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MILITARY MEDICINE, 176, 2:228, 2011

Delayed Diagnosis of Intracerebral Foreign Body From


the Vietnam War
David B. FitzGerald, MD*†‡; Joseph M. Gullett, BS†; Charles E. Levy, MD§; Bruce A. Crosson, PhD†||

ABSTRACT We report on a 22-year-old infantryman who sustained a right frontal wound to his head. He was treated
and returned to duty immediately. During a computed tomography scan, 38 years after the incident, a metallic foreign
body and disruption of the brain consistent with a projectile track were discovered in his brain. In this report, we review
similar cases of delayed discovery of unsuspected foreign bodies and the probable nature of the wound.

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INTRODUCTION shrapnel. He remained on active duty for 8 years after return-
Computed tomography (CT) and roentgenograms (X-rays) ing to the United States and then retired. Following retirement,
are low-risk tools that have become widely available. These he worked as a truck driver, security guard, and bodyguard,
tools are considered routine components of standard evalua- supporting himself, his wife, and children. He was diagnosed
tions for head wounds and suspected brain injury. Thus, it is with posttraumatic stress disorder (PTSD) and alcohol abuse
commonly assumed that foreign bodies in the brain will be as a civilian.
detected as part of a routine evaluation after injury. However, He had a syncopal episode and underwent a noncontrast
injuries may be incurred in austere environments where these head CT in 2006, which was considered to be an unremark-
imaging modalities are not available. This lack of imaging able study with the exception of a finding, “a metallic foreign
may result in delayed discovery of intracerebral foreign bod- body in the medial aspect of the right frontal lobe.” The dis-
ies to the potential detriment of the patients’ health. We pres- covery of a foreign body in his head was not communicated to
ent here such a case. him until an office visit in 2010 for an unrelated matter. The
retention of the metallic foreign body was not considered to be
CASE REPORT related to his syncopal episode.
A 22-year-old, left-handed U.S. infantryman was engaged in His examination in the office in 2010 showed no neuro-
a firefight in Vietnam when he experienced a loud flash. His logical deficits, including full visual field of view to confron-
subsequent loss of consciousness was not witnessed, but was tation. The level of lead in the patient’s serum was found to
estimated by him to be of several seconds in duration. After be <3 mcg/dL, which is considered to be within normal lim-
recovering consciousness, he realized that he had a wound its. Neurosurgical intervention was deferred indefinitely. The
in his right temple and a corpsman came and assisted him. patient’s electronic medical record was flagged for a metallic
He was treated with a field dressing and then told to return foreign body to prevent magnetic resonance imaging (MRI)
to battle. He did not have noticeable deficits at that time and scans being performed in the future.
was able to continue his duties as a squad leader. After several
days, the wound on his temple had healed sufficiently for him Imaging
to discard his battle dressing. No X-rays were performed. He Images of the patient’s CT scan are shown in Figures 1 and 2.
did not experience a headache or an alteration of vision after The single metallic object measures 0.70 cm in the longitudi-
the initial flash. nal direction of the object, which is in line with the object’s
The soldier eventually became aware of a small, palpable apparent trajectory in the brain. The short dimension of the
stationary mass underneath the well-healed area of the original object in the axial plane is 0.47 cm. The object is seen in 2
injury. He attributed this to a retained fragment of bullet or slices; thus, the inferior–superior length of the object is less
than 9 mm (CT slice thickness is 4.5 mm in this study).
*Neurology Service and †Brain Rehabilitation Research Center,
Rehabilitation Research and Development Service (RR&D), Office of DISCUSSION
Research and Development, Department of Veteran Affairs, North Florida/
South Georgia Veterans Health System, 1601 SW Archer Road, Gainesville,
The discovery of unsuspected intracerebral foreign bodies
FL 32608-1197. years after injury has been rarely reported, yet the lack of
‡Department of Neurology, University of Florida, PO Box 100236, detection may have clinical consequences even for an appar-
Gainesville, FL 32610-0236. ently intact survivor. Several case reports exist documenting
§Physical Medicine and Rehabilitation Service, North Florida/South the late discovery of such bodies in symptomatic children and
Georgia Veterans Health System, 1601 SW Archer Road, Gainesville, FL
32608-1197.
adults (Table I).
||Department of Clinical and Health Professions, University of Florida, During evaluation for tonic-clonic seizures of 6 months
PO Box 100185, Gainesville, FL 32610-0185. duration, a wooden fragment from a child’s toy was found in

