Migration of bullet in the spinal canal: a case report

As the spinal canal expands at T10 level naturally, it has been thought that the migration of a bullet within the spinal canal above this level is prevented and the migration of a bullet may only occur between T10 and S1 level. Here, a very rare case of a bullet traversing the length of the spinal canal is reported.     

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.     

Penetrating missile embolisation

The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exist. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X-ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficial femoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years.     

Acute acyclovir neurotoxicity in a hemodialyzed child

A 5-year-old girl with a kidney transplant developed post-transplant Epstein-Barr virus-induced lymphoproliferative disease. She was treated with acyclovir, alpha-interferon, and gamma globulin. A transplant nephrectomy was performed on day 4 due to acute rejection and she was started on hemodialysis. The acyclovir dose was decreased at this time. However, 6 days following the start of acyclovir she developed progressively worsening neurological symptoms resulting in a coma on day 8. Fourteen days after acyclovir was begun pre- and post-dose serum concentrations were 7.02 microM and 182.5 microM, respectively. Acyclovir was then discontinued and 2 days later the child's neurological status began to improve. We conclude that acyclovir in children with end-stage renal failure may lead to severe and reversible neurotoxicity, despite acyclovir dosage adjustment based on renal impairment.     

Retinal detachment in an infant with the ring chromosome 13 syndrome

A 6-year-old fit girl experienced convulsions 44 h after an otherwise uneventful anaesthesia with propofol, alfentanil and nitrous oxide. As an underlying pathology was suspected, the child was kept sedated for 6.5 h for further investigations. During this period she received a continuous infusion of propofol amounting in total to 1600 mg. After having regained consciousness, she was strikingly ataxic and remained so for 5 days. During this period she also experienced two episodes of hallucinations lasting about 2 h. Investigations including lumbar puncture, EEG, cerebral CT and MR scan could not explain the neurological symptoms. She recovered without long-term sequelae.     

The syndrome of acute central cervical spinal cord injury after gunshot lesion. Case report

The authors describe a unique case in which a bullet was lodged in the spinal canal at the C2-3 level. The patient exhibited clinically the syndrome of acute central cervical spinal cord injury. The pathogenesis is discussed with reference to three similar cases in the literature.     

Reversible spinal cord compression caused by extramedullary hematopoietic foci in thalassemia

A now 42-year-old Thai woman was known to have been anaemic since childhood. When aged 33 years she was diagnosed as having beta zero/HBE thalassaemia. Computed tomography demonstrated a tumour in the posterior mediastinum, histologically found to be an extramedullary haematopoietic focus. Subcutaneous infusion of deferoxamine (2 g five times weekly), initiated because of massive iron overload, reduced the serum ferritin level from 3,460 ng/ml to less than 500 ng/ml. The haemoglobin level in the subsequent years was between 6 and 8 g/dl. Five years later sensory deficits were noted from the 5th thoracic vertebra downwards. Magnetic resonance imaging demonstrated a tumour which compressed the spinal cord: it, too, was an ectopic haematopoietic focus. The neurological symptoms disappeared after radiotherapy with 3,000 cGy, but they recurred 4 years later. Because of the low radiation reserve of the spinal cord, hypertransfusion treatment was initiated, namely 16 RBC concentrates within 4 months and afterwards two transfusions every 3 months. By this means the haemoglobin level was kept at about 9 g/dl. The tumour had regressed 4 months after onset of treatment. For 2 years since the beginning of the hypertransfusion treatment the patient has remained free of neurological symptoms.     

When do infants need additional inspired oxygen? A review of the current literature

A previously healthy 8-month-old infant experienced a dramatic change in affect, motor patterns, and appetite after a brief (4-day) separation from her parents. She went from being a happy, interactive, and engaging child to being withdrawn, with limited vocalization, spontaneous motor activity, or interest in her environment. For the first 3 days after her parents returned home, she refused solid food and most of the formula or water she was offered. Over the following week, her appetite increased minimally. Her parents were concerned about her apathy, excessive quietness, and lack of interest in food, toys, or their own attempts to engage her in play. At the pediatrician's office, she was significantly less interactive and playful compared with previous visits. Her temperature, heart rate, and respiratory rate were normal. Although there were no objective signs of dehydration, her weight was 8 ounces less than the previous recorded weight 1 month ago. Results of the physical examination were normal, with the exception of neurological and behavioral findings. She had mild, generalized decreased tone and strength, with normal deep tendon reflexes, a sad facial appearance with sustained furrowing of the lines in her forehead, difficulty in eliciting a social smile, and limited spontaneous sounds. There was an absence of focal neurological findings, a flat open anterior fontanel, and a head circumference measurement consistent with previous recorded results. There were no cutaneous bruises, and findings of her funduscopic examination did not reveal retinal hemorrhage. Before the 4-day holiday, child care was provided almost exclusively by her mother at home. On only two previous occasions, at 4 and 6 months of age, this first child of 20-year-old high school graduate parents was cared for by a neighbor when the parents went out to a movie theater. She cried for about 10 minutes when the parents left on these occasions. Her mother stated that she felt anxious about leaving the child for several days, but she and her husband decided that they needed a break and planned the 4-day vacation. Child care was provided by the neighbor, who did not notice any unusual behavior or refusal to feed while in her care during the parents' absence.     

