A 58-year-old man who survived a nail gun accident that drove a nail 3 inches into his head without causing major damage is being called the "luckiest man" a doctor ever saw.
An X-ray of the nail in the anonymous man's head, taken at least a year ago, is being published today in the New England Journal of Medicine.
"I refer to him when I teach as the luckiest man I've ever encountered," said Dr. Anne Hayman, a professor of neuroradiology at Baylor College of Medicine in Houston and one of the doctors who submitted the photo.
"It's like the only way that could possibly happen" without severe damage, she said. "That's the actual pathway surgeons use to get to the skull base."
The man's case is among a small minority where victims of head puncture wounds suffered no visible permanent damage. Some people have even survived with little evident damage when foreign objects have pierced their brains, a neurosurgeon said.
"Depending upon which part of the brain it passes through, people can do surprisingly well," said Dr. Alex Valadka, a Texas neurosurgeon who is a member of the trauma section and public relations committee of the American Association of Neurological Surgeons.
"A relatively small volume of injured brain from a nail may be tolerated much better than a large brain injury from a stroke or a gunshot wound or something like that," he added. "Me banging my head against the windshield of a car going 75 mph may cause more injury."
In the case pictured in the New England Journal of Medicine, the nail did not penetrate the man's brain; it just narrowly missed. Instead, the nail entered just next to his left eyeball, went through his sinus cavity and stopped at the base of his skull.
According to the journal, the injury occurred when someone working above the man at a home construction site was shooting nails into a board with a nail gun, and the board broke.
"He was looking up," Hayman said. "It went through the board, which I think must have slowed it down. Otherwise, it would have gone straight in and struck his brain stem, which would have killed him instantly."
"If the nail had gone a little higher, it would have taken out his pituitary gland," she added. "If it had gone a little more laterally to the side, it would have taken out his carotid artery and he would have bled to death right on the spot. … If it had gone a little more laterally still, it would have taken out his eyeball, his optic nerve, and he would have lost sight in the eye, probably irretrievably."
As it turned out, surgeons were able to remove the nail and hospital officials believe he had no long-term damage, Hayman said.
Several Other Examples
Valadka, chief of neurosurgery at Houston's Ben Taub General Hospital and an associate professor of neurosurgery at Baylor College of Medicine, did not work on Hayman's case, but said a few years ago he handled the case of a teenager who recovered from a nail gun wound to the brain.
"He was working with his father at a construction site," Valadka said. "A nail gun went off and the nail went right into his head, into [the right frontal lobe of] his brain."
Medical and popular literature contains other examples of people who lived through such wounds, and in many cases remained lucid and functioning during their injuries.
No matter how lucid a head-injury victim seems, "people at the scene should not try to remove the object," Valadka said. "It seems natural to try to do that, but it's probably best to leave the object in until we're in the operating room in a more controlled situation."
According to a 1998 report in Canada's Ottawa Citizen, a 21-year-old college student employed as a construction worker in Wisconsin turned to his co-worker immediately after a nail gun wound to the brain and said, "You just nailed me in the head." He spent less than a week in a hospital.
Perhaps the most famous example is the 1848 Vermont case of a 25-year-old railway foreman named Phineas P. Gage, who survived an explosion that shot a 1 ¼-inch-wide metal rod through the front of his brain. However, Gage experienced drastic personality changes after the accident, was fired from his job and was said to never be the same person.
Can Easily Cause Death
On the other hand, projectiles such as a nail can easily cause rapid death by damaging critical sections of the brain, severing arteries, or causing infections or seizures.
In a high-profile case Valadka handled, a teenager stabbed in the head above the ear with a screwdriver while at school died because the tool damaged a crucial artery.
"If things had gone just slightly differently, if the screwdriver had gone in a different direction or had penetrated a different part of the brain, he might have survived," Valadka said.