[Head injuries and their wound treatment]. / Verletzungen am Kopf und ihre Wundbehandlung.

Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography.

PURPOSE: The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS: A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS: Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION: The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Analysis of Neurosurgical Injuries and The Lessons Learned After the Catastrophic Double Earthquakes in Turkey.

AIM: To identify the patterns and types of neuorosurgical injuries sustained by victims of the double earthquakes affected ten cities with a population of 15 million in southern and central Türkiye. MATERIAL AND METHODS: In this descriptive observational study, we retrospectively analyzed the medical records of a university hospital located in one of the ten cities affected by the earthquake. RESULTS: A total of 1,612 patients with earthquake-related injuries were admitted during the study period, of which 139 (8.6%) had neurosurgical injuries. The mean age of the patients was 42.4 ± 21.1 years (median, 42 years), and 53.2% of them were female. Of the 139 patients with neurosurgical injuries, 41 (29.5%) had craniocerebral injuries, 95 (68.3%) had spinal injuries, and three (2.2%) had both craniocerebral and spinal injuries. A total of 31 surgeries were performed (22.3%) (five [3.6%] for craniocerebral injuries and 26 [18.7 %] for spinal injuries). Ninety-eight patients (70.5%) had concomitant systemic traumas. The overall mortality rate was 5.75%, with crush syndrome (n=4, 50%), being the leading cause of death, followed by neurosurgical pathologies (n=3, 37.5%) and pneumonia with septic shock (n=1, 12.5%). CONCLUSION: Neurosurgical injury is an important cause of post-earthquake mortality and morbidity. To ensure efficient medical rescue and judicious resource allocation, it is essential to recognize the characteristics of earthquake-related neurosurgical injuries. This study provides valuable information regarding the incidence, characteristics, and outcomes of neurosurgical injuries in earthquake-affected patients. Our findings highlight the need for prompt diagnosis and management of such injuries, particularly in those with concomitant systemic trauma.

Double microvascular free flap reconstruction for bilateral lower extremity injury in a paediatric patient.

Many challenges have been described by microsurgeons in paediatric free flaps. With the advancement in microsurgical expertise, it is now possible to achieve excellent results. We present a case of a female child with car-tyre friction injury of bilateral feet with associated extradural haemorrhage who underwent emergency bilateral anterolateral thigh flap. A secondary tendon reconstruction of the left foot was performed at 6 months. No complications were observed in the postoperative period after both procedures and good functional recovery was achieved at 1 year follow-up. The problems unique to this case were the presence of head injury and bilateral extremity injury in the paediatric patient. The technical details of planning, execution, difficulties and recommendations to minimise the risk in such cases are discussed. To the best of our knowledge, this is the only case report of bilateral lower limb paediatric emergency free flap with associated head injury.

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture.

CONTEXT: Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury. METHODS: The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged. CONCLUSION: Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Prophylactic removal of a migratory missile from the cerebral ventricles: case report.

BACKGROUND AND IMPORTANCE: Nonpowder firearm injuries to the head pose major health risks, with retained fragments potentially causing harmful sequelae that require neurosurgical intervention. CLINICAL PRESENTATION: We report the case of 2-year-old girl who sustained an accidental gunshot wound to the head. She sustained a penetrating ballistic intracranial injury caused by a BB shot from a rifle. At presentation, she was neurologically intact with a punctate laceration on her left forehead. Head CT demonstrated a small depressed left frontal skull fracture, a small intracerebral hematoma, and a 5-mm metallic bullet fragment in the deep left frontal lobe near the frontal horn of the left lateral ventricle. She was admitted to the hospital and managed nonoperatively with levetiracetam and intravenous antibiotics, and discharged home in good condition. Follow-up CT in 1 week showed slight migration of the metallic bullet fragment to the left, placing it at the anterior horn of the lateral ventricle. Six weeks later, follow-up CT showed migration of the bullet to the temporal horn of the left lateral ventricle. Intraventricular migration of the bullet raised concern that it could move further to obstruct the foramen of Monro or cerebral aqueduct. Therefore, we removed the bullet through a small left temporal craniotomy with image guidance using a microsurgical approach through a translucent tube. CONCLUSION: The authors discuss the rationale and technique for removing a nonpowder firearm bullet that has migrated within the cerebral ventricles.

