Delayed intracerebral hemorrhage from an extracranial ball bullet pellet

The evaluation of superficial penetrating injuries to the face and scalp is common in the emergency department. We present a patient who presented with a ball bullet pellet to the forehead with an initially negative computerized tomographic (CT) scan of the head, who represented 18 hours later with nausea, vomiting, and mental status changes. A repeat CT scan of the head revealed intraparenchymal hemorrhage immediately posterior to the site of pellet entry. Upon review, the initial CT scan was limited by scatter artifact. In this case report, we discuss the potential for significant injury with compressed air-driven arms, the limitation of CT in the presence of metallic foreign bodies, and the significant risks associated with pediatric radiation exposure.