[Endoscopic projectile extraction in treatment of a gunshot injury to the head].

HISTORY AND CLINICAL FINDINGS

A 14-year-old boy had in war-torn Bosnia sustained a transcranial gunshot wound from a 7.65 mm bullet. After primary medical care with craniotomy and the removal of bony fragments and cerebral debris followed by a duraplasty, he was transported to the French-German Field Hospital. On arrival he was breathing spontaneously and in stable cardiovascular state but with impaired responsiveness and somnolent. His pupils were moderately dilated with slight anisocoria (right > left). His gaze was deviated to the left and he had vertical gaze paralysis as well as right central facial nerve paresis. In addition he had a mild diencephalic syndrome, right hemiplegia and a right hemihypaesthesia with increased muscle tone, especially of the leg, paratonia and right positive Babinski reflex. There also was a marked ciliospinal reflex and he had a bulbar speech as well as cognitive and memory abnormalities.

INVESTIGATIONS

Haemoglobin and haematocrit were below normal (12.1 g/dl and 35.0%, respectively), while biochemical tests were normal. Cranial computed tomography localized the bullet in the pineal recess of the 3rd ventricle and the lamina quadrigemina.

DIAGNOSIS, TREATMENT AND COURSE: These findings indicated endoscopic transcranial removal of the bullet, achieved with a rigid endoscope and forceps along the entry track. Subsequent intensive care proceeded without complication. On discharge the boy was normal oriented and ready to make contact. The neurological defects were regressing.

CONCLUSION

Endoscopic transcranial removal of a bullet wedged in the brain is a relatively sparing neurological procedure which, under unusual circumstances and conditions, can achieve a satisfactory result even with limited facilities.