CASE REPORT

Bali Medical Journal (Bali MedJ) 2023, Volume 12, Number 2: 2228-2232
P-ISSN.2089-1180, E-ISSN: 2302-2914

Penetrating brain injury from an

accidental air gun shot: a case report

Sri Maliawan1*, Steven Awyono2, Eufrata Silvestris Junus2,

Bagus Dwiki Arya Dharma2, Tjokorda Gde Bagus Mahadewa1

ABSTRACT
1
Neurosurgery Division, Department of Background: Air gun shot injury is a gunshot wound from a pistol or rifle that fires a bullet. The most common part of the
Surgery, Faculty of Medicine, Udayana body that penetrates in air gunshot injuries is the head, especially the orbit. The majority of fatal cases have been reported to
University, Prof. Dr. I.G.N.G. Ngoerah enter that location and commonly involve children and adults. This report presents an interesting point of air gunshot injuries
General Hospital, Bali, Indonesia with brain damage surgical management.
2
Neurosurgery Residency Program,
Case Description: A 6-year-old boy got referred from other hospitals and came unconscious after being shot in the head by
Faculty of Medicine, Udayana University,
Prof. Dr. I.G.N.G. Ngoerah General an air gun about eight hours before being admitted to the hospital with a range of about two meters. The patient was said to
Hospital, Bali, Indonesia have accidentally been shot from the front of the head. The patient had a history of vomiting without a history of consciousness
and seizure. On the primary survey, the airway, breathing, and circulation were clear, with a Glasgow Coma Scale (GCS) of 13.
Based on the clinical examination and the result of the head CT scan, the patient was diagnosed with penetrating brain injury
*Corresponding to:
at the left parietal region, with multiple fragmented objects, intracerebral hemorrhage, and intraventricular hemorrhage.
Sri Maliawan / Neurosurgery Division, We then perform urgent surgery to debride and extract the bullet. There was no surgical morbidity in this patient, who was
Department of Surgery, Faculty of allowed to go home.
Medicine, Udayana University, Prof. Dr. Conclusion: Penetrating brain injuries resulting from air gunshot wounds require exceptional management. Early surgery
I.G.N.G. Ngoerah General Hospital, Bali, to debride the wound with consideration of bullet extraction is needed to prevent further complications and for a better
Indonesia / [email protected] outcome for the patient.

Received: 2023-04-17 Keywords: Penetrating brain injury, air gun shot injuries, craniotomy.
Accepted: 2023-06-24 Cite This Article: Maliawan, S., Awyono, S., Junus, E.S., Dharma, B.D.A., Mahadewa, T.G.B. 2023. Penetrating brain injury
Published: 2023-07-20 from an accidental air gun shot: a case report. Bali Medical Journal 12(2): 2228-2238. DOI: 10.15562/bmj.v12i2.4571

INTRODUCTION caused by the gun’s careless use.6,7 was said to have accidentally been shot by
The most common part of the body the air gun from the front of the head and
Air gun use compressed gas to propel that is penetrated in air gunshot injuries then fell with his forehead first hitting the
a projectile, such as a ball-bearing or a is the head, especially the orbit, resulting floor. There were not any seizure episodes
bullet.1 This gun has been used since the in brain injury. Most fatal cases have in this patient. On examination, we found
middle of the 16th century.2 Bullet and been reported to penetrate around that stable vital signs with a Glasgow Coma
ball-bearing guns are non-powdered location, then disrupt major intracranial Scale (GCS) of 13, equal reactive pupil on
bullets that may cause significant injury, vessels, leading to severe brain injury with both sides, without any local neurological
especially in children and teenagers.3 An intracranial hemorrhage.1,9,10 In this case, deficit. We then evaluate the wound at
air guns-related injury is a gunshot wound we report an interesting case of air gunshot the left parietal region (Figure 1). Local
from a pistol or rifle that fires a bullet. The injuries with brain damage managed with wound debridement already performed at
air compression was operated by a spring minimally invasive bullet extraction and the previous hospital. A skull x-ray showed
or pump action mechanism or a carbon surgical wound debridement. a radioopaque mass with a diameter of
dioxide cartridge.3–5 The air guns were about 1 cm on the occipital region (Figure
categorized as low-velocity missiles (<300 2). Later, we performed a head CT scan and
m/s), but they can penetrate through the
CASE PRESENTATION
found a skull fracture on the left parietal
abdomen, thorax, sinuses, and skull.6,7 We reported a case of a 6 years old boy bone. The bullet penetrated through the
These days, the new models of air guns are who got referred from other hospitals and soft tissue at the left parietal region then,
more powerful and capable of producing came unconscious after being shot in the causing the defect in the skull (Figure 3).
more severe damage.8 Most air gun shot head by an air gun bullet about eight hours We then evaluate the trajectory based
injuries occur in children and teenagers, before being admitted to the hospital with on the intracranial lesion and conclude
especially in boys, and most of them are a range of about two meters. The patient that the bullet penetrated through the left

