Remarkable Recovery After Severe Gunshot Brain Injury: A Comprehensive Case Study of Functional Rehabilitation

Abstract

BACKGROUND Penetrating traumatic brain injury (TBI) caused by gunshots is a rare type of TBI that leads to poor outcomes and high mortality rates. Conducting a formal neuropsychological evaluation concerning a patient's neurologic status during the chronic recovery phase can be challenging. Furthermore, the clinical assessment of survivors of penetrating TBI has not been adequately documented in the available literature. Severe TBI in patients can provide valuable information about the functional significance of the damaged brain regions. This information can help inform our understanding of the brain's intricate neural network. CASE REPORT We present a case of a 29-year-old right-handed man who sustained a left-hemisphere TBI after a gunshot, causing extensive diffuse damage to the left cerebral and cerebellar hemispheres, mainly sparing the right hemisphere. The patient survived. The patient experienced spastic right-sided hemiplegia, facial hemiparesis, left hemiparesis, and right hemianopsia. Additionally, he had severe global aphasia, which caused difficulty comprehending verbal commands and recognizing printed letters or words within his visual field. However, his spontaneous facial expressions indicating emotions were preserved. The patient received a thorough neuropsychological assessment to evaluate his functional progress following a severe TBI and is deemed to have had a favorable outcome. CONCLUSIONS Research on cognitive function recovery following loss of the right cerebral hemisphere typically focuses on pediatric populations undergoing elective surgery to treat severe neurological disorders. In this rare instance of a favorable outcome, we assessed the capacity of the fully developed right hemisphere to sustain cognitive and emotional abilities, such as language.

Figure 1.

Acute-phase axial computed tomography scan. The arrow indicates the entry point of the bullet, which caused fragmentation of the left temporal bone (petrosal part) and part of the occipital bone. The presence of cerebral fragments, edema, and diffuse contusions can be identified.

Figure 2.

Acute-phase axial computed tomography scan. The arrow points to the projectile inside the temporal lobe parenchyma, above its entry point.

Figure 3.

Acute-phase axial computed tomography scan. The arrow points to the central mass of the bullet in the occipital lobe, with no exit found.

Figure 4.

Acute-phase axial computed tomography scan. Cerebral edema and diffuse contusions are recognized. The arrow points to bony fragments along the path of the bullet.

Figure 5.

Three-dimensional reconstruction of the acute-phase computed tomography scan. Anterio-lateral view of the left side of the cranium: the entry point is shown by the arrow head.

Figure 6.

Three-dimensional reconstruction of the acute-phase computed tomography scan. Posterio-lateral view of the left side of the cranium: the trajectory of the bullet from the outside of the cranium is represented here with the arrow. The arrow head points artifacts and not exit point.

Figure 7.

Three-dimensional reconstruction of the acute-phase computed tomography scan. Internal view of the entry point and projectiles’ location. The arrow represents the trajectory of the bullet.

Figure 8.

Postoperative axial computed tomography scan. Postoperative findings after left decompressive craniectomy, extensive cerebral edema of the left hemisphere (pointed with arrow). At the occipital lobe, we can recognize traumatic subarachnoid hemorrhage, contusions, and osseus fragments and parafalcine subdural hematoma on the occipital part of the falx cerebri.

Figure 9.

Postoperative axial computed tomography scan. Postoperative findings after left decompressive craniectomy, extensive cerebral edema of the left hemisphere. The projectile that was previously mentioned can be identified at the occipital lobe, as it was not extracted, pointed by the arrow.

Figure 10.

Postoperative axial computed tomography scan. Postoperative findings after left decompressive craniectomy, extensive cerebral edema of the left hemisphere. At the temporal lobe, we can recognize another projectile that was previously mentioned, as it was not removed, pointed by the arrow.

Figure 11.

Axial computed tomography scan obtained at 2.5 months after injury, after performing cranioplasty, revealing extensive gliosis of the left cerebral hemisphere, encroaching into the ipsilateral cerebellar hemisphere, and distention of the ventricular system.