A nail to the brain: Delayed presentation of penetrating craniofacial trauma with intracranial abscess

To describe a case of delayed presentation of penetrating head trauma from a nail gun resulting in intracranial abscess and retained foreign body. A 23-year-old male with no significant medical history presented to an outside Emergency Department (ED) with progressive intermittent headaches. The headaches started after a nail gun kicked back and hit his face at work 1.5 months earlier. He reported no skin penetration, sought no immediate medical care, and continued to work. The patient initially presented to an outside ED with headaches and was discharged after receiving intravenous fluids and acetaminophen. Subsequent presentation at our ED with headaches, fever, and altered mental status resulted in Computed Tomography imaging of his head showing a metallic foreign body consistent with a nail measuring 8 cm extending from the right zygomatic arch, through the right greater wing of the sphenoid, and into the right frontal lobe with associated 4 cm hyperdense collection concerning for abscess. The nail was surgically removed, followed by right frontal stereotactic drainage of the abscess. He was discharged without complication and completed an 8-week course of antibiotics. Post-treatment Magnetic Resonance Imaging brain demonstrated complete resolution of the abscess and improving postoperative changes. We report an unusual case of delayed recognition of penetrating craniofacial trauma from a nail gun with associated intracranial abscess. Despite late presentation, timely surgical intervention and antibiotic therapy resulted in full clinical and radiographic recovery without neurologic deficits.