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| doi:
www.balimedicaljournal.org
10.15562/bmj.v12i2.4571
 CASE REPORT

Figure 1. The bullet enters from the left

parietal aspect of the head.
There is no active bleeding
from entering wound. Figure 2. Ap/Lat skull X-Ray Showing the bullet was in the occipital
region.

parietal lobe to the left occipital lobe with

multiple hyperdense lesions through the
track suggested as bone fragments.
The bullet traveled to the left occipital
lobe, measuring about 9.4 cm from the
entrance wound. We also found cerebral
contusion along the path from the left
parietal lobe to the ipsilateral occipital
lobe with intraventricular hemorrhage and
subarachnoid hemorrhage. Laboratory
examination showed a low hemoglobin
level (10,2 mg/dl), with leukocytosis
(20.430 mg/dl), and slightly elevated PPT
(15,9 seconds). This patient was then
prepared to undergo surgical debridement
with bullet extraction. Based on the CT
scan, we then conclude to perform these Figure 3. Head CT-Scan (A-C) Bone window and (D-F) brain window showing the
two surgeries with different incisions bullet’s trajectory from the left parietal lobe and stopped in the occipital
(Figure 4). lobe. The bullet direction was medially downward, the track left with ICH
The patient was then placed in a prone with perifocal edema, IVH, and SAH.
position with a neutral head position. The
principle of the bullet identification was size around 8 mm (Figure 5) with perfect infection. The patient was then allowed
done using three-points coordinate points visualization about 2.2 cm from the to go home after seven days of treatment
to minimize brain injury by using C-Arm. cortical surface. at the hospital. Routine follow-up was
Careful evaluation and calculation were A linear incision was done, followed by done for his clinical presentation until six
made to predict the depth of the bullet a craniotomy over the wound to expose the months after the surgery. There was not
from the cortical area. A paramedian damaged dura mater’s border. The wound any history of seizures in this patient. We
linear incision was made around 5 cm; a was debrided by saline irrigation with performed an imaging evaluation using
craniotomy was performed. After the dura the evacuation of the superficial clot and a CT scan that showed resolution of the
opening, the final identification of the bone fragment. After meticulous bleeding hemorrhage with good bone healing
bullet was made with C-Arm guidance. control, duraplasty was performed, and we (Figure 6).
We then perform corticotomy around closed the skin layer by layer.
1 cm and mark our bipolar cautery on a After the surgery, he was hospitalized DISCUSSION
two cm level based on our preoperative at the pediatric intensive care unit for
calculation. Accurate identification was three days. No blood product transfusion Gun-powder firearms are heavily regulated
made after our marking reached the is needed. The postoperative evaluation in Indonesia and not easily accessed by
cortex, and we found the bullet with the showed no neurological deficit or sign of citizens, but a non-powder gun is still

Bali Medical Journal 2023; 12(2): 2228-2232 | doi: 10.15562/bmj.v12i2.4571 2229

 CASE REPORT

unregulated (not controlled) by the

government. This lack of regulation made
non-powder guns such as air guns easily
accessed by citizens and often labeled
as “not a weapon” or “toy”.11 Bratton et
al. showed that most non-powder guns
for pediatric cases were unintentional.12
Mostly, air gunshot injuries occur in
children and teenagers, especially in boys,
and the gun’s careless use causes that.6,7
Likewise, in this case, the patient was a six-
year-old boy accidentally shot with an air
gun. An air gunshot penetrated the skull
and led to significant brain injury. Fatal
injuries commonly occur in children and
adults, with the bullet entering through
the eyes and forehead and penetrating the
brain.1,9,10 Bratton et al. found that out of
49 children with air gunshot injuries on
the head resulting, 38 with injuries in the
eye, 10 with intracranial injuries, and 1
with a skull injury.12
Three of the ten children with
intracranial injuries died, and two had
long-term neurologic deficits. This shows
that although air gunshots are grouped
as low-velocity missiles, the impact
caused by them may lead to fatal injury,
even death. Non-fatal injuries are usually
caused a significant brain injury resulting
in permanent neurological deficits or
blindness if it involves the orbit.12 The
Figure 4. A) Bullet extraction procedure; patient on prone position with neutral possible entry of the bullets is the relatively
head position. Skin incision was made based on C-arm evaluation. B) thin skull bones, such as the temporal or
Debridement procedure; patient was positioned in supine position with squamous part of the occipital bone.13 In
head maneuver to the right to expose the wound on left parietal region. this case, the patient was shot from the
front of the head with the bullet’s entry in
the left parietal region, different from the
common entry of the bullet. The patient
also came to the hospital unconscious with
a GCS of 13.
Traumatic brain injury results from the
energy transferred from one object to the
skull and brain. The penetrating object
that penetrated the skull was divided into
a non-bullet and bullet object. The non-
bullet objects have less transferred energy
to the brain because they have more mass,
so they tend to travel slower. The bullet
objects tend to have less mass, so they have
more kinetic energy and higher velocities
that may significantly impact the brain
tissue. Factors such as muzzle velocity,
impacted target mass, and transferring
media may influence the bullet velocities.
Penetrating and perforating brain injuries
Figure 5. Bullet with the size about 8 mm after removal from intracranial.

