Missile embolism - pulmonary vein to systemic bullet embolism

A 32-year-old man sustained a close-range low-calibre gunshot injury to the anterior left chest. He was admitted comatose and shocked. The chest radiograph was normal. A provisional diagnosis of cardiac injury was made and the patient was immediately taken to theatre as part of the resuscitation process, where a trans-oesophageal echocardiogram (TEE) was found to be normal. Thoracotomy was therefore avoided and the patient was admitted to the intensive care unit for further management. He regained consciousness in the morning, but had a dense left-sided hemiplegia, expressive dysphasia and retrograde amnesia. Two months later he presented with additional symptoms of right-sided neck pain, worse on turning his head to the right, occasional left chest pain, and grand mal epilepsy controlled with phenytoin. Both carotid pulses were palpable. Right-sided intracranial embolisation was suspected, and the patient was assessed accordingly. On imaging with fourvessel angiography and computed brain tomography, a bullet was noted in the right internal carotid artery with no distal flow, the circle of Willis was patent, and a right frontoparietal infarct was seen on the brain scan (Figs 1 and 2). Conservative management was pursued with analgesics and phenytoin, but the patient continued to request the removal of the bullet because he could not tolerate the neck pain. The bullet was surgically removed 7 months after injury under local anaesthesia. At operation a marked inflammatory reaction at the bullet site in the proximal internal carotid artery was found. The common and external carotid arteries were patent and proximal and distal control on the common carotid and external carotid artery was obtained. Direct transverse arteriotomy was done on the internal carotid artery where the bullet could be felt. The bullet was retrieved with the segment of vessel it had impacted in, and the internal carotid artery was ligated. Immediately postoperatively there was a dramatic (though transient) complete recovery of the left hemiplegia and expressive dysphasia. At the time of writing the patient was continuing to take phenytoin daily, his speech was normal and he had mild residual left hemiparesis. Histological Missile embolism – pulmonary vein to systemic bullet embolism