Intracranial ricocheted-bullet injuries: An overview and illustrative case

Abstract

The impact of a bullet by firearm is a mortal entity that in recent years has been on the rise due to the increase in crime, confrontations, among other acts of violence. Brain injuries by firearm account for 33.3% of all fatal injuries from this type of weapon. This resulted in a significant number of disabilities with its burden cost at a global level. The types of bullet injuries to the head include: penetrating (inlet without outlet), perforating (through and through), tangential (not enter the skull, causing coupe injury), ricochet (intracranial bouncing of bullet) and careening (rare, enter skull but not brain, runs in the subdural space). There are several situations that can occur once the bullet enters the body or into the intracranial cavity. Unmatched association of the bullet trajectory with the final position of the bullet within the body raise the suspicion for additional phenomena involvement, this can be explained by either internal bullet ricochet or internal bullet migration. The former usually represents an active movement and the latter is a passive movement. Intracranial ricocheting of bullets forms up to 25% of all penetrating bullet injuries to the skull. Such bullets types are commonly tumbling and have an unpredictable trajectory. The surgical management for intracranial bullet injury developed over decades from the time of Harvey Cushing and the World War I till the present. Now, the accepted intervention ranges from simple wound care to a proper surgery that includes hematoma evacuation, removal of only accessible bone fragments and foreign bodies, dural repair and wound debridement with or without decompressive craniectomy. Also, intracranial pressure monitoring is generally indicated. We reported a thirty-three years old male, victim of homicidal bullet injury to the head, presented with Glasgow Coma Scale score of 8 (best eye response: 2, best motor response: 4, best verbal response: 2), upon examination a right parietal (near vertex) inlet without outlet was found. The poor prognostic factors in this patient included bi-hemispheric involvement, associated acute subdural hematoma with interhemispheric extension, ricochet type of injury and effacement of sulci. Intracranial ricocheted-bullet injury is a special entity of bullet injury to the head with its particular ballistics and management that deserve highlighting by the trauma team to gain fluent treatment and better outcome.