A. Chirianc, Giorgiana Ion, Z. Faiyad, I. Poeata

DOI: 10.33962/roneuro-2020-024

The role of strict patient-positioning
during nursing in the management of

intracerebral migration of gravitational
bullet injury

Samir H. Aldelfi,
Salima B. Alsaadi,

Mohammed Maan AbdulAzeez,
Mukarram N. Musarhad,
Mohammed D. Khudhair,

Samer S. Hoz

Romanian Neurosurgery (2020) XXXIV (1): pp. 154-157
DOI: 10.33962/roneuro-2020-024
www.journals.lapub.co.uk/index.php/roneurosurgery

The role of strict patient-positioning during
nursing in the management of
intracerebral migration of gravitational
bullet injury

Samir H. Aldelfi1, Salima B. Alsaadi2, Mohammed

Maan AbdulAzeez3, Mukarram N. Musarhad1,

Mohammed D. Khudhair1, Samer S. Hoz1

1 Neurosurgeon, Department of Neurosurgery, Neurosurgery

Teaching Hospital, Baghdad, IRAQ
2 Radiologist, Department of Neuroradiology, Neurosurgery

Teaching Hospital, Baghdad, IRAQ
3 Medical student, College of Medicine, Baghdad University,

Baghdad, IRAQ

ABSTRACT
The intracranial migration of bullet was described in literature since Cushing time and

the First World War [1]. The literature is still away from delivering a clear guideline

and constitutes more of case reports rather than comprehensive well-designed

studies [2-13], this mostly due to the variability and diversity in the presentation and

management of such cases. The migration of bullet can be a sequel of any type of

penetrating injury to the skull [14]. Intracranial migration after gravitational (falling)

bullet injury is a unique type of injury that constitutes of significant human and

material losses with differences in biomechanics and structural brain changes after

the insult especially regarding the velocity of impact and the degree of yaw for the

intracranially settled bullet [15]. The gravitational bullets injuries are considered by

the international disease classification system as celebratory firing, that is quite

common and is part of the traditional happy (marriage) or funeral event in the middle

east in general and in rural areas of Iraq in particular, and also reported in some areas

around the world (South America, North Africa, and middle of Asia) [15,16].

INTRODUCTION

In the available articles [17-28], the accepted management options for

the retained intracranial bullet with possible migration, include:

• Observation, activity restriction and follow-up: for bullets with

minimal risk of migration, those include small irregular bullet

fragment with pure intraparanchymal location. Here, It is critical to

know that the migration of bullet is rarely expected three months

Keywords
patient-positioning,

intracerebral migration,
gravitational bullet injury

Corresponding author:
Mohammed Maan AbdulAzeez

College of Medicine,
Baghdad University,

Baghdad, Iraq

mohammed.wwt@gmail.com

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ISSN online 2344-4959
© Romanian Society of

Neurosurgery

First published
March 2020 by

London Academic Publishing
www.lapub.co.uk

http://www.lapub.co.uk/

155
The role of strict patient-positioning in the management of intracerebral migration of gravitational bullet injury

from the insult as the gliosis (encapsulated within tough scar) will surrounds the bullet and render it

extremely resistant for migration [22,28].

• Early surgery: for bullets that retained within the

ventrciles that have a high risk for obstructive

hydrocephalus and those just close to a

hematoma cavity [22-26].

• Delayed surgery: for migrating (moving) bullet

that cause new neurological symptoms, large

bullets with smooth (intact) contour, resides near

the ventricles, moves toward an eloquent area,

migrates for a significant distance (2.5 cm), moves

freely in the cistern with risk of neurovascular

compression or injury, and those resides in

accesible and safe location. Still some authors

consider surgical removal of the bullet once

migrated based on their personal experience

[27].

THEORIES ON SPONTANEOUS BULLET MIGRATION

Although the exact mechanism is not always known

or being multifactorial [21], theories suggest

different explanations for the mechanism, the

trajectory and the final destination of the

intracranially migrated bullet.

The gravidity, the pulsating intracranial contents

and softening of the surrounding tissues are the

mechanism that is commonly mentioned [26].

The common expected trajectory is usually

posteriorly either toward the sella turcica for bullets

in the anterior cranial fossa or toward the torchula

herophili for those in the posterior parietal, posterior

temporal and occipital lobes. Otherwise, the

trajectory will be back along the initial bullet tract (the

damaged brain). In rare occasions, the bullet may

take out of the above suggested directions, here,

surgeons should consider abscess development as a

possibility [17-20,27].

PATIENT POSITIONING AFTER ADMISSION

For cases with retained intracranial bullet after

gravitational (falling) bullet head injury, where the

initial decision is close clinical follow-up (non-

surgical), the patient positioning during admission is

critical.

Although activity restriction is part of the general

practice during this observation period, some

surgeons suggest a more strict head positioning

during the nursing period and consider it as pivotal

part of the management of such instances [14,28].

Both Rapp et al. [14] and Taarnhoj [28] describe in

their reports that they use the strict patient

positioning during nursing in few cases, the aim of

this positioning is an attempt to change or control

the direction of bullet migration in migration-

possible cases. In our practice, we routinely

implement this strict-positioning technique to render

a deep bullet with possible migration to an accessible

and easy to remove one.

Although Rapp et al. [14] and Taarnhoj [28]

document using this positioning technique for

penetrating bullet injury in general, our clinical

experience suggests using this technique in

gravitiational (falling) bullet injury will be more

fruitful taking in consideration multiple factors that

are unique for the falling bullets. The gravitiational

(falling) bullets are usually non-fragmented, not very

small nor too large, smooth outer contour and with

less adhesive surrounding brain tissue (less

cavitation and necrosis as compared to other types

of penetrating bullet injuries), these factors make

this falling bullets are more liable for migration and

also more amenable to be affected and guided by

the patient positioning during the early observation

period (Figure 1 shows an illustrative case scenario

for the mentioned technique).

Thus, in cases of gravitational cranial bullet injury

with a retained bullet that not mandate early

surgery, we recommend a patient-specific activity

restrictions and strict head positioning taking in

consideration the possible trajectories of migration

and well-designed for dragging and controlling the

bullet movement into an accessible and a safe to

remove destination.

Figure 1. An illustrative case for the use of strict patient-

positioning during nursing in the management of intracerebral

migration of gravitational bullet injury. A twelve-years-old male,

a victim of gravitational bullet injury, presented to the

emergency department of the neurosurgery teaching hospital.

Baghdad. Iraq with disturbed consciousness (Glasgow Coma

Scale 14), left side weakness (Grade 4 both upper and lower

limbs), pai in the sky (contralateral upper quadrantanopia)

visual field defect, with a small wound (1 cm) in the right frontal

area (inlet). Initial lateral skull X-ray showed the frontal inlet and

the posterior temporal location of the bullet (A), that is

confirmed by an urgent brain CT scan (C). The initial decision

was to observe the patient as there were not significant wound

or hematoma. The patient was put in strict supine position

except for bathroom times with physiotherapy to his left side.

156
Samir H. Aldelfi, Salima B. Alsaadi, Mohammed Maan AbdulAzeez et al.

Three days later, with the patient still having a severe

headache, we did a follow-up skull x-ray then new brain CT scan

that showed the migration of the bullet posteriorly (B and D

respectively). Here, the decision was to remove the bullet as it

moved to a surgically accessible location. the surgery went

uneventful and the post-operative brain CT scan showed no

hematoma at the site of surgery (E). The patient discharged 4

days later, fully conscious with only the same initial visual field

defect. On next visits his vision improved, he returned back to

school and having good marks too.

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