Fallberichte - Case reports 117

Metallic fragment embolization to the middle cerebral artery D. Siccardi'i A. Primauera", P. Tartori-Donati' Departments of'Neurosurgery", Neurology",a nd Neuror adiclogy' . Universityo f Genoa, ltaly

A 25-yea r-old mal e wa s wounded accid entally in the neck by a metalli c fragment, wh ich penetrated his right carotid artery and migrated within th e ipsilateral midd le cerebral artery. Clinical and la ber atDry findings over a 16-mo nth-period are reported. Pro blems a rising from the presence of metallic emboli to the cereb ral circulation are discussed on the basis of the pertinent literature. Metallfr agmentembolisierung der mittler en Zerebralarterie Ein 25jähriger Mann wurde zufälligerweise am Hals durch einen Metallsplitter getroffen, welcher in die rechte A. ca rotis eindrang und von dort aus in die gleichseitige A. cerehri med ia wanderte. Die klinischen und Laborbefunde werden über einen Zeitraum von 16 Monaten dargelegt und die Auswirkungen von Metallemboli auf den Hirnkreislaufwerden anhand der Litera tur er läutert.

manually. A few min utes after admission to the em erg en cy room of a Iocal hospital, the patien t experienced th e su dden ons et of a left hemiparesis and wa s then re ferr ed to our hosp ital. On arrival, the patient wa s alert and coopera tive. In the right antero-lateral region of his neck. medial to th e anterior bord er of the ster nocle idomastoideus muscle. a two mm linear wou nd with subcutaneous hematoma was evident. Blood pressure was 120170 and pulse rat e wa s 70. A mild left hemip ar esis with increa sed deep tendon reflexes and Babin ski sign was pre sen t. In th e following three hours the motor impairme nt progre ssively and completely cleared up. Acere bra l CT sca n showed a metallic foreign body in the region of the right middl e cerebral arter y (MCA) (Fig. l ). Ultras ound and doppl er exa mination sh owed the paten cy of th e major vesse ls of th e neck and th e pr esen ce of hem at om a between Fig. 1 Cl scan, performedonadmission showed ametallic foreign body inthe district oftherightmiddle cerebralartery.There wasnoevidenceof infarction, mass ettect. or hemorrhage.

Key-Words Embolisation - Metallic fragment - Middle cerebral artery

Intr oduelion Migration of a metallic splinter or a shotgun pellet from a large ves sel of the bo dy to an intracranial artery represents a rare event which raises probl ems over the optimal management. both in relation to the IDeation of the fragment and the neurologieal condition ofthe victim . A case is herewith reported in order to high light som e of the problems arising in these unusual circumstances . Case Repor t On August 9th 1988, a 25-year-old man, while moulding an iron-plate was wounded accidentally in th e neck by a metallic fragment broken away from his hammer. He feIt a pin prick on th e right slde , followed by risk bleeding. which he stopped I

Neurochirurgia 35 (1992) 117 - 120 Georg Thieme Verlag Stuttgart · NewYork

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Fig.2 Cl scan, performed onthedayafter injury, showed the presence ot asmalllschemie areainthe right putamino-pallidal

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D. Siccardi. A. Primaoem, P. Tortori-Donoü Fig. 4 The right cerend angiogram clearty visualized the metallicfragment insidethe M1 segment otthe MCA, withoutapparent narrowingof the lumen of the vessel. l enticufararteries werenot visualized. A collateralsuppfyto the lenticulostriatecirculation, viatheperforating branchesarising from theproximalsegment ofthe MCA, was present.

es. Fig.5 Two weeksatterinjury,arepeat scan showed amcderate wideningoftheisehernie area. withan ncrease in densrty.

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Fig. 3 rCBFexaminanon withinhalatoryXenon 133. pertormed ontheday afterinjury, was slightlyreduced in the nght fronto-temporal regions.

