Gunshot pellet embolus
to the middle cerebral artery
Amine BAHNINT, MD, Christian PETITJEAN, MD,
Edouard KIEFFER, MD, Paris, France

A 24-year-old man sustained a gunshot wound to the upper right hemithorax and neck, with
injury to the subclavian and carotid arterles. A cerebral artery pellet embolus resulted in
contralateral hemiplegia. The injured vessels were repaired, but the middle cerebral artery pellet was left undisturbed. Neurologic improvement occurred. Fifteen cases of foreign body embolus to cerebral vessels are reviewed and the management of this unusual injury is discussed. (Ann Vasc Surg, 1986, 7, 139-142).
KEY-WORDS : Carotid artery injuries. - Cerebral artery embolus.

Metallic embolus to cerebral vessels is a very rare
event, usually following low velocity missile wounds
to the thorax or neck. Only 15 cases have been published in the international literature. An additional
case of metallic cerebral embolus following a cervico-thoracic gunshot wound is reported here.
Conservative management without embolectomy resulted in partial resolution of the neurologic deficit.
CASE REPORT
A 24-year-old man was wounded in the chest and neck by a
shotgun blast on August 10, 1983. He was found six hours after
the injury and was immediately transported to our institution. On
arrival to the emergency room, the patient was conscious. Vital
signs were stable. There were multiple punctate wounds on the
upper right hemithorax and right side of the neck and face. A
large dense cervical hematoma was present. Physical examination
disclosed a complete left hemiplegia. Radiographs demonstrated
numerous metallic pellets overlying the upper part of the right hemithorax, the right supraclavicular space, the upper neck, face,
and scalp. Emergency right brachial retrograde arteriography dis-

From the Service de Chirurgie Vasculaire, Groupe Hospiialier
Piti&Yalp&tritre,Paris FRANCE.
Reprint requests : E. Kieffer, MD, Service de Chirurgie Vasculaire. Groupe Hospitalier Pitier-Salpitriere, 47-83, boulevard de
l’H6piia1, 75651 Paris Cedex 13, FRANCE.

closed an irregular margin of the right common carotid artery
(CCA), 4 cm above its origin (Fig. 1). The right middle cerebral
artery (MCA) was occluded by a pellet lodged 1.5 cm distal to
the bifurcation of the internal carotid artery (ICA) (Fig. 2). An
emergency Computed Tomographic Scan (CT scan) demonstrated the metallic foreign body in the Sylvian fissure (Fig. 3). Chest
radiographs showed a pellet in the right ventricle.
Following consultation with the neurosurgical team, MCA embolectomy was not performed because the hemiplegia had been
present for eight hours. An emergency operation was performed
to repair the other vascular injuries. Right presternomastoid and
supraclavicular incisions were used. The right subclavian artery
was injured by two punctate wounds, 0.5 cm distal to origin of
the vertebral artery. This injury was repaired by resection with
end to end anastomosis. The right jugular vein and right common
carotid artery were pock-marked N with contusion over a 2 cm
distance. Jugular vein wounds were treated by simple suture. The
common carotid artery was repaired by resection of the injured
segment and interposition of a saphenous vein graft. No esophagcal or tracheal injury was encountered. Thc brachial lexus was
intact. The pellet in the right ventricle was left undisturled.
((

The postoperative course was complicated by severe adult respiratory distress syndrome necessitating tracheostomy and mechanical ventilation. The patient developed tracheal stenosis that was
treated by laser and later by tracheal resection. The left hemiplegia gradually improved. At five months following the injury, residual right upper extremity paresis was the only neurologic deficit.
Repeat CT Scan showed a frontoparietal infarct involving the superficial territory of the middle cerebral artery and capsulo-lenticular area (Fig. 4).

140

P E L L E T EMBOLUS T O M I D D L E C E R E B R A L A R T E R Y

Fig. 1. - Right brachial retrograde arteriogram showing h e gularities of right common carotid artery wall (arrow).

DISCUSSION

ANNALS
OF
VASCULAK SUKGFKY

-

Retrograde right brachial arteriogram showing pelFig. 2.
let embolus in middle cerebral artery (arrow).