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Intracerebral Foreign Body

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FIGURE 1. CT scout display of the patient shows a single metallic foreign
object measuring approximately 0.66 cm from the anterior tip to the posterior
tip of the object.

a 4-year-old girl in her right temporal lobe. This discovery


was made 3 years after a transtemporal penetrating injury. The
purulent material surrounding the piece of wood was found to
be sterile on aerobic and anaerobic cultures. Immediately after
the initial injury, the child’s neurological examination was
considered normal.1 One year after the removal of the piece
of wood, the child was seizure-free and had no neurological
deficits (Ravi Dadlani, personal communication).
Two cases of penetrating injuries with delays in removal of FIGURE 2. Axial CT scan image showing the apparent entry trajectory in
the right frontal lobe with loss of tissue extending to the right lateral ventricle.
the retained foreign bodies were reported by Orszagh et al.2 Slice thickness is 4.5 mm, with radiological convention used. The long axis of
In one case, a wooden branch was found to have entered a the object is 1.05 cm, and the short axis of the object is 0.59 cm.
2-year-old child’s brain via a transorbital route after a fall onto
a hedge. The entry wound was below the right lower eyelid,
with the object in the mediobasal aspect of the right tempo- swelling and slight headache. The bamboo stick remnant was
ral lobe. Her neurological examination was considered normal found in the left frontal lobe and was removed.3
with the exception of ptosis and a mydriatic right pupil. The A 30-year-old bicyclist crashed his bicycle and sustained a
development of exophthalmos triggered additional investiga- mildly depressed left frontal skull fracture. Two months later,
tions, and an MRI was performed on day 10 after the accident. a retained bicycle wheel valve cap was discovered in his left
The MRI definitively determined the presence of a foreign frontal lobe after evaluation for mild but persistent headache,
body, which was then removed. followed by neurosurgery to remove the object.4
In the second case, a skiing accident resulted in tran- A case of 2 retained objects in the brain were identified as
sorbital penetration of an 8 cm × 0.6 cm tree branch to the a result of psychiatric symptoms by Yamakawa et al.5 They
parenchyma. The entry site was located below the right lower reported a case of a 69-year-old gentleman with seizures,
eyelid, with the tree branch extending across the midline to sometimes accompanied by visual hallucinations. Evaluation
the left basal ganglia. No neurological deficits were seen dur- of the seizures led to the discovery of a bullet (34 mm × 10 mm
ing examination at the time of the accident and the patient was in size) and a metal fragment. The bullet was found to be in
discharged on the same day. He was readmitted the next morn- the right occipital lobe and the fragment was found in the left
ing after being found comatose at home. Chronic meningitis extracranial temporal lobe. Both objects were thought to have
triggered the search for a cause of infection, with discovery of penetrated his brain 45 years earlier during the Sino–Japanese
the retained tree branch in the right orbital roof extending to War. The objects were removed and the patient’s symptoms
the left basal ganglia 64 days after the accident.2 resolved after a 14-day course of penicillin.5
Liu et al3 reported on a bamboo stick that penetrated the Jennett and Teasdale6 pointed out that puncture wounds
left upper eyelid after a fall by an 18-month-old boy. The pres- can be deceptive in their severity. Removal of the penetrating
ence of a retained portion of the bamboo stick was recognized agent may reduce the suspicion that penetration of the skull
1 month after the accident during evaluation for severe orbital has occurred. They noted that this is particularly true in the

