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Shotgun pellet embolization to the posterior cerebral artery
Michael M McDowell1, Xiao Zhu2, Steven Johnson2
1Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, B-400, Pittsburgh, PA, 15213, USA. Mcdowellmm2@upmc.edu.
Insights
A rare case of a pediatric pellet embolus to the posterior cerebral artery occurred after a shotgun blast. Conservative management led to a good recovery, highlighting a less invasive approach for select cases.
Area of Science:
- Neurology
- Vascular Surgery
- Pediatric Medicine
Background:
- Projectile embolization typically affects the anterior cerebral circulation due to arterial anatomy.
- Embolic events in pediatric cerebral vasculature are exceptionally rare.
Observation:
- A 9-year-old boy sustained a shotgun injury with a pellet migrating to the posterior cerebral artery.
- The pellet lodged in the P3 segment of the posterior cerebral artery via the vertebrobasilar system.
Findings:
- The patient developed a small occipital infarct and right superior quadrantanopsia.
- Conservative management with anticoagulation and antiplatelet therapy resulted in stable neurological condition at 2-year follow-up.
- The embolus remained in place without complications.
Implications:
- This is the first reported non-fatal missile embolus to the posterior cerebral artery in a child.
- Conservative management may be a viable option for pediatric patients with minimal symptoms and stable emboli, avoiding risks of surgical intervention.
Introduction:
Projectile embolization to the cerebral vasculature and is almost exclusively seen in the anterior circulation due to the greater diameter and flow of the internal carotid arteries. In children, this phenomenon is ever rarer.
Methods:
We present a case of a 9-year-old boy who suffered from a shotgun blast to the thorax and abdomen. He was subsequently found to have a pellet that had presumably traveled from either the left ventricle or directly via the subclavian artery to the vertebrobasilar system to become lodged in the P3 segment of his posterior cerebral artery.
Results:
The patient developed a small occipital infarct with a corresponding right superior quadrantanopsia. He was managed as an inpatient non-operatively with a heparin drip and was placed on long-term low-dose aspirin on discharge. The patient recovered well from his injury and remains neurologically stable 2 years after the initial injury. Interval imaging demonstrated that the pellet remains stable in its position.
Discussion:
To our knowledge, this represents the first non-fatal missile embolus to the posterior cerebral artery in a pediatric patient. Patients with minimal symptoms may benefit from conservative management given the inherent risks of embolectomy.