Moving bullet syndrome.

Bernardo Ratilal Rua Tristão Vaz, n.31 3. esquerdo 1400-350 Lisbon/Portugal. E-mail: [email protected] Figure 1: CT scan showing a bullet in the deep left occipital lobe. Figure 2: CT scan at the third day showing a backwards migration of the bullet, located adjacent the inner table of the left occipital vault. An eighteen-year-old girl presented a left occipital gunshot wound. At admission, she was fully conscious and the neurological examination revealed a stiff neck and a right hemianopsia. CT scan demonstrated a bullet in the left occipital lobe (Figure 1). Conservative treatment was adopted and the patient was advised to lie in dorsal decubitus position. By the second day she began complaining of an increasing headache. On the third day, CT scan showed that the bullet had migrated backwards and was located adjacent to the inner table of the left occipital vault (Figure 2). A decision was taken to remove the bullet by surgery. A small left occipital craniotomy was performed and the bullet was located 1cm from the cortical surface. The postoperative course was uneventful. At follow-up after 3 months, the patient was asymptomatic. The spontaneous migration of bullets within the brain as a consequence of gravity has been reported sporadically. In the patient treated conservatively, the resting position should be dictated in order to avoid an eventual migrating bullet to eloquent regions of the brain causing additional neurological deficits.