Migration of the retained intracranial bullet to the spinal canal:  A case report

Milan Lepić; Ljubodrag Minić; Slaviša Stefanović; Nenad Novaković; Aleksandra Lokaj; Goran Pavlićević

doi:10.2298/VSP200315033L

Milan Lepić University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Ljubodrag Minić University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Slaviša Stefanović Military Medical Academy, Clinic for Neurosurgery, Belgrade, Serbia
Nenad Novaković University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Aleksandra Lokaj Military Medical Academy, Clinic for Neurosurgery, Belgrade, Serbia
Goran Pavlićević University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP200315033L

Keywords: head injuries, penetrating, neurosurgery, spinal cord compression

Abstract

Introduction. Retained intracranial missiles migration is rarely reported. Most of the time, the missile will migrate and remain intracranially, but in extremely rare cases, it may reach the spinal canal. The aim of the study was to present a patient with this rare clinical entity. Case report. The 29-years-old male suffered from the gunshot wound to the head through the left external auditory meatus. The bullet was located in the posterior fossa. Initial debridement without bullet removal was performed. Four months after the injury, the patient came back complaining of neck stiffness and progressive weakness of all extremities. Plain radiography revealed the bullet in the spinal canal at the level of C2 vertebra and computed tomography confirmed localization in the posterior aspect. An emergency procedure was performed for bullet removal and spinal cord decompression. Conclusion. The bullets tend to migrate. Migration to the spinal canal is rare, but takes a significant risk, due to the potential secondary injury. The removal of a bullet at-all-costs may not be justified. However, the prediction of migration based on the predisposing factors would be of great value to treating these patients adequately.

References

Aarabi B, Tofighi B, Kufera J A, Hadley J, Ahn E S, Cooper C, et al. Predictors of outcome in civilian gunshot wounds to the head. J Neurosurg 2014; 120(5): 1138−46.

Ecker R D, Mulligan L P, Dirks M, Bell R S, Severson M A, Howard R S, et Outcomes of 33 patients from the wars in Iraq and Afghanistan undergoing bilateral or bicompartmental craniectomy. J Neurosurg 2011; 115(1): 124−9.

Alvis-Miranda HR, M Rubiano A, Agrawal A, Rojas A, Moscote-Salazar LR, Satyarthee GD, et al. Craniocerebral Gunshot Injuries; A Review of the Current Literature. Bull Emerg Trauma 2016; 4(2): 65−74.

Rapp LG, Arce CA, McKenzie R, Darmody WR, Guyot DR, Michael DB. Incidence of intracranial bullet fragment migration. Neurol Res 1999; 21(5): 475−80.

Gönül E, Erdogan E, Îzci Y, Baysefer A, Seber N. Craniocerebral Gunshot Wounds: Analysis of 288 Cases, A Clinical Review. Turk Neurosurg 1999; 9(1−2): 1−7.

Raimondi AJ, Samuelson GH. Craniocerebral gunshot wounds in civilian practice. J Neurosurg 1970; 32(6): 647−53.

Cheng JS, Richardson RM, Gean AD, Stiver SI. Delayed acute spinal cord injury following intracranial gunshot trauma: case report. J Neurosurg 2012; 116(4): 921−5.

Pecirep DP, Hopkins HR. Removal of a bullet from the right heart using controlled embolization to a peripheral vein. Ann Thorac Surg 1994; 58(6): 1748−50.

Vilvandre G, Morgan J. Movements of foreign bodies in the brain. Arch Radiol Electrother 1916; 21(1): 22−7.

Kellhammer G. Geschoßwanderung im Ventrikelsystem. Zbl Chir 1939; 66: 1773−6. (German)

Arasil E, Tascioglu AO. Spontaneous migration of an intracranial bullet to the cervical spinal canal causing Lhermitte's sign. Case report. J Neurosurg 1982; 56(1): 158‒

Medina M, Melcarne A, Ettorre F, Barrale S, Musso C. Clinical and neuroradiological correlations in a patient with a wandering retained air gun pellet in the brain. Surg Neurol 1992; 38(6): 441‒

Young WF, Jr., Katz MR, Rosenwasser RH. Spontaneous migration of an intracranial bullet into the cervical canal. South Med J 1993; 86(5): 557‒

Traeger M, Wood BP. Radiological cases of the month. The migrating BB and the medicine man. Am J Dis Child 1993; 147(8): 901‒

Rajan DK, Alcantara AL, Michael DB. Where's the bullet? A migration in two acts. J Trauma 1997; 43(4): 716‒

Castillo-Rangel C, Reyes-Soto G, Mendizabal-Guerra R. Cranio-thoracic bullet migration over a period of 27 years: case report. Neurocirugia (Astur) 2010; 21(4): 326−9.

Karim NO, Nabors MW, Golocovsky M, Cooney FD. Spontaneous migration of a bullet in the spinal subarachnoid space causing delayed radicular symptoms. Neurosurgery 1986; 18(1): 97−100.

Lough EG, Glover B, Brown AL. An unusual case of air rifle pellet migration from the brain to the thoracic spine. Am Surg 2013; 79(1): E33−4.