title: Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note.
abstract: BACKGROUND
  Craniocerebral penetrating injuries from nail-gun accidents are rare and usually are discovered immediately after the trauma. Several surgical procedures have been described to extract a foreign body that is infixed in the skull and has penetrated the surrounding structures; blind extraction, craniectomy, and craniotomy.
  
  
  METHODS
  We report the case of a 25-year-old ex-carpenter who presented with jacksonian seizure at the left limb. Plain radiography of the skull revealed the unexpected presence of a nail hammered in the right parietal bone, penetrating the underlying structures of the frontoparietal area up to a depth of 3 cm. The patient was operated on; a small craniotomy (1 x 1 cm) just around the head of the nail, and a concentric larger frontoparietal bone flap, involving the first craniotomy, were performed. The larger bone flap was elevated first, whereas the small bone flap with the nail infixed was carefully elevated along the axis of the nail, under direct vision of the nail tract.
  
  
  CONCLUSIONS
  Double concentric craniotomy is the only technique that permits the removal of a foreign body that has penetrated both the skull and the brain, under direct vision, without transmitting any undue forces to the underlying structures. With this technique, control of bleeding can also be easily achieved.
authors.affiliation: Department of Neurosurgery, Second University of Naples, 80-131 Naples. Italy. spennato2@libero.it
authors.forename: Pietro
authors.initials: P
authors.lastname: Spennato
authors.forename: Antonio
authors.initials: A
authors.lastname: Bocchetti
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Mirone
authors.forename: Luciano
authors.initials: L
authors.lastname: Savarese
authors.forename: Domenico
authors.initials: D
authors.lastname: Squillante
authors.forename: Michele
authors.initials: M
authors.lastname: Rotondo
authors.forename: Massimo
authors.initials: M
authors.lastname: Natale
mesh_terms: D000062:Accidents, Occupational; D000328:Adult; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D003399:Craniotomy / Q000379:methods*; D005547:Foreign Bodies / Q000601:surgery*; D006801:Humans; D008297:Male; D009044:Motor Cortex / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D011859:Radiography; D012640:Seizures / Q000209:etiology / Q000473:pathology / Q000503:physiopathology; D012886:Skull / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D016896:Treatment Outcome