The trajectory of a low-velocity bullet from the chest to the pituitary gland

Abstract

The diagnosis and treatment of gunshot injuries requires an understanding of the trajectory of the bullet in each individual case. The majority of gunshot wounds present with easily understandable trajectories resulting in a concise, stream-lined work-up. Occasionally, the initial work-up may reveal a trajectory that is atypical. This can be due to internal bullet deflection, bullet embolism, or bullets that traverse multiple body cavities. Here we present the case of a gentleman who was shot in the left posterior chest, with the bullet ultimately lying-in profile with the patient's pituitary gland. The patient suffered injuries to his left lung, left internal jugular vein, and right optic nerve. On hospital day 1, he required neurosurgical operative intervention for increased somnolence and computed tomography findings which revealed tension pneumocephalus. On hospital day 15, he was discharged home after making a full recovery with the exception of continued blindness in the right eye. Gunshot wounds involving multiple body cavities can increase the complexity of a patient's injury pattern and require increased vigilance and complete history, physical examination, and imaging to ensure optimal outcomes.

Keywords: Gunshot; Penetrating trauma; Pneumocephalus; Trajectory.

Fig. 1

CT chest showing a retained hemopneumothorax and pulmonary contusion after the placement of a left chest tube.

Fig. 2

CT angiogram of the neck showing an injury to the left internal jugular vein and a large intramuscular hematoma of the sternocleidomastoid.

Fig. 3

CT brain showing the retained bullet and pneumocephalus.

Fig. 4

CT brain showing a tension pneumocephalus with bifrontal compression of the brain.