Clinical Characteristics and Prognoses of Chronic Subdural Hematoma Patients with and without Head Trauma: A Retrospective Comparative Study.

OBJECTIVE: Head trauma is considered as the main cause of chronic subdural hematoma (CSDH). However, many patients develop CSDH with no identified cause. Herein, we conduct a comparative study to investigate the differences in clinical characteristics and surgical outcomes of CSDH patients with and without a history of head trauma. METHODS: We retrospectively reviewed CSDH patients who underwent surgical treatment in our hospital between January 2013 and December 2021. Patients were categorized into a with head trauma (WHT) group and a without head trauma (WOHT) group for comparative analysis. RESULTS: A total of 219 patients were included, 119 (54.3%) cases in the WHT group and 100 (45.7%) cases in the WOHT group. More cancer patients were found in the WOHT group than in the WHT group (P = 0.045). Both at discharge and 6-month follow-up, patients in the WOHT group achieved better clinical outcomes than the WHT group cases (P = 0.025 and 0.034, respectively). Furthermore, ordered multiclass logistic regression analyses indicated that a history of head trauma (odds ratio 2.151, 95% confidence interval 1.052-4.386; P = 0.036) was a risk factor significantly related to the unfavorable outcomes at 6-month follow-ups of CSDH. However, we did not find significant differences between the 2 groups in clinical manifestations, radiological characteristics, postoperative complications, mortality, and recurrence rates. CONCLUSIONS: CSDH patients with a history of head trauma may be more susceptible to unfavorable outcomes; thus, they should be carefully evaluated and given more attention during hospitalization and after discharge.

Effects of Dexmedetomidine on Cognitive Function, Oxidative Stress and Brain Protection in Patients Undergoing Craniocerebral Surgery

Background: The protective mechanism of dexmedetomidine on the brains of patients undergoing craniocerebral surgery remains unclear. The aim of this study was to examine the impact of dexmedetomidine on cognitive function, oxidative stress, and brain protection in such patients. Methods: Fifty-four patients who underwent craniocerebral surgery at our hospital from January 2020 to June 2023 were retrospectively selected as study subjects. They were divided into two groups: the control group (n = 27) and the study group (n = 27), based on different auxiliary anesthesia protocols. Patients in the study group received dexmedetomidine before anesthesia induction, using a midline intravenous pump to assist anesthesia, while the control group received an equivalent amount of normal saline. The remaining anesthesia induction and maintenance protocols were consistent for both groups. Cognitive function was assessed using the Mini Mental State Examination (MMSE) before and 1 day after surgery for both groups. Oxidative stress indicators, including malondialdehyde (MDA), glutathione peroxidase (GSH-Px), and superoxide dismutase (SOD) levels in the serum of both groups, were measured using enzyme-linked immunosorbent assay (ELISA). Additionally, changes in postoperative brain injury indicators, namely neuron-specific enolase (NSE) and central nervous system-specific protein (S100β), were detected and compared in the serum of both groups. Concurrently, postoperative adverse reactions were recorded for both groups. Results: The MMSE scale scores of both groups of patients 24 hours after surgery were significantly lower than those before surgery. However, the MMSE scale scores of the study group patients were notably higher than those in the control group, with a statistically significant difference (p < 0.05). One hour after surgery, the serum levels of MDA, GSH-Px, and SOD in both groups of patients were significantly elevated compared to pre-surgery levels. ... (AU)

[Application Effect of Continuous Lumbar Cistern Fluid Drainage Combined With Decompressive Craniectomy in the Treatment of Severe Craniocerebral Injury].

