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Darwazeh R, Darwazeh M, Sun X. Spontaneous migration of retained intracranial missiles: experience with 16 cases. Neurosurg Rev 2022; 45:2417-2430. [DOI: 10.1007/s10143-022-01763-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/22/2022] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
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Yue JK, Chang D, Han KJ, Wang AS, Oh T, Sun PP. Management of migrating intracranial bullet fragments in a 13-year-old female after firearm brain injury: technical and surgical nuances. Brain Inj 2022; 36:432-439. [PMID: 35099341 DOI: 10.1080/02699052.2022.2034185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
INTRODUCTION We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH). CASE PRESENTATION A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to -15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be .45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation. DISCUSSION During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Albert S Wang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Taemin Oh
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Peter P Sun
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Leone A, Parsons AD, Willis S, Moawad SA, Zanzerkia R, Rahme R. Sinking bullet syndrome: A unique case of transhemispheric migration. Clin Neurol Neurosurg 2021; 204:106607. [PMID: 33774506 DOI: 10.1016/j.clineuro.2021.106607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/21/2021] [Accepted: 03/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spontaneous migration of retained intracranial bullet fragments is an increasingly recognized phenomenon. However, such migration is usually limited in extent, since it occurs along the bullet tract or cerebrospinal fluid (CSF) spaces. Transhemispheric migration through an intact cerebral hemisphere has not been previously reported. OBSERVATIONS A 20-year old man sustained a gunshot wound (GSW) to the head with a left parieto-occipital entry point, resulting in retained bullet fragments within the anterior right frontal lobe. The patient developed medically refractory intracranial hypertension, necessitating a left decompressive hemicraniectomy. He exhibited a favorable postoperative course, with gradual neurologic recovery, and was ultimately discharged to a rehabilitation facility. Notwithstanding, serial head CT scans during the first 2 weeks revealed gradual transhemispheric migration of bullet fragments from the right frontal pole to the right occipital pole, traveling through largely intact, uninjured brain tissue. LESSONS Transhemispheric migration of bullet fragments via intact brain tissue may rarely occur. While the exact mechanisms underlying this phenomenon remain unclear, potential factors may include: bullet weight, CSF pulsations, dissection through white matter tracts, and biomechanical effects of large skull defects. Bullet migration does not necessarily delay or prevent neurologic recovery.
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Affiliation(s)
- Augusto Leone
- Division of Neurosurgery, SBH Health System, Bronx, NY, USA; Department of Adult and Pediatric Human Pathology, Università degli Studi di Messina, Messina, Italy.
| | | | - Sean Willis
- Division of Neurosurgery, SBH Health System, Bronx, NY, USA
| | | | | | - Ralph Rahme
- Division of Neurosurgery, SBH Health System, Bronx, NY, USA; CUNY School of Medicine, New York, NY, USA
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Duddleston PJ, Gendreau JL, Little KA, Andrews A, Thompson WD. Navigation-guided neuroendoscopic removal of an intracranial migratory pellet from the thalamus of a 4-year-old girl. J Neurosurg Pediatr 2020; 26:445-448. [PMID: 32650311 DOI: 10.3171/2020.4.peds19606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/20/2020] [Indexed: 11/06/2022]
Abstract
Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.
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Affiliation(s)
| | | | | | - Amber Andrews
- 2Neurological and Spine Institute of Savannah, Georgia
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Rahimizadeh A. Intracranial Migration of a Broken Rod After Orbitocranial Injury in an Adult. World Neurosurg 2018; 121:232-238. [PMID: 30292033 DOI: 10.1016/j.wneu.2018.09.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Craniocerebral injuries due to the induction of sharp objects are relatively rare and are nearly always observed in the pediatric rather than the adult population. Orbitocranial injuries involving a piece of smooth steel rod are extremely rare and to our knowledge have yet to be reported in previous publications. When this particular category of injury does occur, the invading intracranial foreign body usually remains lodged within its entry position. This is most often near the entry point and within the frontal lobe after penetrating the orbit. Migration of the penetrating object far from the initial entry point is quite rare and has been historically confined to low-velocity bullet wounds. CASE DESCRIPTION An adult man was injured on the right eyelid by a section of steel rod. The rod had entered the cranium through the right orbital roof and was lodged within the corresponding right frontal lobe. An initial plain radiograph showed that the rod was within the right frontal lobe. However, computed tomographic angiography of the brain performed during the second day of admission demonstrated displacement of the rod to the left hemisphere. This finding was clearly demonstrated through subsequent imaging. As a result of the migration, the rod could be distracted fairly easily through a left parasagittal and interhemispheric approach. Postoperatively, the patient made a full recovery. CONCLUSIONS Migration of traumatically introduced intracranial foreign bodies far from their initial entry places should be suspected in objects possessing sufficient weight and a smooth surface. This means that a correct assessment of the final position of such objects is necessary before surgery, even while the patient is on the operating table.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Charry JD, Rubiano AM, Puyana JC, Carney N, David Adelson P. Damage control of civilian penetrating brain injuries in environments of low neuro-monitoring resources. Br J Neurosurg 2015; 30:235-9. [DOI: 10.3109/02688697.2015.1096905] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Luo W, Liu H, Hao S, Zhang Y, Li J, Liu B. Penetrating brain injury caused by nail guns: two case reports and a review of the literature. Brain Inj 2012; 26:1756-62. [PMID: 22823496 DOI: 10.3109/02699052.2012.700085] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To the best of the authors' knowledge, there are few case reports of penetrating brain injuries (PBI) caused by nail guns and these have usually involved incomplete penetration of the skull. Complete penetration of a nail into the intracranial cavity is extremely rare. CASE STUDY Here, two such cases are presented. In the first, the nail entered through the right temporal bone, lodged in the right temporal lobe and was removed via craniotomy with intra-operative ultrasound guidance. In the second, the nail destroyed the left parietal bone, damaged the left internal capsule and lodged in the left temporal lobe near the left petrous apex and the brain stem. According to the latest literature retrieval, this is the first reported case of nail-gun injury to the internal capsule. The position of the nail precluded removal without further neurologic damage. Treatment strategies designed to optimize outcome, with or without surgery, and possible complications are discussed in this report.