the right thyroid lobe and thc right carotid trunk , partially comp ressin g the jugular vein. Thc day after, a re peat er sca n showed th e prc sen ce of a sm all ischemi c arca in the puta min o-pallldal region (Fig. 2). Regional cereb ral blood flow (rCBF), recorrled by Xenon 133 inh alatic n. was slightly red uced in tbe right [ca nto-temporal regio ns (Fig. 31. EEG exa mi nation det ected a diffuse the ta activity, more marked in the righ t tempora l region . In the territori es orthe right a nte rio r ce reb ral a rtery (ACAI and MCA. a tran scran ial doppler exami natio n showed a n acceleration ofblood fiow, s ugges ti ng a ste nosis. A right carotid a ngiog ram was pe rformed . The metallic fragment was clearly visualized insi de the Mt segment of the righ t MCA (Fig. ol l. wit hout narrowing ofthe lumen ofthe vessel. Lenticular arte ries were not visualized . but th er e was a collateral sup ply to the len ticulostriate circ ulation. via the perforaring br anches ari sing from the proxi mal segment ofthe midd le cere bra l artery. Six days late r. uh rasound and do ppler exa mi na tio n of th e neck s howed a resto ration of th e norm al so nogra phie values . In the meanwhile. the re wer e no cha nges in th e neu rological status. Two weeks after injury. a re peat ed CT sca n showed a moder at e wid en ing of the isch emic a rea , with an increase in density (Ftg. 5). Duri ng hos pitalization , the patient received a nticoag ula nt a nd anti biot ic therapy. On Sept. 9 th , he was discha rged in good healt h . On the firs t da ys of Octo be r, a repeated tra nscranlal dop pler examina tion showed only a sligh t increase of the blood flow velocity. Rare theta waves wer e recorded on EEG in the right te mpora l regions. rCBF was norm alized on rep eat exa mlnations. These findi ngs we nt unchanged at th e las t co ntrols. perfo r med sixteen months after injury. The pa tient rem a ined symptom free throughout the observed per iod .

Discussion Embolization ofthe cer ebral circulation due to migration of intravascular meta llic fragm ents is a rar e occurrence. To the best of our knowledge. only 21 cases have been reported so far (2.3.6.8. 10. 11. 13. 14, 15, 16, 18.19.20. 21.22. 23.24.25.26.27). Most ofthese meta llic

emboli wer e pellets fired by shotguns to the head, neck and/ or ehest of the victims. Though severe neurological deficits wer e present in the majority of the patients with a metallic cerebral embolus. altempts to remove the foreign body were done only in a few cases. Out of 4 patients with an occluded middle cerebral artery, 3 experienced some improvemen t of their preoperative neurological impairmen t following embolectomy (13.25 .26). A partial recovery occurred in a further patien t, in whom a meta llic fragment was withdr awn upstrea m from the proximal segment of the mlddle cerebra! artery to the intracrani al portion of the internal caro tid arte ry by using a long blunt forceps applied to the wall ofthe vessel (20). The only neurologically intac t pati ent, who was submitted to surgery following a shotgun wound to the ehest, had a pellet buried in the wall of his right common carotid arte ry (24). Surgery was not perform ed in two asymptomatic patients, both bea ring metallic fragments within an intern al carotid artery at the neck (18. 19). In OUT case , neurological normalization occurred within a few hours after injury. transcranial doppler and rCBF evaluations document ed a prompt return to normal patt erns. lasting over a l ö-month-pen od. A collateral supplyto the lenticulo-str iate circulation,via the perforating bran ches arising from the proxima l segment of the middle cerebral artery, was ang iogra phica lly demo nstra ted.

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Neurochirurgia 35 (1992)

Metalli cfragment emboliza tion to the middle cerebral artery

119

Authors

Foreign body

Involvedaftery

Wounds

Leeene (1920) Dowzenko (1946) Barrett (1950)

Metallic fragmente metallic fragments shotgurr pellets

Piazza (19581 Kinmcnth (1961) Sandok(1968)

shotgun pellets shotgunpellets shctgun pellets

RM.C.A. RC.C.A., L.C.C.A. RM.C.A.

Tnrnble (1968) Vangilde(1970)

shotgurr pellets shotgun pellets

RC.C.A. L.M .C.A.

head, face andneck

Cebalios(1971)

shctgun pellets

L. M.C.A.

head, neck andchest

Kapp 1(1972) Kapp 2( 1973) Yamada (1974)

metallic fragments metallic fragments shotgon pellets

R.M.C.A. R.M.C.A. L.M.CA

head, face and ehest neck neck

Padar (1975) Sethi (1978) Miner(1978) Cooper(1980)

shotgun pellets shotgun pellets shotgun peltets shotgurrpellets

R.I.C.A. R.l C.A. R.l.C.A. R.M.C.A.

neck heart neck ehest and abdomen

Reines(19801 Kase (19811 Gipe (1981) Vaseik(1982)

shotgurr pellets shotgun oeüets shotgurr pellets shotgun pellets

P.CA R.M.CA RM.C.A. R.M.C.A.

neck ehest and abdomen

Hayes(19891

shotgunpellets

L.M.C.A.