Good Samaritan surgeon wrongly accused of contributing to President Lincoln's death: an experimental study of the President's fatal wound

BACKGROUND: When President Abraham Lincoln was shot in the back of the head at Ford's Theater in Washington, D.C., on April 14, 1865, he was immediately rendered unconscious and apneic. Doctor Charles A. Leale, an Army surgeon, who had special training in the care of brain injuries, rushed to Lincoln's assistance. When Doctor Leale probed the wound in Lincoln's thickened scalp, feeling for the bullet, he dislodged a blood clot, and Lincoln began to breathe again. However, Lincoln progressively deteriorated and died at 7:22 AM on April 15, 1865. During the postmortem examination of Lincoln's body, numerous secondary missiles of bone and metal were found in the track of pultaceous brain tissue, extending completely through the brain to the front of the skull. In February 1995, an article in a popular magazine alleged that Doctor Leale had caused further (fatal) damage to Lincoln's brain by thrusting his finger into the brain through the bullet hole. The article alleged (wrongly) that most bullet wounds of the brain incurred in Civil War times were not fatal. STUDY DESIGN: The following study demonstrates that it is impossible to introduce even the tip of the little finger through a hole in the skull resulting from a .41-caliber bullet fired from a derringer. In our study, a .41-caliber derringer was used to fire bullets into numerous fresh skulls; the bullet holes all had razor-sharp edges and were much too small to accommodate a fingertip. RESULTS: Thus, the allegation that President Lincoln's brain was damaged further because Doctor Leale thrust his finger through the bullet hole into the brain parenchyma is not valid. In this study, experimental data are presented to demonstrate the foregoing point. CONCLUSIONS: The wound made by John Wilkes Booth's derringer ball in Lincoln's brain was devastating; it was clearly the cause of his death. Good Samaritan surgeon Leale has been falsely accused of contributing to Lincoln's death.     

A case of encephalitis due to Mycoplasma pneumoniae: detection of specific DNA from cerebrospinal fluid and elevation of interleukin-6

A 9-year-old female was admitted to our hospital due to a generalized seizure and consciousness disturbance. The patient had a fever and rash four days before admission, but she had no respiratory symptoms. The seizure and consciousness disturbance was prolonged and intractable. We diagnosed the patient as having encephalitis because of the increase in the cell count in the cerebrospinal fluid (CSF) and a diffuse slow EEG wave. The computed tomography of the head was normal. The causative agent was identified as Mycoplasma pneumoniae because of the increase of antibodies, and the detection of a specific DNA with a polymerase chain reaction. The interleukin (IL)-6 level of CSF was high (384 pg/ml). In spite of intensive treatment she had severe neurological sequelae. The invasion of Mycoplasma pneumoniae to the central nervous system appeared to have a role in the development of encephalitis in the patient. We speculated that there is a possible relationship between the IL-6 levels of CSF and clinical severity of encephalitis.     

Peripartum management of a patient with Isaacs' syndrome

PURPOSE: To describe the peripartum management of a patient with Isaacs' syndrome with specific reference to the anaesthetic implications of the disease process. Associated medical problems included obesity, pregnancy induced hypertension and a difficult airway. CLINICAL FEATURES: This 30-yr-old gravida V para 0 woman presented to the anaesthesia consultation clinic at 37-wk gestation to discuss pain relief options for labour and delivery. She had a history of Isaacs' syndrome (a peripheral motor neuron disorder), congenital heart disease (ASD and VSD), treated Hashimotos thyroiditis, obesity and a family history of haemachromatosis. On the day of consultation, she was hypertensive and peripheral oedema was noted. Her urine showed trace protein. Four days later, she presented to the labour suite and her cervix was 9 cm dilated. An epidural anaesthetic was given without difficulty and she had an uneventful labour and delivery course. There were no subsequent neurological complications. CONCLUSION: Isaacs' syndrome is an extremely rare peripheral motor neuron disorder. This patient was successfully managed with epidural analgesia for labour and delivered a healthy child with no congenital anomalies.     

