Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 51, Num. 3, 2003, pp. 411-412

Neurology India, Vol. 51, No. 3, July, 2003, pp. 411-412

UNUSUAL SELF-INFLICTED PENETRATING CRANIOCEREBRAL INJURY BY A NAIL

Shenoy SN, Raja A
Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal - 576119, Udupi

Correspondence Address:
Department of Neurosurgery, Kasturba Medical College and Hospital, Manipal - 576119, Udupi
shenoysn@yahoo.com

Code Number: ni03136

ABSTRACT

Penetrating injuries of the brain caused by a nail are rare. An interesting case of a patient with schizophrenia who attempted suicide by a self-inflicted penetrating intracranial injury using a nail is reported here. The literature related to this unusual case is reviewed.

INTRODUCTION

Penetrating craniocerebral injury caused by foreign bodies is uncommon in civilian surgical practice. Very few cases of penetrating injuries of the brain caused by a nail have been reported in the literature.[1],[2],[3],[4] An interesting case of intentional penetrating craniocerebral injury by a nail in a known case of paranoid schizophrenia is reported here.

CASE REPORT

A 45-year-old gentleman was brought to the emergency department of our hospital with a history of self-inflicted penetrating nail injury to the head. The patient held the nail in his left hand and using a stone with his right hand, with great patience and determination hammered the nail into his head. Six hours following injury he had developed left side hemiparesis. There was no history of loss of consciousness or seizure. Past history revealed that he was a known case of paranoid schizophrenia on various treatments and had attempted suicide by various other methods. His vital parameters were stable. He was alert, cooperative, oriented and had left hemiparesis with grade 4/5 power in the upper limb and grade 2/5 power in the lower limb. The ipsilateral plantar reflex was extensor. Local examination revealed that the head of the nail was flush with the scalp, 6 inches from the nasion and about 1 cm on the right side of the midline. Skiagram of the skull confirmed the presence of an intact metallic nail measuring about 10 cm, driven into the skull just near the midline, on the right side [Figure-1]. Plain computed tomographic (CT) scan showed the presence of the nail in the center of the head with metal artifacts and the tip entering the third ventricle [Figure-2].

He was admitted to the neuro-intensive care unit and was given primary treatment. While extracting the nail, initially there was resistance, as the thicker portion of the nail was fixed tightly within the skull. However, the rest of the nail was extracted easily by gentle traction with rotatory movement under local anesthesia. The tip of the nail was very sharp. Following extraction of the nail there was minimal bleeding from the puncture side. The skin edges were cleaned and sutured. The patient was subsequently monitored closely. A repeat CT scan of the head revealed evidence of contusion along the nail track and presence of blood in the ventricle. He improved progressively and at discharge, his motor power improved, with grade 5/5 power in the upper limb and grade 4/5 power in the lower limb. Neuropsychiatric assessment revealed auditory hallucinations and suicidal thoughts. At a follow-up 6 months after surgery, he had no focal neurological deficit. However, he was having recurrent episodes of severe depression.

DISCUSSION

Very few cases of craniocerebral injuries due to a nail have been reported in the literature.[1],[2],[3],[4],[5],[6] Nailing of the head is an unusual type of penetrating injury, which may be the result of a suicide, homicide, punishment or accident.[1],[2],[4],[6] This type of injury dates back to ancient times when criminals were punished by driving long nails into the head.[4] The case reported here is of a suicidal attempt to overcome severe depression in a schizophrenic patient. Similar to the case presented here, in most of the cases reported in the literature, the nails were situated on or close to the midline,[2],[4],[5] due to the belief that it will cause instant death.[3] Most of the cases reported in the literature survived and suffered no significant neurological deficit.[1],[2],[4],[6]

The extraction of such nails is usually done easily and can be accomplished by gentle traction.[4] Contrary to belief, serious hemorrhage at the time of injury is unusual even when the nail has transfixed the sagittal sinus.[1],[2] Most of these patients had a history of severe psychosis.[7] Hence, these patients require careful observation in an effort to prevent further self-mutilation injury.

REFERENCES

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