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 CASE REPORT

but the bullet and fragment extraction

should be done if accessible. The goals
are to reduce the toxicity effects and
permanent neurostructural changes that
can develop into permanent neurological
deficits. The mass effect found on the
imaging is an indication of the surgery.16
If the indication was appropriate, the
intervention should be done as soon as
the patient is stabilized and with a golden
period under 12 hours. Debridement
over 12 hours after the initial injury, there
will be an increased risk of infectious
complications.14 There is still debatable
which technique is best to achieve the
most optimal result. In the past study, there
was no statistically significant advantage
between craniotomy and craniectomy.17
Antibiotics may be used to prevent
intracranial infections. Early surgery
and debridement should be applied for
cerebrospinal leakage or intracerebral
hemorrhage.18,19 On this patient, the bullet
Figure 6. Head CT-Scan Brain Window showing the the bullet was completely extraction was performed by craniotomy
remove from left parietal lobe. ICH with perifocal edema, IVH, and technique to reduce the toxicity from
SAH was resolved. the bullet and minimize the permanent
neurologic deficits. The indication in this
surgery was because there is a mass effect
are associated with cerebral contusions, patient, the bullet entered through the left at the head CT-scan of the patient, and
hematomas, cerebrospinal fluid leaks, parietal region and penetrated through the the path of the projectile can be accessed
pseudoaneurysms, and arteriovenous parietal lobe. Then, the projectile path is with the surgery. The craniotomy on
fistula. The projectiles can penetrate the made from the left parietal lobe to the left this patient was performed using mini
skull and ricochet off the inner aspect of occipital lobe. The bullet was found at the craniotomy, and minimal corticotomy was
the skull; this occurs most often with low- left occipital lobe, with the length of the performed based on detailed calculation
velocity shots and creates a new wound path ±9.4 cm from the entrance wound. preoperatively to minimize brain injury.
tract to the uninjured brain tissue. A Small multiple fragmented bones were The evacuation of the bullet and the
projectile that travels through intracranial also found along the track as identified remnant is through the occipital. At the
tissue destroys the neuronal and vascular, as a hyperdense lesion on the head CT. same time, the parietal craniotomy is
resulting in an immediate intracranial Penetrated bullet caused permanent and used to debride the wound and extract the
injury. The destruction will occur in the temporary cavitation, then disrupted the superficial bony fragment. A duraplasty
projectile’s path and distant tissues around neural membrane and hemorrhaged along has also been done on the patient to
the path when the bullet strikes the head the projectile’s path proofed by the CT complete the surgical procedure. After the
and transfer its kinetic energy to the extra scan result, which showed intracerebral surgery, he was observed in the pediatric
and intracranial tissues. This mechanism hemorrhage at the left parietal lobe until intensive care unit for about three days and
will result in permanent cavitation on brain the left occipital lobe with perifocal then moved to the pediatric ward. During
tissues directly in the projectile’s path, but edema, and intraventricular hemorrhage observation, he was fully conscious with
there are sonic waves followed by pressure at the right and left lateral ventricle, stable vital sign and discharged from
waves that cause temporary cavitation. third ventricle, and fourth ventricle, and the hospital without any complaints or
This expansion of the temporary cavities subarachnoid hemorrhage at the anterior neurological deficits. The patient was
causes distant punctate hemorrhages and posterior interhemispheric fissure. scheduled for a Head CT Scan evaluation
and neuronal membrane disruption. As This hemorrhage and edema caused an one month after the surgery.
a result, intracranial pressure will rise elevation of intracranial pressure in this
as the hematoma enlarges and edema patient. CONCLUSION
increases. Infarction also can happen Management of penetrating brain Air gun shot injuries cause penetrating
due to decreases in cerebral perfusion injury has been broadly published.15 There brain injury and require special
pressure.14 Based on the CT scan in this is still much debate over the management, care because they can lead to a fatal

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 CASE REPORT

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