Hemostasis in patients with diabetes mellitus. I. Markers of endothelial dysfunction

This report describes a 17-year-old man with piggyback bullets to the abdomen followed by bullet embolization to the right pulmonary artery. The first bullet was removed from the abdomen while the second missile in the lung was left intact. We believe this is the first case in Thailand of a bullet embolus resulting from piggyback bullets.     

An autopsy case of Binswanger's disease without hypertension and associated with cerebral infarction in the terminal stage

We report here an autopsy case of Binswanger's disease (BD) without hypertension and associated with cerebral infarction in the terminal stage. The female patient, who was 74 years old at the time of death, had initially demonstrated manic-depressive disorder-like mental disorder, followed by dementia and neurological deficits. A brain CT scan showed white matter low attenuation bilaterally and symmetrically. BD was clinically diagnosed despite the lack of hypertension. In the terminal stage, she suffered an infarction in the left anterior cerebral artery region, and died of pneumonia. Neuropathologically, we found the infarction of the left anterior cerebral artery region, demyelination, fibrillary gliosis, lacunae and arteriosclerosis of the small arteries and arterioles in the white matter.     

Right laparoscopic lumbar sympathectomy]

In three separate shooting incidents involving multiple gunshots, two FMJ bullets and one bullet fragment found at the scene (one from each case) were investigated for the presence of biological material from the victim after perforation. The surface of the missiles, which did not show obvious tissue traces when examined under a macroscope, was swabbed. PCR typing of up to five STR loci was performed on the small amounts of DNA extracted, which were seen below the detection limit of the slot blot quantification in one case. Nevertheless, individualisation of cellular material from the perforating projectiles was successful in each of the three cases presented. Consequently, identification of the victim wounded by a perforating bullet can reliably be achieved if contamination or removal of evidentiary material by improper handling is prevented. This technique is especially useful in cases where more than one person has fired a gun because the bullet carrying DNA can be linked to the firearm by investigation with a comparison microscope. As a by-product of this investigation, a variant allele 14 (14+4) at the VWA locus was detected.     

Endoscopic management of subcutaneous gunshot wound with irrigation technique

The application of the endoscope to the treatment of gunshot wounds has never been reported to our knowledge, with the exception of the laparoscope and the sigmoidscope in abdominal gunshot wounds. We report a patient with a subcutaneous gunshot wound who was treated endoscopically using the irrigation technique. The patient was a 25-year-old man who had been shot in the upper arm. The bullet was found near the thoracic spine via radiograph. At surgery the endoscope was inserted into the wound and irrigation was started. Excellent views could be obtained by irrigation, and the endoscope was advanced along the path of the bullet. The bullet and several fragments were removed with two additional small incisions. The method described herein seems beneficial in that (1) it is less invasive than conventional surgical debridement with a long incision, (2) it may provide information helpful in diagnosing the condition and the location of the bullet and its path, and (3) saline irrigation may have a cleansing effect.     

Occult pseudoaneurysm of the abdominal aorta following gunshot wound: the importance of plain film findings

A traumatic pseudoaneurysm of the abdominal aorta eluded detection at initial laparotomy, but was later detected serendipitously. Early abdominal x-ray film and appreciation of paraspinal bullet fragments could have led to its earlier detection. A portable abdominal x-ray film should be a routine part of the preoperative resuscitation of abdominal gunshot wounds.     

