A B S T R A C T

STRAY BULLET PENETRATING DEEPINTO BRAIN WITHOUT CAUSING

NEUROLOGICAL DEFICIT

Key words Stray bullet injury, Missile injury – brain, Firearms.

MIRAJ US SIRAJ

INTRODUCTION:Physicians have been challenged by the penetratingwounds to the head since antiquity.1 within a fewhundred years of Mongol’s bringing gun powder toEurope from China in the 1300s, a firearm wasinvented that could propel a projectile at 1000 ft/secand could inflict previously unimaginable wounds.2

Bullet injury to the head accounts for majority of thepenetrating wounds of the brain and is responsiblefor a significant number of deaths. The exact dataof missile injury to the brain is not known in Pakistanat present.

There are very few cases reported in medicalliterature regarding stray bullet penetrating into theskull and brain and even much less number of caseswhere bullet penetrated so deep into the brain causingvirtually no neurological deficit in the patient. Hereinwe present one such case.

CASE REPORT:A 12years old boy presented in emergencydepartment with history of loss of consciousness forfive minutes. Detailed history revealed that 6 daysback the boy suddenly fell unconscious on the groundafter getting an injury on his skull by some hardobject while playing outside his home. Blood trickled

Correspondence:Dr. Miraj Us SirajDepartment of NeurosurgeryFoundation University Medical College & HospitalRawalpindi, Pakistan.E. mail: musiraj@hotmail.com

down his face and he regained consciousness afterfew minutes. He was taken to a general practitionerwho stitched a wound on parietal region of scalp.

On examination patient was generally well andhaemodynamically stable with Glasgow Coma score(GCS) of 15/15 with no focal neurological deficit. X.rays skull (AP and Lateral) was performed whichshowed a bullet in his skull (Figure I, I a). He wasadmitted in the neurosurgery ward for observationand further investigations. CT scan of the brainshowed a large bullet deep in brain, near to themidline in the medial part of left parietal lobe(Figure II). Patient was kept under neuro-observationfor two weeks in the hospital. He did not developany neurological deficit or fits or any other symptom.Patient was managed conservatively and dischargedafter two weeks. At two years follow up he remainedwell.

DISCUSSION:Stray bullets injuries are not uncommon in Pakistan.Most of these bullets are fired in the air at the timeof wedding ceremonies. These bullets can causeserious damage to the brain with disastrousconsequences. Stray bullet injuries to the brain withno neurological deficit are very rare. There is plentyof literature available on the bullet injuries in generalbut very few cases reported in the medical literatureabout stray bullets. Most of the cases are found isin the newspapers.

The conservative management of penetrating bulletinjuries to the brain without intracranial surgery in aselected patient population is a reasonable option.5

Bullet or missile injuries to skull and brain are not uncommon. Management of missileinjury to brain and skull are described in detail in various texts available. Deep penetratinginjury to the brain due to stray bullet causing no neurological deficit is exceptionally rare.This is a case of 12 years old boy who presented with stray bullet that penetrated deepinto the brain without neurological deficit. He was managed conservatively and is doingwell two years following injury.

Journal of Surgery Pakistan (International) 15 (2) April - June 2010

CASE REPORT

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In literature there is an evidence of conservativemanagement with a simple closure of scalp woundand the bullet left as it is in the brain.6 Consideringthe fact that it is very difficult or sometimes impossibleto remove the bullet which is deeply seated in the

brain without having catastrophic consequences perand post operatively, our patient was managedconservatively.

This rare case highlights that modern day surgeonstreating trauma patients should be aware of thiscondition happening and high index of suspicionshould be maintained in patients presenting withbleeding scalp wound with no significant historyavailable. Radiological investigations like plain x-ray skull should be obtained in all patients suspectedof intracranial missile injuries.

REFERENCES:

1 Breasted JH. The Edwin Smith SurgicalPapyrus. Chicago: University of ChicagoPress, 1930.

2: West CGH. A short history of the managementof penetrating missile injuries of the head. SurgNeurol 1981; 16;145-9.

3. Taha JM, Saba MI, Brown JA. Missile injuriesto the brain treated by simple wound closure:results of a protocol during the Lebanese conflict.Neurosurgery 1991;3:380-3.

4. Singh P. Missile injuries of the brain: results ofless aggressive surgery. Neurol India2003;51:215-9.

5. Taha JM, Saba MI, Brown JA. Missile injuriesto the brain treated by simple wound closure:results of a protocol during the Lebaneseconflict. Neurosurgery 1991 Sep; (3):380-3;discussion 384.

6. Singh P. Missile injuries of the brain: resultsof less aggressive surgery. Neurol India 200351:215-9.

Miraj Us Siraj

Journal of Surgery Pakistan (International) 15 (2) April - June 2010

Fig-I, Ia: X-ray skull AP and Lateral views showingbullet.

Fig-II: CT Scan showing bullet in braintissue.

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