An otherwise healthy 34-year-old male presented with a loss of consciousness to the emergency department (ER). A gunshot wound entry was observed on his occiput with the right orbital swelling. His Glasgow Coma Scale (GCS) was 10 (E3, V3, M4), with a left-sided weakness grade of 3 on the Medical Research Council of Canada (MRC) scale. An ophthalmological examination was performed and revealed avulsed damaged globe. A head computed tomography (CT) scan was performed, which revealed a bullet lodged in the right orbit with an entrance point from the right occipital bone [Figure 1]. In addition, the CT scan showed an intraventricular hemorrhage in the lateral ventricle due to the spontaneous migration of the bullet through the brain [Figure 2].
The patient is transferred to the operating room, where an interdisciplinary team of surgeons is prepared. The surgery was focused on three targets (1) hematoma evacuation, (2) scalp debridement, and (3) gentle bullet removal, which was performed successfully. The surgery went unremarkable. Furthermore, the postoperative course featured GCS 12 (E3, V4, M5) and a left-sided weakness MRC grade of 3. In the neurointensive care unit (ICU), measures were taken to decrease the intracranial pressure (ICP), including head elevation and mannitol boluses, according to the follow-up neurological examinations alone, as ICP monitoring is not available. In addition, essential care was performed, which included primary wound care and closure of both inlet and outlet in the neuro ICU. However, the patient died on the 7th day postoperatively, which mainly contributed to the patient's TBI.