Cranio-thoracic bullet migration over a period of 27 years: case report

Abstract

SummaryWe report the case of a 36 year old woman that was hurt in the head with a lost bullet while walking through the street when she was 9 years old. On admission, the patient was fully conscious with no neurological deficits. Skull radiography showed the intracranial bullet but she was dispatched after 24 hours of observation without neurological deterioration. Six months later she suddenly presented quadriplegia and after one year of rehabilitation she recovered the mobility and strength in all her limbs. 25 years latter she began with thoracic pain (dermatomal sensory changes), constipation, paresthesias and weakness in the lower extremities; the X-Ray showed a bullet caliber 9 mm in the thoracic canal at T4 level. The bullet was removed via posterior laminectomy and dorsal midline mielotomy. 12 hours after surgery, the patient presented signs of medullar shock. The post-operatory MRI showed the trajectory of the bullet through the brain to the spinal cord in FLAIR, and spinal cord edema as well. The patient received steroids as treatment for the spinal cord edema, and with the help of rehabilitation she recovered movement in the lower extremities 30 days after the surgery.KEY WORDS: Thoracic canal. Quadriplegia. Laminectomy. Bullet. Migration. Migración craneo-torácica de una bala: descripción de un caso ResumenPresentamos el caso de una mujer de 36 años de edad, que resultó herida en la cabeza con una bala perdida mientras caminaba a través de la calle cuando tenía 9 años de edad. Ingresó en otro hospital consciente y sin déficit neurológico. La radiografía de cráneo mostró una bala intracraneal, pero se envió a su domicilio después de 24 horas de observación sin deterioro neurológico. Seis meses más tarde presentó quadriplejía de forma súbita. Después de un año de rehabilitación recuperó la movilidad y fuerza en sus miembros inferiores. Tras 25 años comenzó con dolor torácico (cambios sensoriales), estreñimiento, parestesias y debilidad en las extremidades inferiores; las radiografías simples de tórax mostraron una bala a nivel T4. La bala fue extirpada mediante laminectomía posterior y mielotomía dorsal de línea media. Doce horas después de la cirugía, el paciente presentó signos de shock medular. La resonancia magnética de cráneo mostró la trayectoria de la bala a través del cerebro a la médula espinal mediante FLAIR. Después de la operación la paciente continuó con esteroides y rehabilitación, recuperando la movilidad de los miembros inferiores, treinta días después de la cirugía.

Spontaneous migration of a retained bullet within the brain: a case report

“…The time course for migration ranges from 2 days to 3 months. [2,7,10] The course of a ricochet bullet is different from migration movement of a retained bullet. A ricochet bullet changes its direction after hitting the wall of the cranium or spinal canal, whereas retained bullet migration may be affected by several factors, such as gravitational factors.…”

“…[3] Gravitational force acting on the bullet, which is denser than the surrounding medium, has been suggested as a cause for migration caudally by the effect of gravity related to the position of the body, especially in the absence of significant cranial swelling. [7,10] Castillo-Rangel and Salvati [2,12] suggested that the ventricular system provides transport of the bullet from one area of the brain to another. Cerebrospinal fluid (CSF) flow and pulsation will facilitate the bullet's movement within the ventricle.…”

“…Bullets reaching the CSF may migrate to a distant part of the brain or the spinal canal through the CSF. Lang [2] noted an intraventricular bullet had migrated to the aqueduct of Sylvius, producing acute hydrocephalus. Increased intracranial pressure due to cerebral swelling has been reported as a cause that prevents migration by compressing the pathway in the brain parenchyma.…”

“…[1] The velocity, distance of flight, refraction, caliber, trajectory, bullet migration, brain damage degree, and vascular injury are the factors that affect mortality. [2] One of the most important factors in the prognosis is the Glasgow Coma Scale (GCS) score of the patient at the time of the initial evaluation. [1] The frequency of gunshot injuries to the head is on the increase and it becomes an important public health problem.…”

“…[3,4] Many cases of spontaneous migration have been reported in the brain and spinal canal. [2,3,[5][6][7][8][9] Treatment of gunshot injuries is still debatable. The neurological status at the time of entry and location of the bullet often dictate the decision regarding surgical removal.…”