Interesting question ...

I believe there can be no single specific answer to this question. The treatment of intracranial foreign body is aimed at preventing subsequent brain injury that might further limit recovery. There are reported cases of migrating bullets when the bullets are left behind. So follow up might be required on a regular basis.

The case details are not complete and except for the fact that the victim is 60 year old, no other information is available. I think the rest of the case details got deleted by mistake. It is very difficult to comment with just this information about the case. For example, if the patient is asymptomatic and it's an old bullet it might be best left as it is. Or if the patient has minimal morbidity, surgical removal might be more traumatic and risky. The current neurological deficitis and symptoms might be relevant for planning the treatment. In short, without full case information, it is very difficult to comment on this case.

Regards

Dr. Akilesh R

India

Dear Akilesh Ramasamy,

thank you very much for your kind response.

I'm sorry for my careless: I want to give you more details about this patient.

He was victim of an unwitnessed gunshot the day before hospital admission and he received about 120 bullets in the body: the major number of bullets was in the abdomen, some in the right lung (4-5 bullets) and just 1 in the heart (the right side of the interventricular septum). No bullet in the brain.

He had no symptoms except for trivial reduction of hemoglobin levels. No pericardial effusion was detected and he had no arrhythmias. No signs of bleeding were detected by CT scanning. Thus, considering that he did not suffer of cardiac symptoms and because of the location of the bullet in the heart (right side of the interventricular septum), we decided for avoiding surgery. In fact, even in case of bullet migration from the interventricular septum, patient can suffer of pulmonary embolism caused by a 2 mm bullet.

Patient was discharged two weeks ago and he had no further complications. 

Best regards

Fabrizio Sansone, MD 

Thanks for the details.

Error on my part as well ... I had erroneously assumed this interventricular septum is that of the brain being mentioned as the question was categorised under "Maxillofacial Injury".and thought it was an intracranial projectile via facial gun shot wound!

At the outset, the man has been extremely lucky I'd say ... And cardiac projectiles are by far rare in occurence. The mangement is still controversial!

Disclaimer: And I am not a thoracic surgeon. I am a craniomaxillofacial surgeon. I am taking part in this discussion as an academic exercise only based on literature search. So, if there are any errors, I request you to kindly forgive my error and point them out. Thanks in advance.

The patient was and is hemodynamically stable. No cardiac symptoms (ECG Normal) No arrythmias or murmurs I believe. A follow up to find out about his current cardiac symptoms is warranted. On this note, I believe the bullet is located in the myocardium. Interestingly, such bullets may be tolerated.(From what I understand from literature).

Symbas PN has published two articles of which one is an excellent review on foreign objects in the heart including bullets and bullet fragments.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1358242/ (full text)

http://www.ncbi.nlm.nih.gov/pubmed/2764610

Most literature seem to point out that with asymtomatic cases, it might be prudent to follow a conservative method of management with follow up. The risk of surgery might be too much especially in this case with a patient aged > 60 years. Inspite of the proven presence of the projectile, it might be difficult to localize the projectile precisely and literature has many cases where the projectile was not localized in the operating table. In our case, we might require intra operative imaging for more precise localization of the projectile for successful retrieval.

http://www.fac.org.ar/1/revista/14v43n1/casclin/caclin03/marelli_ingles.php

If there is no intracardiac shunt due to the trauma and the bullet is lodged in the myocardium a conservative management might be adopted.

http://circ.ahajournals.org/content/100/12/1361.full

This case report discusses a case where the patient is operated but the bullet was not removed. It was left behind.

http://www.scielo.br/scielo.php?pid=S0102-76382005000100020&script=sci_arttext&tlng=en

The risk of retaining the bullet is that there have been cases of saturnism (lead poisoning). This needs to be considered as well.

I believe getting in touch with army hospitals/specialists might be a good idea. Jonathan Lundy has published a review with case report of conservative management of intracardiac missiles. http://www.jsurged.org/article/S1931-7204%2809%2900062-2/pdf (jonathan.lundy at amedd dot army dot mil)

With today's imaging capabilities and low risk of cardiac surgeries, removal may be attempted if there is good support for intra operative imaging (CT) for larger projectiles, intrapericardial projectiles or those partially embedded in the myocardium, with the aim of preventing possible complications. Ref: http://www.scielo.br/scielo.php?pid=S0102-76382005000100020&script=sci_arttext&tlng=en

But the risk - benefit ratio needs to be assessed and treatment plan individualised.

And at 2mm, the bullet, as you mentioned rightly, has the chance of becoming a pulmonary embolus. Reports of migratory bullets have been published even 30 years ago. http://www.ncbi.nlm.nih.gov/pubmed/371424

Older literature seem to have followed a more aggressive approach while recent literature seems to suggest conservative approach may be adopted but that the decision has to be individualized.

Personally, I think a wait and watch approach might be warranted if the projectile is firmly and completely embedded. Others might require removal Ref: http://www.ncbi.nlm.nih.gov/pubmed/3418770 but the decision has to be individualized.

Please keep me posted on how things go with this case. I'd be interested.

Regards,

Dr. Akilesh R

India

Thank you very much for your excellent review of the literature.

Best regards

You are most welcome, Sir