superior sagittal sinus with concurrent AV fistula.
我们报告了一例与钉枪相关的穿透性颅脑损伤病例，钉子穿透了上矢状窦的前 1/3，且窦仍然通畅，并在导管血管造影中发现动静脉（AV）分流。
一名既往健康的 35 岁男性患者因自行使用气动钉枪受伤就诊。神经系统检查无明显异常。颅脑 CT 显示钉子穿透颅骨，穿过上矢状窦前 1/3、右侧额叶实质、右侧侧脑室额角、尾状核和右侧大脑脚。CT 血管造影未显示相关血管损伤，CT 静脉造影显示上矢状窦邻近钉子穿透处有一小段充盈缺损。然而，数字减影血管造影显示在硬脑膜穿透部位前 8mm 处存在相关动静脉分流，该分流在动脉期充盈上矢状窦。使用围绕钉子入口部位的双同心开颅术取出钉子。在取出钉子之前，用丝线结扎并切断位于钉子穿透部位之前的上矢状窦，并在镰状韧带处凝固和切断，同时也结扎位于钉子穿透部位之后的上矢状窦，以隔离穿透的上矢状窦段。患者恢复良好，重复数字减影血管造影显示无残留动静脉分流。
本病例报告旨在强调进行导管血管造影的重要性，并描述我们在治疗伴有 AV 瘘的上矢状窦穿透性损伤时的逐步考虑和方法。
