Bullet fragments spontaneously migrating in opposite directions after a cardiac arrest treated with extracorporeal cardiopulmonary resuscitation following a gunshot wound to the head: A case report

Gunshot injuries to the head are associated with a poor neurological prognosis, have a high risk of mortality, and make the return of spontaneous breathing and circulation after cardiopulmonary arrest difficult. Bullets or bullet fragments can cause penetrating injuries to the brain tissue and sometimes remain in the skull, potentially migrating within the skull. Herein, we describe a rare patient who achieved a return of spontaneous circulation after cardiopulmonary (ROSC) arrest caused by a gunshot wound, following extracorporeal cardiopulmonary resuscitation. After ROSC, repeated computed tomography (CT) identified spontaneously migrating bullets/fragments in the right hemisphere and the metal fragment was excreted from the skull, while another fragment had moved from the left temporal to the occipital fossa. The patient died on the 15th day of hospitalization. The present case had a rare clinical course, suggesting that ROSC may be achieved under adequate respiratory and circulation management in cases of cardiac arrest with a head injury. The scans showed differing movements of the bullet fragments at each lesion, which was difficult to predict from the first CT scan. When surgical treatment is required to remove bullet fragments remaining in the skull (due to lead poisoning, or infection, among others), it may be useful to be aware that fragments may move in various directions, even out of the skull. Furthermore, we recognized the usefulness of CT scanning for detecting the location of the foreign body in cases of gunshot injury to the head.