Alcohol, Valium and What?

A 67-year-old man was brought in by ambulance after being found unconscious with empty alcohol and pill bottles nearby. A review of his old emergency department visits showed he had a long history of drug and alcohol abuse.

He was so intoxicated there was concern he would stop breathing. So, he was intubated, which means a tube was placed into his windpipe and he was placed on a ventilator. However, other than a high alcohol level and Valium in his urine toxicology screen, nothing else turned up on his emergency department evaluation to explain his altered level of consciousness.

The intensive care consultant who came to see him wanted a CT scan of his brain. Even though there was no evidence the patient had suffered any trauma, the consultant wanted to make sure he didn’t have bleeding in his brain that would explain why he was so out of it.

Everyone was totally surprised when this picture showed up on the scan:

Here is a close up:

Let me help you understand what you are looking at here. This is a side view of the patient’s head. Only the bones show clearly. It can be seen that a nail entered his head from the front, in the middle of his forehead. As it passed back (from right to left on the image,) it went through the skin of the forehead, into the skull and through the frontal sinus, which is an air-filled space in the skull right above the eyes. The nail went in with enough force that it continued through the frontal sinus and stopped with the head of the nail pressed against the back of that same sinus. At the same time, the tip of the nail broke into the space where the brain sits. As it went in, it apparently missed injuring any important structures, sliding right under the bottom of the brain. The tip of the nail then continued out of the brain compartment and ended up in the sphenoid sinus, another air-filled cavity in the skull, back behind the nose.

A recheck of the patient’s forehead, where the nail would have entered, showed no open wound. A recheck of his old visits showed no mention of a nail in the brain. In fact, when the patient was seen two months earlier for a similar spell of intoxication, he had also had his head scanned and there was no nail there then. Because the nail did not seem to have injured his brain, it was felt that the patient’s unconsciousness was due to alcohol and Valium.

The next day, the patient woke up. He said he didn’t know he had a nail in his head and had no memory of any event that might have left him with one. He also denied any headaches or other symptoms that might be caused by having a nail in his head.

The patient was seen by a neurosurgeon who felt that, if having a nail in his skull did not bother the patient, there was no reason to remove it. The patient was discharged with referral for drug and alcohol counseling.

I am sure no one will ever understand exactly what happened. However, the best guess is that some time in the previous two months, the patient was shot in the head with a nail gun. It had been long enough for the puncture wound on the forehead to completely heal over so there was no sign left on the outside.

Beyond that, we have only more puzzling questions. Was he shot on accident at a construction work site? Did someone shoot him on purpose trying, unsuccessfully, to kill him? Did he shoot himself with a nail gun, trying to kill himself? Was he so drunk he really didn’t remember the event or was he lying when claiming to have no knowledge of what happened?

How could you get a huge nail shot into your head, have it penetrate your skin, frontal sinus, inside of the skull around the brain and out into your sphenoid sinus and never develop headaches or an infection? A truly amazing story that is hard to even believe.