MILITARY MEDICINE, Vol. 176, February 2011 229


Intracerebral Foreign Body

TABLE I. A Summary of Historical Cases of Delayed Diagnosis of Intracerebral Foreign Bodies

Age at Trauma Time From Injury to


(years) Location of Foreign Body Nature of Foreign Body Symptoms Nature of Symptoms References
1 Right Temporal Lobe via Wood From a Toy 3 years Generalized Tonic-clonic 1
Right Squama Temporalis Seizures
2 Lateral to Right Oculomotor Wooden Branch Within Few hours, Meningitis, Followed by 2
Nerve to Parapontine Cistern Meningitis; Then 4 Exophthalmos of
via the Right Superior or More Days Later, Right Eye
Orbital Fissure Exophthalmos
35 Right Medial Orbit to Left Wooden Branch Next Morning Comatose 2
Basal Ganglia (8.0 cm × 0.6 cm)

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1.5 Left Frontal Lobe With Entry at Bamboo Stick >1 cm 1 month Severe Orbital Swelling and 3
Left Orbital Roof in Length Slight Headache
30 Left Frontal Lobe via Left Bicycle Wheel Valve Cap 2 months Mild, Persistent Headache 4
Frontal Bone (approximately
1 cm × 1 cm)
24 Right Occipital Lobe Near Bullet (35 mm × 10 mm) 4 months Minimum, Epileptic Seizures Sometimes 5
the Right Tentorium With Definitive Accompanied by Visual
Diagnosis 45 years Hallucinations With Todds
Later Palsy on the Left Side

With the exception of the case we report on, all foreign bodies were discovered after the presentation of new symptoms. All foreign bodies were in noncritical
structures, e.g., not in the diencephalon, the brain stem, the cerebellum, or the major motor pathways.

case of eyelid or sclera. In our review, 2 of the 6 cases had many more penetrating wounds were fragment wounds in con-
entry through the orbital fissure or the orbital roof. trast to bullet wounds. Of 2,187 admissions in his study, 1,790
Infection is a major medical complication of gunshot were attributed to fragment wounds and 351 were attributed
wounds.7 However, in a study of missile wounds that pene- to bullet wounds. Forty six of the admissions were for other
trated to the brain, in Vietnam, only 5 of the brain wound sites causes.11
in 45 patients showed bacterial contamination. Contamination In our case, the discovery of the foreign body was inci-
was also observed in 44 of the skin wounds. In-driven bone dental. Using the standard clinical guidelines for diagnosing
chips were estimated to be sterile in up to 75% of the wounds, traumatic brain injury (TBI), this veteran would be diagnosed
suggesting that in rare cases penetrating head wounds might with a mild TBI (no focal deficits and loss of consciousness
not result in infection.8 for less than 30 minutes).12 However, the extensive dam-
Karger9 suggests in a review of wound ballistics that age caused by the foreign object with loss of parenchyma
either hunting or military rifles cause comminution of bone changes the classification of his injury to moderate or severe
and laceration of the brain in penetrating head injury. In a TBI.
companion review article of gunshot wounds and preserved Although the veteran appeared to be without major deficits
capacity to act, he also suggests that wounds limited to the following the initial injury, he was later diagnosed with PTSD
frontal lobes, which avoid the brain stem, diencephalon, and alcoholism. It is speculative, but we wonder if the dam-
major motor paths of conduction, and cerebellum, may be age to the veteran’s right temporal lobe might have contrib-
survivable and not incapacitating.10 All the cases of delayed uted to his PTSD and alcoholism. As noted by Damasio and
diagnosis that we have listed earlier and in Table I avoid the Anderson,13 there can be a wide set of symptoms associated
brain stem, the diencephalon, the major motor paths of con- with frontal lobe dysfunction, including cognitive deficits,
duction, and the cerebellum, although some do involve the impairments of social behavior, impulse control, and decision
temporal lobes. making. For this patient, the ability to estimate his premor-
North Vietnamese forces typically used AK-47 rifles in bid functioning is complicated as he was left-handed; thus,
the Vietnam war. The standard cartridge in an AK-47 is a the lateralization of his language is not easily predicted. The
7.62 mm × 39 mm cartridge. The bullet dimensions for this preservation of speech suggests that he was left hemisphere
size cartridge are approximately 23 mm long with a 7.92 mm language–dominant, but this is difficult to prove. The patient
diameter. The dimensions of the foreign body in our case are has never received neuropsychological testing.
smaller than this, suggesting that the foreign body is either a Early detection of the brain injury might have led to a more
bullet fragment or a piece of shrapnel. nuanced appraisal of the veteran’s limitations, to a differ-
In addition, the lack of penetration through the opposite ent course of treatment, and to provide some explanation for
side of the skull suggests that a spent bullet fragment or a symptoms attributed at the time to PTSD. In addition, ear-
piece of shrapnel was responsible for the wound rather than lier diagnosis might have affected the veteran’s compensation
a full-sized bullet from a military rifle.9 Hammon11 found that entitlement and vocational choices.

