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Fatal cranial gunshot injury

Case contributed by Mohamed Mahmoud Elthokapy
Diagnosis certain

Presentation

Brought unconscious to the ER after a gunshot injury to the head.

Patient Data

Age: 25 years
Gender: Male

Post gunshot head injury by a missile showing internal beveling with the entry site at the right frontoparietal calvarial bone suture with the larger exit site seen at the left anterior parietal calvarial bone with everted bony fragments and surrounding radiating fracture lines.

Long sagittal mid-frontal bone fracture as well as left lower frontal transverse bone fracture.

Bilateral temporal squamous bone fractures are seen radiating posteriorly.

Significantly diastatic both sagittal and coronal structures.

Subsequently elevated displaced left frontal calvarial bone.

Extensive subarachnoid hemorrhage is noted along cortical sulci and Sylvian fissures (traumatic subarachnoid hemorrhage).

Intra-parenchymal hemorrhagic tracks delineate the missile track along high frontal regions with multiple intracranial scattered bony fragments along the track line.

Evident extra-axial hemorrhage was mainly subdural at both frontoparietal regions.

Multiple subdural and intra-parenchymal gases foci are noted denoting pneumocephalus.

Significant dense falx cerebri and tentorium cerebelli smeared by hemorrhage.

Diffuse cerebral edema with attenuated ventricles and diffuse cerebral parenchyma hypodensities.

Early cerebellar tonsilar herniation

Marked right and to less extent left frontotemporo-parietal subgaleal hematoma with gases foci (emphysema).

Opacification of right middle ear cleft and mastoid suggesting haemotypanum.

Marked opacification of ethmoidal and right frontal sinuses with fluid levelling and minimal hyperdensities inside suggesting hemosinuses.

Opacified nasopharynx and nasal cavities by retained secretions with nasopharyngeal tube and oral endotracheal tube.

Case Discussion

Gunshot wounds to the head are frequently, but not invariably fatal. The distance from the gun, bullet speed, caliber, type of bullet, course and the parts of the brain involved will impact the mortality risk. 

Bullet fragmentation gives a piece of important information about the mechanism and direction of injury. 

The patient died soon after medical imaging, and he was a victim of the war in Yemen.

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