I L.M.CA head,neck andehest RM.C.A, supposed neck L.M.C.A. supposed neck face, neck and chest

ehest chest

ehest

ehest Head, neck ehest and abdomen neck

Neurological examination

Surgical therapy

Outcome

Right Hemiptegia Left Hemiplegia

none none none

Death Left Hemiplegia Right Hemiplegie

none

Partial recovery Good Left Hemiparesis

Embolectomy Embolectomy

Good Partia l recovery

none

Death

Embolectomy Embolectomy none

Left Hemiplegia Gradual recovery Good

none none None none

Good Death Good Good

none none none Embolectomy

Death Death Death Mild lett hemiparesis

none

Good

Aphasta R Hemiplegie Left Hemip'egia Drowsiness L.Hernoarests Headache Nondenen Aphasie R Hemiplegia Aphasia R Hemiplegia Left Hemiplegie Lett Hemiparesis Transient R Hemiparesis No-deftcü Lett Monoparesis No-deficit Transient L. Hemiparesis Deep coma Deep coma Deep coma L.Hemiplegia, herniancpsiaandcoma No-deflcit

• The meta llic tragmentwas withdrawn upstread lrom the proximal segrnent of themiddlecerebra l arteryto theintracranial portion of theinternaI carotidartery by using a long blunt lorcepsapplied to the wall ot the vesse l. •• Heart surgery only. RM.C.A. = Right Middle Cerebral Artery R.lC.A. = Right Internal Carotid Artery R.C.C.A. = Right CommonCarctid Artery L.M.C.A. = Left Middle Cerebra! Artery P.CA = Posteriet Cerebra! Artery L.C.C.A. = Left Common Carotid Artery

Surgery was considered, in relation to the possible onset of th rombosis (1, 5, 28), erosi on ofthe ar terial wall (12), infectious arte ritis (12), or forma tion ofa mycotic aneurysm (4). However, it is known that metallic fragmen ts lodging in a cerebra l vessel without appa re nt impa irment of flow can become encysted an d harmless (13).

References I

2 3

Furt hermore, erosio n of the ar ter ial wall in the presence of a buried foreign body, an d subseq uent hemorrhage ar e weil documen ted only in lar ge extrac ra nial vessels (12). There is also no evidence of development of myocotic aneurysms in any of the cases so far reported of metallic embolization of cereb ral arte ries. Furthermore . embolectomy would necessarily require a tem porar y trapping ofthe proximal segme nt ofthe middle cere bral arte ry, with probable impai rme nt of the alread y established collateral circulation (9, 17). A microvascular by-pass between superficial temp oral artery an d a distal bran ch ofthe middle cerebral artery was envisaged as a prevention against an ischemic insult possibly resulting in Ihe future from thrombosis of the middle cerebral artery (7). This pr ocedure was regarded, however, as unsuitable, beca use of the expected low rate of pate ncy of the anastomosis in the pr esence of a normal flow within the middle cere bra l art ery an d the consequen tlack ofa positive gradien t pressur e at the level ofthe by-pass.

4

5 6

7 8 9

10

11

12

13

Allock, 1. M.: Occlusion of the middle cerebral art ery: serial angiograph y as a guide to conservative therapy. J. Neurosu rg. 27 (1967) 353-3 63 Barren . N. R.: Foreign bodies in the cardiovascular system. Br. J. Surg. 37(19 50J416-445 Ceballos, R.. A. Ronderos: Shotgun pellet em bolus of the middle cerebral art ery. Ala. J . Med. Sei. 8 (197 1) 410 -41 3 Su wanwela , C, N. Suuiamoela. S. Charu chinda, C. Hongsapra bhas: Intracr an ial mycotic aneurysms of extravascular origin. J . Neurosurg. 36 (1972)55 2- 559 Cnou. S. N.: Embolectomy of middle cere bra l artery. Report of a case . J. Neurosurg. 20(1963)161 -163 Coooer. D. F.: Personal comunication 1979 , reported by Vaseik, J . M. and Tew. J. M. Foreign body embolization of the middle cer ebral artery: Review of the liter ature and guidelines for manage ment . Neurosurg. 11 (1982)5 32- 536 Day, A. L. : Indications for surgical interven tton in middle cerebral arte ry obstruction. J. Neurosurg. 60 (1984) 296- 304 Dotozenk a. 0. : Rare case of embolus to middle cere bral arte ry caus ed by foreign body. Polski Tygod. lek. 1 (1946) 1047 - 1047 Garri do, E., B. M. S tein: Middle cerebr al artery embolectomy. Case report. J. Neurosurg. 44 (1976) 517- 521 Gipe. B. T., B. Aker. R. Smi th: Delayed cerebral em bolization of a shotgun pellet with fatal consequence. J. Traum a 21 (1981) 326- 329 Hay es. E., R. Ashenburg. D. Phillips: Cerebra l embolism after gunshot wound s. AJNR 10 (1989) 77 Harkin. D. E., A. C. Willi ams: Foreign bodies in an d in relation to the thor aeic blood vessels and hear t migrat ory foreign bodies within th e blood vascu lar system. Am. J. Surg. 72 (1946) 80- 90 Kapp. 1. P , I. Gielchinsky. R. Jelsma: Metallic fragmen t embolization to the cerebra l eirculation. J. Traum a 13 (1973) 256- 61

