J. Neurosurg. / Volume 32 / June, 1970

Shotgun Pellet Embolus of the Middle Cerebral Artery*
Case Report
JOHN C. VAN GILDER, M.D., AND WILLIAM S. COXE, M.D.
Division o[ Neurosurgery, Washington University School o/Medicine, St. Louis, Missouri

could be seen to account for direct penetration. A left percutaneous common carotid
angiogram disclosed occlusion of the left
middle cerebral artery by a pellet lodged approximately 1.5 cm distal to the bifurcation
of the internal carotid artery (Fig. 1). There
was delayed filling of the Sylvian triangle
through collateral arterial anastomosis from
the anterior cerebral artery, with retrograde
flow to the site of obstruction (Fig. 2).
Operation. Following the angiogram, a
left frontotemporal craniotomy was performed. The brain did not appear discolored
Case Report
On January 6, 1968, this 21-year-old or hemorrhagic, and no evidence of cranial
right-handed man was shot at close range in penetration by the shot was found. The midthe left side of the head and neck with a dle cerebral artery was exposed by splitting
shotgun. When examined by his family doc- the Sylvian fissure, and the pellet identified.
tor 30 minutes later, he was comatose with a The vessel appeared dilated and red proximal to the occlusion, but narrow and blue
right hemiplegia.
Examination. On admission to the John J. distally. The vessel wall was distended and
Cochran Veterans' Hospital 7 hours after in- thinned at the metallic fragment locus. Mayfield temporary clips were applied to either
jury, the patient's blood pressure was 120/
70, pulse 72, and respirations 22. There side of the occlusion; a 6 mm longitudinal
were multiple pellet entry sites about the left arteriotomy was necessary for extraction of
side of the face, scalp, and neck; a large la- the metallic fragment. Following removal
ceration of the nose; and an anterior there was good backflow from the distal seghyphema of the left eye. Both carotid arte- ment, and the opening was closed with a 7-0
ries had good pulsations, and no bruits were continuous silk suture. Upon release of the
clamps, the vessel appeared bright red distal
audible.
to
the previous obstruction. A slight conThe patient had a global aphasia. The pupils were equal and reacted to light, the left striction observed at the site of arteriotomy
more sluggishly. A severe right hemiplegia was not altered by topical application of
was evident, the only movement being inter- phentolamine (Regitine). Surgery was connal rotation of the arm in response to painful cluded 11 hours after the injury.
Postoperative Course. After awakening
stimuli. The right side was areflexic except
from
anesthesia, the patient had minimal
for a minimal brachioradialis reflex. There
right
leg
movement but no change in the
was a right Babinski sign. He moved the left
flaccid
paralysis
of the right arm. By the 5th
side purposefully and with good strength.
Skull films showed multiple No. 2 buck- postoperative day, he was alert and walking
shot subcutaneously in the face, scalp, and with aid. A left percutaneous arteriogram, 8
neck. Stereoscopic views suggested that one days after surgery, showed patency of the
pellet was intracranial, but no bone defect left middle cerebral artery with slight constriction at the arteriotomy site (Fig. 3).
The right hemiparesis gradually improved,
Received for publication July 1, 1969.
* Aided by a grant from the Allen P. and and he walked unassisted with a hemiparetic
Josephine B. Green Foundation.
gait. At discharge on February 29, 1968, the
711

ASES of middle cerebral artery endarterectomy or embolectomy for arterial
occlusion secondary to a plaque or
thrombotic emboli have been documented. ~,~,~,8,~,~-~ However, reports of intracerebral emboli by foreign bodies incident to
extracranial penetrating wounds are r a r e Y ,~~
We report a case of successful embolectomy
of a metallic pellet to the middle cerebral
artery following a shotgun wound to the
head and neck.

C

712

John C. Van Gilder and William S. Coxe

FIG. 1. Preoperative left carotid angiograms, arterial phase. The left middle cerebral artery is completely occluded by a metallic fragment (arrows) distal to the anterior temporal branch. Multiple buckshot are present in the soft tissue of the scalp and face. Le/t: Anteroposterior view following cross compression with filling of the right middle cerebral artery. Right: Lateral view.
patient was able to say a few monosyllabic
words. His verbal reception and intellect
were good. A severe paresis of the right arm
continued, with only minimal shoulder and
elbow movement.
When examined on March 16, 1969, the
patient could enunciate multisyllabic words
and three- to four-word phrases dearly.
Speech reception, visual interpretation, and
reading were normal, and he was totally independent for self-care. His gait had a slight

steppage quality. There was good voluntary
shoulder and elbow motion, but only minimal finger and wrist movement.
Discussion
It was disappointing but not surprising
that more dramatic neurological improvement did not ensue postoperatively. The
time required and the quality of recovery
were comparable to that which might have
h a p p e n e d spontaneously2 However, with

FIG. 2. Preoperative left carotid angiograms, late venous phase, demonstrating retrograde filling of
the left middle cerebral artery to the point of obstruction. Le/t: Anteroposterior view. Right: Lateral
view.

Shotgun Pellet Embolus

713

Fro. 3. Postoperative left carotid angiograms, arterial phase. LeJt: Anteroposterior view showing
constriction of the middle cerebral artery (arrow) immediately distal to the anterior temporal branch
at the site of arteriotomy. The pericallosal artery is shifted to the right secondary to postoperative edema.
Right: Lateral view.
restoration of normal circulation, areas of
marginal ischemia m a y have been saved and
neurological i m p r o v e m e n t enhanced.
T h e r e are other indications for removal of
this type of vascular obstruction. If the pellet
remains, it could conceivably erode the thinned out and stretched arterial wall so as to
produce intracranial hemorrhage; however,
previously reported instances of h e m o r r h a g e
secondary to vessel erosion and rupture by a
foreign b o d y have been limited to larger and
extracranial vessels. ~ Another consideration
is the possible failure of collateral circulation
at a later time, thus producing additional
neurological deficit.
In a similar case, Piazza and Gaist TM
milked the pellet b a c k downstream into the
distal internal carotid artery, and occluded
that vessel distal to the foreign object. Circulation through the middle cerebral artery was
reestablished via collaterals f r o m the o p p o site side. It appears to us that e m b o l e c t o m y
is preferable since additional ischemia might
occur f r o m internal carotid ligation.
I n o u r case, the pellet did not enter the
skull, and the site of penetration into the extracranial vasculature is unknown. There
was no h e m a t o m a in the neck and no evidence of irregularity of the distal c o m m o n or
internal carotid arteries by angiography. T h e

location of m u c h of the buckshot suggests
that the penetration m a y have occurred
proximal to the location of the needle in the
c o m m o n carotid artery.

Summary
The unusual occurrence of a metallic embolus in the middle cerebral artery following
a gunshot wound to the head and neck has
been reported. T h e patient had a severe right
hemiplegia and aphasia. E m b o l e c t o m y resuited in postoperative patency of the artery
and clinical improvement.

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