Objective: To analyze the application effect of continuous lumbar cistern fluid drainage combined with decompressive craniectomy in the treatment of severe craniocerebral injury. Methods: A total of 87 patients with severe craniocerebral injury admitted to our hospital between March 2016 and March 2021 were retrospectively enrolled. They were divided into two groups according to the decompression methods applied, with 42 patients who received standard decompressive craniectomy assigned to the control group and 45 patients who received continuous lumbar cistern fluid drainage combined with standard decompressive craniectomy assigned to the observation group. The primary indicators that were monitored and compared between the two group included the amount of time for patient CT imaging to be clear of subarachnoid hemorrhage, the length-of-stay, the duration of post-operative intubation, the mannitol dose, scores for Glasgow Coma Scale (GCS), prognosis, the incidence of cerebral edema and cerebral infarction, and complications. The secondary indicators that were monitored and compared included intracranial pressure, cerebrospinal fluid antinucleosome protein SP100, and red blood cell count of the two groups before treatment and after continuous drainage for 7 days. Results: The amount of time for CT imaging to be clear of subarachnoid hemorrhage and the length-of-stay of the observation group were shorter than those of the control group, the mannitol dose of the observation group was lower than that of the control group, the incidence of cerebral edema and the incidence of complications of the observation group were lower than those of the control group, and the rate of patients with good prognosis in the observation group was higher than that in the control group ( P<0.05). There was no significant difference in the rate of poor prognosis or mortality between the two groups ( P>0.05). The duration of postoperative intubation of the observation group was (8.24±1.09) d, while that of the control group was (9.22±1.26) d, and the difference between the two groups was statistically significant ( t=3.887, P<0.05). There were 2 cases (4.44%) of cerebral infarction in the observation group, with the infarct volume being (8.36±1.87) cm 3, while there were 9 cases (21.43%) of cerebral infarction in the control group, with the infarct volume being (8.36±1.87) cm 3, and there were statistically significant differences in the incidence and volume of cerebral infarction between the two groups ( χ 2=5.674, t=9.609, P<0.05). After treatment, the intracranial pressure and red blood cell count decreased in both groups and the intracranial pressure, cerebrospinal fluid SP100, and red blood cell count of the observation group were significantly lower than those of the control group ( P<0.05). The cerebrospinal fluid SP100 of the observation group decreased after treatment in comparison with the level before treatment ( P<0.05), while the pre- and post-treatment levels of the control group did not demonstrate any significant difference. Conclusion: Continuous lumbar cistern fluid drainage in patients with severe craniocerebral injury effectively shortens the time required for the body to recover, significantly reduces the level of intracranial pressure, improves the levels of cerebral edema and cerebral infarction, and has a high degree of safety for prognosis and recovery.

Effective Epilepsy Surgery for Post-Traumatic West Syndrome Following Abusive Head Trauma.

West syndrome, an infantile developmental and epileptic encephalopathy with a deleterious impact on long-term development, requires early treatment to minimize developmental abnormality; in such cases, epilepsy surgery should be considered a powerful therapeutic option. We describe a 10-month-old female admitted with West syndrome associated with a hemispheric lesion following abusive head trauma. Her seizures were suppressed by hemispherotomy at 12 months of age, leading to developmental improvement. Surgical treatment of West syndrome following traumatic brain injury has not been reported previously but is worth considering as a treatment option, depending on patient age and brain plasticity.

Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma.

BACKGROUND: The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT). METHODS: We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL). RESULTS: Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt. CONCLUSIONS: For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.

History of Cranial Surgery in World War I: Experience on the Italian Front.

Since ancient history, men have been attempting to intervene when skull trauma occurs. The majority of traumas were always linked to war injuries, and in the modern era, the culprit was reached during World War I. Cranial traumas in wartime were very common, and consequently, physicians in wartime became particularly interested in the subject of cranial traumatology. In the following text, we want to bring to light the experience of some of the pioneers of cranial surgery in Italy during the First Great War. In fact before the war, very few medical officers had received training in central nervous system surgery. In addition, the surgical instruments for that clinical activity were inadequate and obsolete, but to deal with the medical emergency that had arisen on the front lines, the Italian government established Battlefield Medical Schools. And it is also from the reports and lectures of surgeons working on the front lines that the next generations of neurosurgeons were able to develop this surgical field into the complex and well-established surgical specialty that it is today.

The historical rationale for operating on cranial fissures.

