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Neurology India, Vol. 58, No. 1, January-February, 2010, pp. 151-152 Letter To Editor Intracranial moving bullet syndrome Alok A. Umredkar, Sandeep Mohindra Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India Correspondence Address: Alok A. Umredkar, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, alokumr@yahoo.co.in Date of Acceptance: 23-Oct-2009
Code Number: ni10041 DOI: 10.4103/0028-3886.60422 Sir, Moving bullet within the brain parenchyma is rarely reported. There are a few case reports in the literature exhibiting intracerebral bullet migration, causing progressive neurological deficits. [1],[2],[3] The present report describes a unique case of bullet impaction within the brain parenchyma and its dynamic movement, without any added neurological deficits. A 39-year-old male suffered a gunshot injury and an open wound at the frontal region. The open wound was sutured, which healed well, and the patient was referred to a higher center. A computed tomography (CT) scan at that time revealed a bullet in the posterior frontal cortex, just lateral to the midline [Figure - 1]. As the patient was asymptomatic, no intervention was undertaken. At 5 months of follow-up, the patient underwent check CT scan, which showed bullet migration to the right parieto-occipital region, away from the midline [Figure - 2]. Again, the asymptomatic state of the patient prevented us from undertaking bullet extraction. At 2.5 years of follow-up, the patient remains symptom free. Spontaneous movement of bullets within the brain has been reported sporadically. The removal of intracerebral bullets is obviously warranted in patients undergoing craniotomy or craniectomy for debridement or evacuation of intracerebral clots or bone fragments if the metallic fragment is in proximity to the operative site. [1] Further, neurologic deterioration and diagnostic CT imaging may indicate surgical removal of the bullet. [2] The bullets in the brain may migrate into the adjacent lateral ventricle and move freely as a consequence of gravity. [3] This spontaneous migration of intracerebral bullets is influenced by cerebral softening, the specific gravity of the bullet compared with brain tissue and the sink function of the cerebral ventricles. [3] Hence, it is not only the fire-arm injury but also any foreign body, with a different density as compared to the brain and cerebrospinal fluid, that will migrate intracerebrally. The decision of nonsurgical management is more likely in case of high-velocity bullet injury due to the sterile nature of the bullet. The risk for late complications increases with organic wooden foreign objects such as tree branches and pencils that can harbor bacteria and fragment during removal. [4] Bullet fragment emboli are uncommon, and there have been only a few reports of intracranial-to-extracranial migration of these fragments. [5] Few reports of movement of hemostatic clips from the ventricles through the aqueduct to the lumbar spinal canal have been described. [6] The potential for further neurological injury from migration, formation of neurotoxic breakdown products and the danger of infection are factors to be assessed when considering the removal of retained intracranial metallic foreign bodies. [7] Hence, we open the debate of managing the migrating bullet patient nonsurgically, lest there are neurological deficits. In conclusion , the extraction of an asymptomatic, moving bullet is not warranted. These patients may be put on regular follow-up. The migration of the bullet should be kept in mind whenever surgical removal is being undertaken. References
Copyright 2010 - Neurology India The following images related to this document are available:Photo images[ni10041f1.jpg] [ni10041f2.jpg] |
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