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Table 1 Summary 01 21 previously reported case ot foreign bodyembolization to the carottd andcerebral artenes

D. Siccardi, A. Primaoera, P. Tortori-Donaü

Ne uroc hirurgia 35 (1 992) 14

Kase, C. 5.• R. L. White. T. L. Vinson. R. P. Eichelberger: Shot gu n

23

pellet embolus to the middle cereb ral artery. Neu rology 31 (t 98 1)

458-461 Kinmontn , J. S.• J . D. Bu rton. D. S. Lonqmore, W. A. Cook: Guns hot wound s of the heart with emboltsm. Br . Med. J. 2 (1961 11666- 1668 16 Lecen e. P.• J. Lhermitte: Une observation anatomo-cllniq ue l'une cas de remollisse me nt ce reb ra lconsecutif'ä I'obliteration de l'artere sylvienne gauehe per une embolie metallique. Rev. Neurol . 27 (1920) 1116- 1121 11 Meyer, F. S .. D. G. Piepgras, T. M. Sundt. T. Yanagiha ra: Eme rge ncy embolectomy for acute occlusion of the middle cerebral artery. A review of20 cases. J. Neurosurg. 62 (19 85) 639-647 18 Mi ner. M. E.. S . F. Handel: Traumatic embolization ofthe int ra cranial tnte mal ca rotid artery. Neuroradiology 15 (978) 141- 143 19 Padar. S. c.: Air gun pellet embolizing the intracranial carotid artery. J. Neu rosurg. 43 (1975) 222 -224 ao Piazza. G.• G. Gaist: Occlusion of middle cerebral artery by Ioreign body embolus: report ofa case. J. Neuro su rg . 17 ( 960 ) 172- 176 21 Reines. H. D.. L. Dill. S . Saad. G. A . Hunqerford: Neu rogenic pulmonary ede ma and missile emboli . J. Trauma. 20 (1980) 698-701 22 Scndok; B. A.. P. K. Spiegel: Foreign body embolus to the middle ce rebral artery. Va. Med . Montl y 9 5 (968) 151- 153

24

IS

2S

26

21

28

Seth i. 1. M.. B. Rozdilsky: Intern al ca ro tid artery embo lism by sbotgun pellet. Can. J. Neurol. Sei. 5 (197 8) 325 -326 Trimble, C.: Arterial bullet embolis m following th ora eie gun sh ot wounds . Ann . Surg. 168 (1968 ) 9 11-916 Vascik. J. M. . J . M . Teur: Foreign body embolization of th e middle cere bra l arte ry : Review ofthe literature and gu idelines Ior management. Neurosurg ery 11 (19 82) 532 -536 Wan Gilde r. J. c.. W S. Coxe: Shotgun pellet embo lus of the middl e cereb ral arte ry. Case report . J. Neurosurg. 32 (1970) 711- 7 14 Yarnada. K., H. A r a, T. Abe: Shotgun pellet em bolus of the left middle cere bra l artery via th e common ca ro tid artery. Case rep ort Iauthor's translaucnl , Neu rol. Surgery I'Iokyol 2 (197 4) 8 1-84 Zknnik; E. I.: Thrombectomy of the midd le cerebral a rtery. Case report . J. Neurosurg. 4 2 u 975) 723-725

D. Siccardi Chnica Neuroch iru rgia dell'U niv. di GenovalOspeda le S. Mart ina Viale Benedetto 15 )-16 132 Genova

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