OBJECTIVE: Cranial fissures are not an indication for surgical intervention. It should be emphasised that the term fissure refers to linear skull fractures as defined in MESH. However, it was the universal term for this injury in the literature which forms the basis of this paper. Nonetheless, for over two millennia, their management was a major reason for opening the skull. The reasons for this deserve analysis, in particular taking into account the available technology and conceptual background. MATERIALS AND METHODS: The texts of significant surgical practitioners from Hippocrates to the eighteenth century were examined and analyzed. RESULTS: The need for fissure surgery was based on Hippocrates' teaching. It was considered that extravasated blood would suppurate, and extracranial suppuration could leak inwards through a fracture. Trepanation to facilitate pus drainage and cleansing was considered vital. Avoiding surgical damage to the dura was also emphasized with a preference for operating only when the dura had separated from the cranium. The enlightenment with an increasing reliance on personal observation rather than the teachings of received authority enabled the accumulation of a more rational basis for treatment concerned with the effects of injury on brain function. This culminated in the teachings of Percivall Pott, who despite some minor errors, provided the framework on which modern treatments would develop. CONCLUSIONS: Examination of the surgical management of cranial trauma from Hippocrates to the eighteenth century shows that cranial fissures were judged to be of great importance and required active treatment. This treatment was not aimed at improving the healing of the fracture but at avoiding deadly intracranial infection. It is worth noting that this sort of treatment persisted for over two millennia while modern management has only been practiced for just over a century. Who can say how it will change in the next hundred years.

Outcomes of SUBGALEAL Drain Placement after two Burr-Holes Craniectomy for Chronic Subdural Hematoma.

OBJECTIVE: To evaluate the efficacy and complications of subgaleal drain placement after two burr-holes evacuation of chronic subdural hematoma (CSDH). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Neurosurgical unit of the Lady Reading Hospital, Peshawar, from April to November 2021. METHODOLOGY: Sixty-four consecutive patients diagnosed with surgically significant unilateral chronic subdural hematoma were prospectively included after obtaining informed consent. All the patients underwent two burr-holes craniectomies and evacuation, followed by subgaleal drain placement. Patient demographics, pre- and postoperative clinical information including hematoma resolution and complications were collected. RESULTS: This study included 44 (69%) males and 20 (31%) females with a mean age of 70.1 ± 8 years. The most common presenting symptoms were headaches (70%) and confusion (68%). Eighteen patients (28%) were taking warfarin or other anticoagulants, whereas, 23 patients (36%) were taking antiplatelet medications at the time of presentation. Thirty-six (56.3%) patients had a history of head trauma. Warfarin use was statistically significant in the patients with no history of head injury. Fifty-five patients (85%) showed no significant recurrence on the 2 week postoperative computed tomography (CT) scan. None of the patients had intraparenchymal hematoma or contusion of iatrogenic origin on postoperative CT scans. CONCLUSION: Subgaleal drain placement after two burr-holes craniectomy led to high-resolution rates. However, no parenchymal injuries were attributed to the procedure. KEY WORDS: Chronic subdural hematoma, Subdural drain, Subperiosteal drain, Burr-hole craniostomy.

Prevalence, severity, and neurosurgical management of abusive head trauma during the COVID-19 pandemic.

