Neurosurgical Management of Self-Inflicted Cranial Crossbow Injury

BACKGROUND: Although gun-related penetrating traumatic brain injuries make up the majority of cranial missile injuries, low-velocity penetrating injuries present significant clinical difficulties that cannot necessarily be identically managed. Bow hunting is an increasingly popular pastime, and a crossbow allows a unique mechanism to cause a self-inflicted cranial injury with a large, low-velocity projectile. Historically, arrow removal is described in an operating room setting, which provides limited knowledge of the location of vascular injury in the setting of postremoval hemorrhage, and may represent an inefficient use of operating room availability. CASE DESCRIPTION: Two patients presented after self-inflicted cranial crossbow injuries. Both were neurologically salvageable. Initial assessment with computed tomography angiography allowed triage into likely or unlikely vascular injury. Arrow removal was performed in a radiology setting rather than in the operating room to allow immediate postremoval imaging to localize hemorrhage. While an operating room was on standby, neither patient required neurosurgical operative intervention. Both patients made a good recovery with no further injury caused by arrow removal. CONCLUSIONS: We describe a novel approach to retained cranial arrow removal in a radiologic, rather than operative, setting and describe its relative benefits over traditional removal in the operating room.