Bullet fragments spontaneously migrating in opposite directions after a cardiac arrest treated with extracorporeal cardiopulmonary resuscitation following a gunshot wound to the head: A case report

Abstract

Gunshot injuries to the head are associated with a poor neurological prognosis, have a high risk of mortality, and make the return of spontaneous breathing and circulation after cardiopulmonary arrest difficult. Bullets or bullet fragments can cause penetrating injuries to the brain tissue and sometimes remain in the skull, potentially migrating within the skull. Herein, we describe a rare patient who achieved a return of spontaneous circulation after cardiopulmonary (ROSC) arrest caused by a gunshot wound, following extracorporeal cardiopulmonary resuscitation. After ROSC, repeated computed tomography (CT) identified spontaneously migrating bullets/fragments in the right hemisphere and the metal fragment was excreted from the skull, while another fragment had moved from the left temporal to the occipital fossa. The patient died on the 15th day of hospitalization. The present case had a rare clinical course, suggesting that ROSC may be achieved under adequate respiratory and circulation management in cases of cardiac arrest with a head injury. The scans showed differing movements of the bullet fragments at each lesion, which was difficult to predict from the first CT scan. When surgical treatment is required to remove bullet fragments remaining in the skull (due to lead poisoning, or infection, among others), it may be useful to be aware that fragments may move in various directions, even out of the skull. Furthermore, we recognized the usefulness of CT scanning for detecting the location of the foreign body in cases of gunshot injury to the head.

Identificação E Proveniência De Fragmentos Metálicos Encontrados Em Crânio Humano via Espectroscopia De Raios-X Por Energia Dispersiva (Edx)

“…Tabela 1 -Teores elementares de diferentes regiões dos orifícios ósseos cranianos, obtidos por espectroscopia de raios X por energia dispersiva (EDX) Elemento (%) Na Figura 3, é possível observar dois espectros complementares em relação à composição química semi-quantitativa referente à região I do orifício craniano com bisel interno (Figura 2a), nas faixas de detecção Zn-As, Pb e Cr-Fe, ambos com intensidade média entre 0,0 a 0,002 cps/ua e faixa de varredura entre 0,0 e 13,0 keV, respectivamente. 7 v.9 n.3 2023 indicativos da presença de fragmentos metálicos derivados de projétil de arma de fogo, conforme relatado em trabalhos desenvolvidos anteriormente (HIRAMATSU, 2020;SARAPURA et al, 2019;SHAH et al, 2021;SHUKER e SADDA, 2010;SILVA et al, 2006;STERZIK, 2016). Por outro lado, os demais elementos apresentados na tabela, particularmente o Ca, se refere à própria composição óssea do material, assim como para os teores de P (SCHOLEY e BURTON, 2017;KÜNZEL et al, 2019;ROBISON e KARCHER, 2019;PRITCHARD et al, 2020).…”

“…Quando uma arma de fogo é disparada, grandes quantidades de material gasoso são geradas e expelidas concomitantemente ao lançamento do projétil. Ao longo da trajetória do projétil de arma de fogo (PAF), o material gasoso pode sofrer solidificação, tornando-se particulado pela ação da temperatura, resultando em resíduo de disparo de arma de fogo (DELANNOY et al, 2013;AYUSTA e NIRYANA, 2019;HIRAMATSU, 2020;GARG et al, 2021;Shah et al, 2021).…”

Wartime penetrating skull base trauma with unpredictable internal fragment ricochet and migration: illustrative case

“…Another complication of PBI is delayed migration of the projectile, which was reported in 4.2% of cases in the largest reported series of 213 patients who suffered a gunshot wound to the head. 6 – 18 The timing of migration of intracranial bullets is quite variable and has been reported to occur within hours to days to as long as 4–5 years after injury. Most migrating projectiles are bullets, possibly related to their shape.…”