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CONCLUSION 2. Orszagh M, Zentner J, Pollak S: Transorbital intracranial impalement


Delayed recognition of retained intracerebral foreign bod- injuries by wooden foreigh bodies: clinical, radiological and forensic
aspects. Forensic Sci Int 2009; 193: 47–55.
ies can occur. Usually, these cases come to light as part of 3. Liu W-K, Ma L, Mao B-Y: A delayed frontorbital abscess caused by
the diagnostic process for determining the source of infec- a penetrating nonmissile foreign body (A bamboo stick). Neurol India
tion, seizure, or headache. However, not all retained foreign 2009; 57: 208–10.
objects trigger infection or other symptoms. Survival after a 4. Tessitore E, Buttner M: Delayed intracerebral abscess due to retined bike
penetrating head injury is more likely with shrapnel or bullet wheel valve cap. J Clin Neurosci 2008; 15: 172–3.
5. Yamakawa H, Takenaka K, Sumi Y, et al: Intracranial bullet retained
fragments as opposed to intact bullets. Shrapnel or bullet frag- since the sino-japanese war manifesting as hallucination. Neurol Med
ments are of lower velocity and, thus, are less likely to affect Chir (Tokyo) 1994; 34: 451–4.
critical structures. Physicians should be cautious in assuming 6. Jennett B, Teasdale G: Management of Head Injuries. Philadelphia, F.A.
that apparent superficial wounds are truly only superficial and Davis Company, 1981.

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should obtain screening films before ordering MRI-based pro- 7. Martin J: Early complications following penetrating wounds of the skull.
J Neurosurg 1946; 3: 58–73.
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ACKNOWLEDGMENTS 9. Karger B: Penetrating gunshots to the head and lack of immediate inca-
We thank the staff of the Malcom Randall Veterans Affairs Medical Center pacitation: I. Wound ballistics and mechanisms of incapacitation. Int J
Library for their help in obtaining reference materials. Dr. FitzGerald is spon- Legal Med 1995; 108: 53–61.
sored by Veterans Health Administration RR&D grant B6698W. Dr. Crosson 10. Karger B: Penetrating gunshots to the head and lack of immediate incapac-
is sponsored by Veterans Health Administration RR&D grant B6364S and itation: II. Review of case reports. Int J Legal Med 1995; 108: 117–26.
NIH grants R21-DC009247 and R01-DC007387. 11. Hammon WM: Analysis of 2187 consecutive penetrating wounds of the
brain from Vietnam. J Neurosurg 1971; 34: 127–31.
12. Kay T, Harrington DE, Adams RA: Definition of mild traumatic brain
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