Localization of Missile Tract and Intrapericardial Foreign Body with Computed Tomography: Case Report and Review of the Literature

Abstract

enetrating chest injuries involving the heart and great vessels are associated with high morbidity and require rapid determination of the anatomic compartment(s) involved to guide urgent therapy. The decision to explore the mediastinum and cardiac structures is often based on clinical signs, but cardiac penetration may occur without acute hemodynamic compromise or hemopericardium. We describe a case of a hemodynamically stable patient who presented to the emergency department (ED) after projectile lawn mower injury, describe the utility of computed tomography in this context, and review the literature regarding these wounds. CASE REPORTA 67-year-old ambulatory man with a medical history of chronic obstructive pulmonary disease and no known surgical history presented to the ED complaining of anterior right chest wound suffered while mowing the lawn. The patient described a fragment of chicken wire fence striking his chest, but claimed it fell out when he removed his shirt. There was no loss of consciousness, and he was alert and oriented ϫ3 in the ED. Physical examination revealed equal breath sounds bilaterally with no peripheral cyanosis, pericardial rub, or jugular venous distention. Blood pressure was 145/89, pulse was 62, and respiratory rate was 18. Oxygen saturation was 100% on room air, and electrocardiogram revealed normal sinus rhythm with first degree atrioventricular block and prolonged QT interval. Erect posteroanterior (PA) and lateral chest radiographs demonstrated a linear high attenuation foreign body overlying the anterior cardiac silhouette (Fig. 1). Transesophageal echocardiography performed in the ED revealed normal left ventral function with no evidence of hemopericardium or intracardiac shunt, but was unable to locate the foreign body.Urgent computed tomography (CT) was then performed and accurately depicted soft tissue stranding in a missile tract that extended inferiorly, posteriorly and leftward from the right parasternal chest wall wound (Fig. 2). The foreign body was readily identified as linear and metallic, lying between the cardiac base and the anterior aspect of the distal esophagus within the mediastinum (Fig. 3). Its position had clearly changed with assumption of supine position for CT (Fig. 1), and a determination of "tumbling" dependent pericardial missile was made. There was no evidence of hemopneumothorax or hemopericardium, and no indication the missile had entered the abdominal cavity.

Diagnostic challenges and treatment options of a suspected pericardial metallic projectile foreign body in a dog

“…Radiography, echocardiography (ie, transthoracic and esophageal), fluoroscopy, and computed tomography (CT) are useful for localizing cardiac foreign bodies . Accurate localization of pericardial, myocardial, and intrachamber foreign bodies is essential to help guide appropriate intervention.…”

“…Projectile metallic foreign bodies that remain free in the thoracic cavity are thought to be less likely to cause major complications . Similarly, postsurgical complications associated with the pericardectomy itself are rare …”

Cardiopulmonary bypass for removal of bullet in the posterior pericardium-A case report

“…Radiology in the form of plain chest X ray and fluoroscopy can be helpful but in the present era CT angiography and transthoracic echocardiography are the investigations of choice for bullet localization. 8,9 Both AP and lateral chest X ray views obtained in our patient failed to reveal the metallic bullet probably because of overlapping by cardiac shadow and vertebral column. Oblique chest X ray views which might have been beneficial were not obtained in our case as it was felt that a CT scan would still be required to localize exact position and to exclude associated cardiac injuries that might alter therapeutic management.…”

Dynamic monitoring of a migrating and penetrating intracardiac foreign body by echocardiography perioperatively

“…Studies showed that TTE provides information regarding the size, and location of cardiac foreign bodies with almost 100% sensitivity 8 . Moreover, TEE is a favorable imaging modality in assessing functional and structural damage of the heart, especially in the unstable patient 9 . It was important to note that the foreign body may migrate with blood flow, gravity, or through the myocardial tissues along with the systolic and diastolic beat of heart, resulting in location changes.…”