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✓ In this case report, the authors describe a 33-year-old man who presented with headache due to the presence of 12 nail-gun nails impacted in his cranium and cerebral parenchyma. The authors also review the relevant literature regarding penetrating brain injury. The patient's physical examination revealed a Glasgow Coma Scale score of 15 and impairment of abduction of the right eye and abduction of the jaw producing dysarthria; the remaining results of the neurological examination were normal. Both x-ray films and computerized tomography (CT) scans of the head revealed the presence of 12 nails, the majority of which were located intracranially. A scattering artifact limited the ability of CT scanning to demonstrate any intracranial hemorrhage. Angiography did not demonstrate any evidence of traumatic vascular injury. After general anesthesia had been induced in the patient, the nails were removed in the operating room. Following removal of the final nail, a small left temporal craniotomy was performed to control hemorrhage from a tear in the left middle meningeal artery. Despite the development of a postoperative insular hematoma, the patient was discharged home with minimal deficits. This patient is the only known survivor of the largest number of foreign objects (12) to penetrate the skull intentionally. Overall, self-inflicted nail-gun injuries are less common than accidental discharges. A review of the literature, however, suggests that for penetrating brain injury, self-infliction is the more common mechanism. For those patients who survive such an injury, clinical decision making must focus on preventing further cortical or vascular damage. A rational management strategy should permit these patients to be discharged with no additional injury.

607 Traumatic carotid artery dissections are rare, and the majority of these lesions are clinically silent. They may present with a delayed stroke related to thromboembolic dissemination from the site of the dissection.2 Less frequently, the dissection may progress to cause significant luminal stenosis or occlusion with subsequent hemodynamic consequences.1 This 37-year-old female presented with Grade V subarachnoid hemorrhage (SAH) secondary to basilar aneurysm rupture. She had sustained bilateral carotid artery dissections and mandibular fractures 12 years previously after a motor vehicle accident. No aneurysms were noted on the angiogram report. She received no specific treatment for the dissections and made a full recovery without any neurological sequelae, with no subsequent follow-up. Computed tomography demonstrated diffuse subarachnoid and intraventricular blood and a filling defect anterior to the pons (Fig. 1A). Angiography demonstrated a large 10-mm basilar apex aneurysm (Fig. 1C), an occluded right internal carotid artery (ICA; Fig. 1B), and a string sign involving the left ICA (Fig. 1D). The anterior circulation was supplied through external collaterals (Fig. 1D) and large posterior communicating artery (PCoA) vessels filled retrograde by the posterior circulation (Fig. 1C). The patient remained in poor neurological condition, her family elected to withdraw life support, and she died. Intracranial aneurysm formation has not been recognized in the literature as a possible long-term complication of blunt carotid artery injury. We present the first such case, in which a patient with prior known bilateral traumatic carotid artery dissection developed a de novo basilar apex aneurysm, which may relate to the increased flow in the posterior circulation. (DOI: 10.3171/JNS/2008/108/3/0607)