24 hours with an intracranial bullet without neurological deficit

Gunshot injuries occur when oneis shot by a bullet or other sort of projectile from a firearm. Peace time gunshot injuries occur in a variety of different situations: criminal and terrorist incidents (including shots fired by law enforcement agents), attempted suicides as well as unintended firearm 'accidents' (both civilian and amongst the armed forces). Penetrating traumatic brain injury is the most lethal form oftraumatic head injury. Approximately 70-90% of these victims diebefore arriving at the hospital, and 50% of those who survive to reachthe hospital die during resuscitation attempts in the Emergency Department. We report a case of a 17 year old male patient whowas previously well.He wasaccidentally was shot on his head by a friend, he did not lose consciousness and neither did he have any seizures, but was complaint of mild headache. On examination, hemodynamically stable, he had a punctate scalp wound on the left temporal area anterior to the ear with crusted blood around it and no exit wound, his Glasgow coma scale was 15/15, hispupils were 3mm bilaterally andreactive to light, he had no cranial nerve deficit with normal conjugate eye movement,Motor and sensory examination was normal. He was communicating and mobilizing very well. Skull x-ray showed the bullet in the cranium. Unenhanced Computer Tomography (CT) scan of the brain confirmed the intracranial bulletin the suppratentorial space with hemorrhagic contusion in the left cerebellar hemisphere and posterior fossa pneumocephalus. There was effacement of sulci and gyri and no evidence of intraventricular hemorrhage. The patient was then admitted to a high dependency unit for observation with a diagnosis of penetrating head injury secondary to gunshot wound. He remained fully conscious and neurologically intact for 24hours after which his level of consciousnesssuddenly started deteriorating associated with vomiting; he passed on while he was being taken for repeat and futher imaging of the brain. A post mortem examination was consistant with the CT Scan findings including massive subarachnoid hemorrhage and brain swelling.