Delayed acute spinal cord injury following intracranial gunshot trauma

Case report

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The authors report the case of a patient who presented with a hoarse voice and left hemiparesis following a gunshot injury with trajectory entering the left scapula, traversing the suboccipital bone, and coming to rest in the right lateral medullary cistern. Following recovery from the hemiparesis, abrupt quadriparesis occurred coincident with fall of the bullet into the anterior spinal canal. The bullet was retrieved following a C-2 and C-3 laminectomy, and postoperative MR imaging confirmed signal change in the cord at the level where the bullet had lodged. The patient then made a good neurological recovery. Bullets can fall from the posterior fossa with sufficient momentum to cause an acute spinal cord injury. Consideration for craniotomy and bullet retrieval should be given to large bullets lying in the CSF spaces of the posterior fossa as they pose risk for acute spinal cord injury.

Abbreviations used in this paper:ASIA = American Spinal Injury Association; GCS = Glasgow Coma Scale.

Article Information

Address correspondence to: Shirley I. Stiver, M.D., Ph.D., Department of Neurological Surgery, University of California, San Francisco, 1001 Potrero Avenue, Room 101, San Francisco, California 94110-0899. email: sstiver@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online January 13, 2012; DOI: 10.3171/2011.12.JNS111047.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Initial CT scan obtained at the time of admission to the hospital. A and B: Bone window imaging of the posterior fossa showing an entry wound in the left, inferior subocciput (arrow) and a comminuted fracture (arrowhead) displaced into the region of the cisterna magna. C and D: Noncontrast images demonstrating the bullet situated in the area of the right lateral medullary cistern. The left lateral medullary cistern (arrow) can be observed in panel C.

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    Right vertebral artery angiograms obtained on hospital Day 10. Anteroposterior (A) and lateral (B) views showing no evidence of vertebral artery injury. The bullet (arrows) was still intracranial and had not moved or shifted orientation.

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    Computed tomography images of the posterior fossa and cervical spine obtained before and after the bullet migration. A: Sagittal reconstruction of the cervical spine CT scan obtained at hospital admission showing the bullet posterior to the clivus with no evidence of a bullet at the level of C-2. B–E: Images obtained 12 days after the gunshot injury. A bone window scan (B) of the posterior fossa shows that the bullet present in the right medullary cistern in Fig. 1 is no longer observed. An axial CT image at the level of the C-2 (C), and sagittal (D) and coronal (E) reconstructions of the cervical spine show that the bullet is now situated in the spinal canal at the level of C-2.

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    Intraoperative images of bullet retrieval. A: Image obtained prior to extraction of the bullet. The C-2 nerve root has been cut (arrowhead) and a glimpse of the bullet can be seen lying beneath and anterior to the spinal cord. B: Image obtained after extraction of the bullet, showing that it was of comparable diameter to the cord itself.

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    Postoperative MR images. A: Sagittal T2-weighted MR image of the lower posterior fossa and cervical spine showing areas of signal hyperintensity corresponding to sites where the bullet first lodged in the posterior fossa (arrow) and subsequently in the spinal canal at the C-2 level (arrowhead). B: FLAIR axial image showing signal change in the medulla, predominantly on the right side (arrow). C: Axial T2-weighted image demonstrating areas of signal hyperintensity in the spinal cord at the C-2 level with more extensive involvement on the left than the right side.

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