Craniocerebral gunshot injury bullet migration to the cardiac right ventricle

Missile embolism is the process of slow velocity projectiles penetrating into vascular spaces followed by arterial, venous, or paradoxical embolism of the fragments. This is a rare complication in craniocerebral gunshot injuries (CGI), with only five other cases previously published demonstrating pulmonary or arterial emboli from these injuries. There is a high rate of mortality from these injuries.

A patient presented with a CGI from an occipital trajectory, causing penetrating fragments into the venous sinus system. The weapon was a Glock Model 17M 9 mm with a hollow-point bullet, fired close range. Initial chest X-ray demonstrated only atelectasis. After stabilization, 18 min from the initial chest X-ray, subsequent computed tomography (CT) imaging demonstrated extensive intracranial injuries and fragmentation of the bullet with the expected devastating intracranial injuries. Unexpectedly, chest CT revealed metallic fragments in the right cardiac ventricle which was redemonstrated on follow-up chest X-ray. Unfortunately, his extensive intracranial injuries and poor clinical status were nonsurvivable, and thus the family elected to discontinue supportive measures.

This case demonstrates radiographic imaging of a metallic intravascular fragment from CGI through presumed transvenous mechanisms. The imaging provides a consistent timeline demonstrating migration can occur in the acute phase. This study additionally supports the presumed mechanism for pulmonary of migration through the right heart. Fragment embolization should be considered in cases of acute deterioration in this patient population.