Delayed cerebral embolization of a shotgun pellet with fatal consequences

A case of shotgun pellet embolization to the middle cerebral artery is presented. Embolization occurred approximately 36 hours following successful resuscitation of blood pressure, respirations, and neurologic function in a 21-year-old man who had sustained a massive chest wound. The diagnosis of pellet embolization was made within 8 hours of the onset of neurologic deficits; however, fatal cerebral infarction had occurred before surgery could be undertaken. Seven similar cases are briefly reviewed and it is concluded that low velocity and low kinetic energy missiles are more likely to embolize, and that left lower extremity injuries are more frequently involved in embolization. In all cases of shotgun trauma to the chest cerebral embolization of pellets should be considered at any sign of neurologic change and skull films obtained. Surgical intervention is necessary before cerebral infarction.