Diagnostic accuracy of Alzheimer''s disease: a neuropathological study

We report a 83 year-old woman with dementia. She was apparently well until December of 1993 when she was 81-year-old. At that time, she was operated or her cataract. Her post operative course was uneventful, however, shortly after her operation, she had an onset of memory loss and abnormal behavior. She showed a fluctuating course in her mental disturbance. In 1995, her dementia worsened with nocturnal agitation. She was admitted to our service on June 12, 1995. She was alert and her blood pressure was 140/100 mmHg. She showed recent memory loss and disorientation to time. Motor wise, she was unable to stand unsupported. Her gait with support showed small steps and a wide base. She was bradykinetic and ataxic in her finger-to-nose and heel-to-knee test, however, no rigidity or tremor was noted. Her MRI showed T2-high signal lesions in both medial thalamic areas, in the right occipital lobe, and in the bilateral cerebral white matters as well as in the basal ganglia. She was discharged for out-patient follow up on July 3, 1995. Four days after the discharge, she showed declining responses to stimuli and she developed dyspnea on July 14, 1995. She was admitted again on the same day. Her body temperature was 38.5 degrees C and moist rales were heard in the left lung field. She appeared drowsy and no verbal response was obtained; no apparent motor palsy was noted. Blood count showed leukocytosis (14,300/ml). Blood gas analysis under 61 of oxygen inhalation through a mask was as follows: pH 7.460, PCO2 39.6 mmHg, PO2 67 mmHg, and HCO3-28.5 mEq/l. Two days after admission, she developed a convulsion in her left arm and she became unconscious. Her EEG showed periodically recurring lateralized epileptic discharges on the right fronto-central areas. Her subsequent course was complicated by status epilepticus and respiratory distress. She died on July 26, 1995. She was discussed in a neurological CPC. The chief discussant arrived at a conclusion that she suffered from multi-infarct dementia. Bilateral thalamic infarctions were considered to have played a significant role in her dementia. Post-mortem examination revealed subcortical leukoencephalopathy of Binswanger's type and cerebral infarctions in the thalamic and basal ganglia regions and in the right occipital lobe. In addition, she showed isolated angitis of the central nervous system involving mainly in the small arteries located in the superficial areas of the brain and the spinal cord. This patient was interesting in that despite relatively mild leukoaraiosis in MRI, post-mortem examination revealed profound pathologic changes in the subcortical white matters. In addition, she showed the isolated angitis of the CNS. The cause and the clinical correlates of her angitis were unclear.     

T-tube intubation in the management of late traumatic esophageal perforations: case report

Delayed diagnosis of esophageal perforations can lead to high mortality and morbidity and presents a surgical dilemma. A case report of a bullet wound of the esophagus that was diagnosed late is presented. Placement of a biliary T-tube and pleural decortication were carried out after the perforation was found at esophagoscopy. The patient had no fistula nor esophageal narrowing at discharge 31 days after injury.     

Case report of a 22-week fetus with 47,XXX karyotype and multiple lower mesodermal defects

Tandem loading of a cartridge of the same caliber is possible only if the diameter of the barrel is sufficiently wide. This requirement is met by the .22 long shot Anschütz miniature clay pigeon gun. Ballistic experiments with tandem-loaded cartridges of the same caliber as those loaded in the normal way showed the bullet of the regularly loaded cartridge to impact the muzzle-loaded cartridge. On firing a shot, the bullet of the posterior cartridge penetrates the anterior one, expanding the case of the first cartridge to the diameter of the barrel and disintegrating the bullet. Regardless of whether the muzzle-loaded cartridge is ignited or not, the discharge speed of the projectiles (v0) is considerably below that of single shots. Calculations yielded a theoretical reduction by about 60%. In accordance with the formula E=1/2*m*v2, in terms of the energy released, the elevated mass of the projectile is of secondary importance compared with the reduction of v0. Although the "projectile" mass is more than twice the normal rate, the energy density is significantly reduced and the biological effect is attenuated. This also became apparent in the failed suicide attempt of a 43-year-old male who used a miniature clay pigeon gun to shoot himself in the forehead at a range of a few centimeters. He had inserted a second cartridge, base to head with the first cartridge, in the factory-bored barrel of the gun. The leading cartridge was destroyed by the regularly loaded one. The pierced and expanded case of the leading cartridge was found nearby the injured man and was at first taken to be the jacket of a larger-caliber bullet.     

Estrogen and cancellous bone loss in the fowl

Long-term follow-up study with positron emission tomography (PET) has been conducted in a patient with superficial siderosis for ten years. A 63-year-old right-handed woman began to exhibit a cerebellar ataxia when she was 52 years old. Thereafter she has been exhibiting a slowly progressive course of pyramidal signs, hearing loss, anosmia, bilateral sciatica and memory disturbance in addition to the cerebellar ataxia. Series of x-ray CT and MRI disclosed a progressive atrophy of the cerebellum, specifically in the superior vermis, and a mild diffuse atrophy in the cerebral hemispheres, whereas no significant atrophy was seen in the brainstem. A marked hypointensity was seen along the rim of the brain structures including brainstem, cerebellum, sylvian fissures and the medial temporal lobes on MR T 2-weighted images. This hypointensity was also found at the edges of the third and fourth ventricles. These findings were regarded as haemosiderin deposit. By using oxygen-15, PET was carried out repeatedly with ten-year interval. In the initial PET study, both cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO2) were mildly decreased in the cerebellar hemispheres and the occipital cortices. The follow-up PET study revealed a progressive reduction of CMRO2 in the brainstem, cerebellar hemispheres and temporal cortices including the hippocampus in which the haemosiderin deposition was marked on MRI, whereas the reduction of CBF was not advanced as compared with CMRO2. It was suggested that the progressive reduction of CMRO2 in the brain sites where the haemosiderin deposition was observed on MRI reflected the clinical course of neurological deterioration.