Combined Skull Base Approaches for Extraction of Clival/Brainstem Nail

Introduction: We describe a rare pneumatic nail-gun injury to the clivus, basilar artery, and brainstem that required combined skull base approaches for extraction, repair, and inspection.

Method and Materials: A 46-year-old man suffered an accidental pneumatic nail-gun injury. The nail penetrated the clivus and brainstem, with its distal tip lodged in the collicular region of the midbrain. Because the nail maintained a midline trajectory, the patient regained full consciousness and, surprisingly, only suffered from left hemiparesis, right 6th and 7th nerve palsies, and right-sided hearing loss. The nail head was visible in the oropharynx, just below the soft palate. Because of the exposed nail, and the perceived risk of meningitis, extraction was recommended. Angiography suggested that the nail had penetrated the basilar artery at the level of the anterior-inferior cerebellar arteries (AICAs), therefore, a lateral skull base approach was recommended to secure vascular control.

Results: We performed a right transcochlear skull base exposure to gain access to the anterolateral, mid-basilar region. Once vascular control was achieved, the nail was extracted, under direct visualization, through the mouth. The basilar artery was clip reconstructed with exclusion of the left AICA. The clival defect was packed with muscle and secured with DuraSeal. The clivus was then inspected anteriorly with the endoscope. No further repair was deemed necessary. The patient recovered to his baseline neurological status and was discharged to rehabilitation.

Conclusion: This case illustrates a rare skull base injury that required aggressive skull base exposure to address the complicated neurological and vascular issues involved. The multidisciplinary effort, including neurosurgery, neuro-otology, and rhinology, was essential for proper execution of the surgical plan and the favorable outcome.