This 50 year old gentleman presented with one day history of bleeding from the nose the day before admission he was under the influence of alcohol so we don’t know what happened we don’t know if he had an injury or somebody hit him or somebody poked him an X ray skull was done which showed a needle a metal object extending from the nose two inside the brain apart from this he was otherwise clinically intact he was fully conscious oriented talking normally moving upper limb lower limbs normally able to walk eat and drink normally but when we did a CT scan there was a metal object in the form of a needle extending from the nasal cavity to inside the brain we had to do an angiogramto delineate the exact root the needle was traversing from the nose to the brain the patient was taken up for skull base surgery.His skull has to be opened first and then the needle was pulled out from the nose. it is important to do the craniotomy within bracket opening of the skull first, so that the needle can be removed under vision which means when the needle is pulled out from the nose we can tackle any tearing injury that can occur to the major blood vessels inside the brain. this patient recovered well after the operation he had only minor problems. he had local nasal bleeding which was managed with simple ice packs and he was discharged home in three days.
But the main point to be noted is that this is a foreign object and it is going through a relatively dirty area the nose and contaminating a very clean area which is the cranial cavity which contains the brain and all the major blood vessels. this operation has to be done as a priority as soon as the patient is admitted. Otherwise the infection will spread through the needle from the nose into the brain. the second point is an angiogram has to be done to find out if the needle is close to any of the major blood vessels and the Third Point is although the patient is neurologically well he can deteriorate during the operation and immediately after the operation because the needle is very close to the major blood vessels and important brain structures. it is also important to seal the tiny hole left after removing the needle from the nose otherwise the patient will have leak of cerebrospinal fluid from the cranial cavity thereby causing the infection to spread from the nose to the brain.
He also needs long term follow-up in the form of a CT scan to rule out any brain Abscess and an angiogram to rule out any delayed development of aneurysm.
(Medical team – Dr Aditiya Mantry (Neuro Surgeon), Dr Amit Kumar Ghosh(Neuro Surgeon), Dr Christopher Gerber (Spine Surgeon), Dr Chandramouli Balasbharamanian (Neuro Surgeon) Hospital – Institute of Neurosciences Kolkata at Mullickbazar)