delays have been reported ranging from a few days
[8, 121 to several months [4]. These delays can be
explained by the various mechanisms in vascular inMissile embolus to peripheral arteries is a rare
Immediate embolization occurs from direct
event with only one hundred cases reported [15]. jury.
puncture of the vessels, while delayed migration is
The cerebrovascular location is of particular interest more likely caused by a pro ressive erosion of the
because of the importance of the cerebral structures vascular wall by the missile ['7f
and difficult access to intracranial vessels. Fifteen
cases of metallic foreign body embolism in cerebral
Central neurologic deficit after a cervical wound
vessels have been reported [l-141 (Table). The penetrating agent has been in all cases a small, low-ve- usually means interruption of cerebral blood flow by
locity missile (shotgun pellet, airgun pellet, metallic direct injury of a major cervical artery [16]. Howefragment). Metallic foreign body penetration sites ver, the possibility of an embolus should be kept in
are equally distributed between the chest and the mind, If the patient is stable, emergency arteriograneck. The exact location of the original vascular in- phy is indicated to provide information about the
jury is not always known because not all cases have type and site of injury [16, 171.
been explored. In those patients wounded in the
The most common site of cerebral artery embolineck, the vascular penetration site is presumably the
carotid artery. For those wounded in the chest, the zation has been the middle cerebral artery resulting
metallic foreign body can reach the cerebral vessels in a contralateral deficit. The common carotid artery
via the aorta, the supraaortic vessels, the left ventri- was involved in one case [2] and the intracranial carotid artery in three cases [7, 8, ll]. In this latter
cle, or even the pulmonary veins [4, 151.
group, only one patient developed a monoparesis.
Although cerebral embolization often occurs ra- Multiple emboli can occur [ l ] as in the case reported
pidly following the trauma [l, 3, 4, 131, significant here.

VOLUME1
No 1 - 1986

PELLET EMBOLUS TO MIDDLE CEREBRAL ARTERY

141

-

Fig. 3.
CT scan showing
pellet embolus in Sylvian fissure.

-

CT scan 5 months
Fig. 4.
post-injury showing frontoparietal infarct (arrows).

TABLE I . - Review of cerebral artery emboli of metallic foreign objects.

* Delayed treatment for a false aneurysm ; R : right ; L : left ; MCA : middle cerebral artery ; CCA : common carotid artery ; ICCA : intracranial carotid

artery ; ECA : external carotid artery.

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PELLET EMBOLUS TO MIDDLE CEREBRAL ARTERY

Despite the well-known risk of conservative management of vascular trauma, only five of the 15 reported cases had an operation on the injured vessels. One of them was operated three months
following injury for a false aneurysm of right
common carotid artery. Three niddle cerebral artery embolectomies [4, 131 and one common carotid
artery embolectomy [13] have been reported. Aggressive treatment has not resulted in a better outcome when compared with conservative management of the cerebral embolic injury. Time delay between migration and embolectomy is of crucial importance. In the case reported here, conservative
management of the middle cerebral artery embolus
was chosen because of the eight hour delay between
the accident and the operation. The need for cerebral intravascular metallic foreign body extraction is
theoretically supported by the benefit of re-establishing cerebral blood flow, subxquent extension of
the infarct 4, 131 and the risk of infection or vascular erosion 181. Although vascular erosion has been
documented in the great vessels of the thorax and neck
[18], it has never been reported in intracranial vessels. It is concluded that embolectomy is indicated if
performed in the immediate post-migration period.

1

REFERENCES
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2. CEBALLOS R., RONDEROS A. - Shotgun pellet embolus of the
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3. DOWZENKO 0. - Rare case of embolus to middle cerebral artery
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ANNALS
OF
VASCULAR
SURGERY

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middle cerebral artery. J Neurosurg, 1970,32, 71p-714.
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BAHNINI A ., PETITJEAN C., KIEFFER E. - Embolia de
un perdigon de caza en la arteria silviana.
Ann Vasc Surg, 1986, 1, 139-142.

RESUMEN : Son escasas las publicaciones de embolias arteriales intracraneales por cuerpo extraiio
metAlico. Se trata de un var6n de 24 afios con heridas puntiformes multiples por perdigones de caza,
afectando el lado derecho del torax, cuello y cara.
A1 ingreso en el hospital se aprecio hematoma cervical y hemiplejia izquierda completa. Mediante angiografia, TAC y radiologia simple se diagnosticaron
lesiones de las arterias carotida primitiva y subclavia
derechas, embolia de la cerebral media y presencia
de un perdigon en el corazon a nivel del ventriculo
derecho. No se evidenciaron lesiones traqueales ni
esofagicas. Se corrigieron quirurgicamente las lesiones arteriales mediante reseccion segmentaria y las
yugulares por sutura simple. Se descarto cualquier
actuacion sobre la cerebral media dado el tiempo de
evolucion de la hemiplejia (8 horas). En el postoperatorio se present6 una neumopatia severa y estenosis traqueal recidivante que precis0 reseccion segmentaria de la misma. Neurologicamente remitio la
sintomatologia del miembro inferior, persistiendo
paresia del superior. Se han hallado publicados 15
casos de embolismos de similares caracteristicas,
provocados todos ellos por proyectiles de baja velocidad. La clinica neurologica ha aparecido inmediatamente despuCs del accidente o tardiamente segun
la embolia haya sido instantanea o tras erosion de la
pared del vaso. La arteria afectada con mayor frecuencia ha sido la cerebral media. No se han apreciado mejores resultados neurologicos en 10s casos
de tratamiento neuroquirurgico agresivo respecto a1
tratamiento conservador.

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