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Affiliation(s)
- Wei Luo
- Department of Neurosurgery, Zhongda Hospital, Southeast University, Nanjing, PR China
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Moores LE. Practical Considerations for the Management of Migrating Intracranial Bullets. World Neurosurg 2012; 77:481-3. [DOI: 10.1016/j.wneu.2011.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 07/27/2011] [Indexed: 11/16/2022]
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Rammo RA, DeFazio MV, Ross Bullock M. Management of Migrating Intracranial Bullets: Lessons Learned from Surviving an AK-47 Bullet Through the Lateral Brainstem. World Neurosurg 2012; 77:591.e19-24. [DOI: 10.1016/j.wneu.2011.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 04/25/2011] [Accepted: 06/03/2011] [Indexed: 10/15/2022]
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Misra AP, Gupta A, Awasthi R. Spontaneous relocation of intracranial bullet. INDIAN JOURNAL OF NEUROTRAUMA 2011. [DOI: 10.1016/s0973-0508(11)80013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Unusual penetrating head injury in children: personal experience and review of the literature. Childs Nerv Syst 2009; 25:909-13. [PMID: 19452157 DOI: 10.1007/s00381-009-0901-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 03/30/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION A penetrating head injury belongs to the most severe traumatic brain injuries, in which communication can arise between the intracranial cavity and surrounding environment. DISCUSSION The authors present a literature review and typical case reports of a penetrating head injury in children. The list of patients treated at the neurosurgical department in the last 5 years for penetrating TBI is briefly referred. Rapid transfer to the specialized center with subsequent urgent surgical treatment is the important point in the treatment algorithm. It is essential to clean the wound very properly with all the foreign material during the surgery and to close the dura with a water-tight suture. Wide-spectrum antibiotics are of great use. In case of large-extent brain damage, the use of anticonvulsants is recommended. CONCLUSION The prognosis of such severe trauma could be influenced very positively by a good medical care organization; obviously, the extent of brain tissue laceration is the limiting factor.
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Abstract
AbstractAn important though uncommon complication of retained missiles is that of spontaneous migration. A 22 years young man presented to us with alleged firearm injury to head. The bullet migration was evident on the third day after injury when it was seen lying in the left posterior occipital region as compared to previous posterior frontal location. Softening of contused cerebrum along the missile tract and free weight of the bullet due to gravity were probably responsible for the bullet migration in this case. The patient underwent surgical exploration and progressively recovered. This case report emphasizes the fact that spontaneous migration of a foreign body in side the cranium should be watched for, resulting in damage to vital structures producing significant neurological damage. The presence of migration should be considered to be an urgent indication for surgical intervention.
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Liu SY, Cheng WY, Lee HT, Shen CC. Endonasal transsphenoidal endoscopy-assisted removal of a shotgun pellet in the sphenoid sinus: a case report. ACTA ACUST UNITED AC 2008; 70 Suppl 1:S1:56-9. [PMID: 18789498 DOI: 10.1016/j.surneu.2008.04.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 04/27/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gunshot accidents are not uncommon in Taiwan, but involvement limited to the ocular region and sphenoid sinus is rare. Minimal invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure should be considered if there are no additional injuries in the craniocerebral region. CASE DESCRIPTION A 39-year-old man had severe pain in the left eye with resulting blindness after being accidentally hit in the left eye by a gunshot pellet while walking in a wooded area. He was referred from another hospital with the impression of left eyeball rupture. There was no severe neurologic deficit except for blindness of the left eye when he arrived at the emergency department of our hospital. Brain and orbits CT scans showed a round metallic foreign body at the right sphenoid sinus without predominant damages of brain parenchyma. Endonasal transsphenoidal endoscopy-assisted procedure was used to remove the shotgun pellet, and the patient had good clinical outcomes. CONCLUSION Herein we present this rare case to show the possibility of a shotgun pellet injury remaining in the sphenoid sinus. The role of radiological studies such as CT scans and intraoperative C-arm fluoroscope plain films in diagnosis and management of this case is affirmed. The strategy of minimally invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure for those limited injuries is a good choice for treatment.
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Affiliation(s)
- Szu-Yuan Liu
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung 40705, Taiwan, ROC
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