OBJECTIVE: Reports published during the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) pandemic suggest that hospitals potentially experienced an increased incidence in the presentation of abusive head trauma (AHT) in children; however, it remains unknown if the pandemic influenced the severity or need for neurosurgical intervention during this time. METHODS: This study is a post hoc analysis of a prospectively collected database of pediatric patients who sustained traumatic head injuries from 2018 to 2021 and were treated at the Children's Hospital of Pittsburgh that was screened for concern of AHT at the time of presentation. Pairwise univariate analysis of AHT prevalence, Glasgow Coma Scale (GCS) score, intracranial pathology, and neurosurgical interventions was performed to investigate differences before, during, and after the initial lockdown in Pennsylvania, which was defined as March 23, 2020, to August 26, 2020. RESULTS: Of 2181 pediatric patients who presented with head trauma, 263 (12.1%) with AHT were identified. Prevalence of AHT did not differ during (12.4% before vs 10.0% during, p = 0.31) or following (12.2% after, p = 0.92) lockdown. Need for neurosurgery after AHT remained unchanged during lockdown (10.7% before vs 8.3% during, p = 0.72) and after (10.5% after, p = 0.97). Patients did not differ in terms of sex, age, or race between periods. Average GCS score was lower after lockdown (13.9 before vs 11.9 after, p = 0.008) but not during (12.3, p = 0.062). In this cohort, mortality associated with AHT was 4.8 times higher during lockdown (4.3% before vs 20.8% during, p = 0.002) and returned to pre-lockdown rates thereafter (7.8%, p = 0.27). The primary contributor to mortality was ischemic brain injury (5% before vs 20.8% during, p = 0.005). Patients were 5.5 times more likely to undergo decompressive hemicraniectomy in the months after lockdown compared with prior (1.2% vs 6.6%, p = 0.035). CONCLUSIONS: The authors have presented the findings of the first study to examine the prevalence and neurosurgical management of AHT during the Sars-Cov-2 lockdown in Pennsylvania. The overall prevalence of AHT was not affected by lockdown; however, patients were more likely to experience mortality or traumatic ischemia during lockdown. The GCS score of AHT patients was significantly lower, and these patients were more likely to require decompressive hemicraniectomy after the initial lockdown period.

Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report.

INTRODUCTION: Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. CASE PRESENTATION: A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.

Sunken Skin Flap Syndrome: Neurological Dysfunction After Decompressive Craniectomy.

Sunken Skin Flap Syndrome (or Syndrome of the Trephined) following a head trauma is rare, but most often results from complications after decompressive craniectomy. This syndrome is most often characterized by neurological dysfunction that improves with cranioplasty. Early diagnosis and treatment are critically important to long term neurological improvement. This is a case report of a 49-year-old male who fell down a flight of stairs and was found unresponsive. Initial imaging revealed extensive head trauma. Neurosurgery performed an emergency decompressive craniectomy, but his post-operative course was complicated by the development of sunken flap syndrome one month after his initial surgery, diagnosed by an acute neurological decline and emergent CT imaging. A review of the literature indicates that this is a rarely documented finding, and this case report discusses the critical components of diagnosis and treatment of this unusual and potentially lethal condition.

Surviving a Self-inflicted Transorbital Pen Intrusion to the Cerebellum: Case Report.

BACKGROUND: Although intracranial traumas by penetrating foreign objects are not absolute rarities, the nature of trauma, the kind of object, and its trajectory make them a one of a kind case every time they occur. Whereas high-velocity traumas mostly result in fatalities, it is the low-velocity traumas that demand an individualized surgical strategy. METHODS: We present a case report of a 33-year-old patient who was admitted to our department with a self-inflicted transorbital pen injury to the brain. The authors recall the incident and the technique of the pen removal. RESULTS: Large surgical exposure of the pen trajectory was considered too traumatic. Therefore, we opted to remove the pen and have an immediate postoperative computed tomography (CT) scan. Due to its fragility, the pen case could only be removed with a screwdriver, inserted into the case. Post-op CT scan showed a small bleeding in the right peduncular region, which was treated conservatively. The patient was transferred back to intensive care unit and woken up the next day. She lost visual function on her right eye, but suffered from no further neurologic deficit. CONCLUSION: Surgical management of removal of intracranial foreign bodies is no routine procedure. Although some would favor a large surgical exposure, we could not think of an approach to do so without maximum surgical efforts. We opted for a minimal surgical procedure with immediate CT scan and achieved an optimal result. We find this case to be worth considering when deciding on a strategy in the future.

Repair of the superior sagittal sinus following penetrating intracranial injury caused by nail gun accident: case report and technical note.

We report a 45-year-old man who suffered a penetrating nail gun injury resulting in damage to the lateral edge of the superior sagittal sinus. The injury was successfully treated via a parasagittal craniotomy that enabled removal of the nail under direct vision, allowing for rapid suturing of the sagittal sinus. Two neurosurgeons worked together; one carefully withdrew the tip of the nail back into the sinus itself while the second rapidly sutured the hole in the inner superior sagittal sinus leaflet. Postoperatively, the patient made a rapid recovery without neurological deficit.