Management of Migrating Intracranial Bullets: Lessons Learned from Surviving an AK-47 Bullet Through the Lateral Brainstem

• Published in: World neurosurgery Vol. 77; no. 3; pp. 591.e19 - 591.e24
• Main Authors: Rammo, Richard A, DeFazio, Michael V, Ross Bullock, M
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-03-2012
• Subjects: Adolescent; Anti-Bacterial Agents - therapeutic use; Arrhythmias, Cardiac - etiology; Brain Stem - injuries; Brain Stem - pathology; Bullet; Cerebellar Cortex - pathology; Cerebellar Cortex - surgery; Cerebellum - injuries; Cerebellum - pathology; Cerebral Angiography; Cerebral Hemorrhage, Traumatic - etiology; Cerebral Hemorrhage, Traumatic - surgery; Craniotomy; Eye Injuries - surgery; Fluoroscopy; Foreign Bodies - pathology; Foreign Bodies - surgery; Foreign-body; Foreign-Body Migration - pathology; Foreign-Body Migration - surgery; Gunshot wound; Head Injuries, Penetrating - complications; Humans; Intracranial; Male; Meningitis, Bacterial - drug therapy; Meningitis, Bacterial - etiology; Meningitis, Bacterial - microbiology; Migration; Missile; Neurosurgery; Penetrating brain injury; Spontaneous movement; Surgery, Computer-Assisted; Tegmentum Mesencephali - injuries; Tegmentum Mesencephali - pathology; Tomography, X-Ray Computed; Traumatic brain injury; Wounds, Gunshot - pathology; Wounds, Gunshot - surgery; Bullet; Intracranial; Penetrating brain injury; Traumatic brain injury; Gunshot wound; Intravenous; Migration; Spontaneous movement; GSW; Cerebrospinal fluid; IV; Foreign-body; Missile; CT; Computed tomography; CSF
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2011.06.015

Objective Survival after a gunshot wound (GSW) to the head is becoming more common, with an accompanying increase in spontaneous migration of these intracranial bullet fragments. This phenomenon is well described in current literature and is a potentially life-threatening delayed complication of GSW to the head. Methods We present the case of a 17-year-old boy who survived a penetrating GSW to the cranium and cerebellum after an accident involving an AK (Automatic Kalashnikov)–47 (7.62 mm). Results Following initial attempts to remove the bullet and associated hematoma from the cerebellar hemisphere, intraoperative fluoroscopy revealed that the bullet had migrated to lie within the right middle cerebellar peduncle with the development of intraoperative cardiac arrhythmia. The bullet could not be retrieved without risk of damage to the superior and inferior cerebellar arteries. The patient then developed bacterial meningitis, and further imaging revealed the bullet had again migrated under the cerebellar cortex to an accessible location. The infection was treated with aggressive antibiotic therapy and the bullet was removed from the posterior fossa, thus preventing recurrence of infection and further migration. The patient regained full motor, speech, and proprioceptive function within months after injury. Conclusion The potential for spontaneous migration exists with any penetrating brain injury involving a retained foreign body. When a retained intracranial foreign body is unable to be safely extracted during initial debridement, close clinical evaluation is essential and plain-film or computed tomographic imaging should be considered in order to enhance the early detection of delayed-onset life-threatening deterioration, such as meningitis and occlusion of cerebrospinal fluid drainage, because of spontaneous migration.