Look away: arterial and venous intravascular embolisation following shotgun injury

Abstract

We describe two cases of intravascular embolization of shotgun pellets found distant to the entry site of penetrating firearm injury. The cases demonstrate antegrade embolization of a shotgun pellet from neck to right middle cerebral artery, and antegrade followed by retrograde venous embolization through the left lower limb to pelvis. Radiologists and Trauma Physicians should be aware that post shotgun injury, the likelihood of an embolised shot pellet is increased compared to other types of firearm missile injury, and should therefore search away from the site of injury to find such missiles. Shotgun pellets may travel in an antegrade or a retrograde intravascular direction – both were seen in these cases - and may not be clinically obvious. This underscores the importance of a meticuluous search through all images, including CT scout images, for evidence of their presence.

Case report - Embolic shotgun pellet to the right internal carotid artery causing hemiplegia

“…Although the site of penetration into the arterial system was often not clearly identified, cases involving neck injuries typically saw penetration through the carotid artery, with one instance involving the vertebral artery. In cases where the chest was involved, the metallic foreign body dislodged into the intracranial circulation through the aorta, supra-aortic vessels, left ventricle, or even the pulmonary veins [ 2 , [7] , [8] , [9] , [10] , [11] , [12] ]. The hemispheric site of embolization in these instances was largely influenced by the anatomy of the arterial system.…”

Large thoracic defect due to shotgun violation – surgical emergency management

“…Ricochets generate particularly problematic impacts because they hit other body areas (e.g. contralateral thorax or abdomen) and cause additional damages [ 3 ], [ 4 ].…”

“…For example in cases of heart or abdominal injuries, median sternotomy and median laparotomy are performed while in cases of a ipsilateral lung injury a lateral thoracotomy is performed [ 12 ], [ 14 ]. If the patient is haemodynamically stable, whole-body CT scan is the best diagnostic tool for detection of foreign bodies [ 4 ]. If there is not enough time for this investigation, because the patient is haemodynamically unstable, the whole-body CT scan has to be performed postoperatively.…”

Embolic Shotgun Pellet to the Left Middle Cerebral Artery Causing Hemiplegia and Aphasia With Near Complete Clinical Recovery on Nonoperative Management

“…Initial CT brain without contrast showedmultiple shotgun pellets; these were located along the left temporal lobe in the Sylvian fissure, in the right frontal scalp, and in the soft tissues of the face without any evidence of skull fracture or intracranial hemorrhage (figure [5][6]. The route of the intracranial pellet was unknown at the time and was thought to possibly be from prior gunshot since there were no large arterial injuries identified and the patient was neurologically intact.…”

“…Missile embolization to the cerebral circulation remains an unusual and rare complication of gunshot wounds that usually has devastating outcomes [1][2][3][4]. Embolism from shotgun wounds are attributed to the combination of small pellet size, wide surface area of injury, and low velocity projectiles whose low kinetic injury allows for incomplete perforation of the affected vessel, thus trapping it in systemic circulation [4][5][6]. The current management guidelines of pellet embolization to the cerebral vasculature remain limited with the literature reporting surgery, anticoagulation, and observation, all as acceptable treatment options [1][2][3][4][5][6][7][8][9].…”