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1.  A new model for the characterization of infection risk in gunshot injuries:Technology, principal consideration and clinical implementation 
Head & Face Medicine  2011;7:18.
The extent of wound contamination in gunshot injuries is still a topic of controversial debate. The purpose of the present study is to develop a model that illustrates the contamination of wounds with exogenous particles along the bullet path.
Material and methods
To simulate bacteria, radio-opaque barium titanate (3-6 μm in diameter) was atomized in a dust chamber. Full metal jacket or soft point bullets caliber .222 (n = 12, v0 = 1096 m/s) were fired through the chamber into a gelatin block directly behind it. After that, the gelatin block underwent multi-slice CT in order to analyze the permanent and temporary wound cavity.
The permanent cavity caused by both types of projectiles showed deposits of barium titanate distributed over the entire bullet path. Full metal jacket bullets left only few traces of barium titanate in the temporary cavity. In contrast, the soft point bullets disintegrated completely, and barium titanate covered the entire wound cavity.
Deep penetration of potential exogenous bacteria can be simulated easily and reproducibly with barium titanate particles shot into a gelatin block. Additionally, this procedure permits conclusions to be drawn about the distribution of possible contaminants and thus can yield essential findings in terms of necessary therapeutic procedures.
PMCID: PMC3213150  PMID: 22032229
gunshot; infection; basic research; radiology
2.  Comparison of Gunshot Entrance Morphologies Caused by .40-Caliber Smith & Wesson, .380-Caliber, and 9-mm Luger Bullets: A Finite Element Analysis Study 
PLoS ONE  2014;9(10):e111192.
Firearms can cause fatal wounds, which can be identified by traces on or around the body. However, there are cases where neither the bullet nor gun is found at the crime scene. Ballistic research involving finite element models can reproduce computational biomechanical conditions, without compromising bioethics, as they involve no direct tests on animals or humans. This study aims to compare the morphologies of gunshot entrance holes caused by.40-caliber Smith & Wesson (S&W), .380-caliber, and 9×19-mm Luger bullets. A fully metal-jacketed.40 S&W projectile, a fully metal-jacketed.380 projectile, and a fully metal-jacketed 9×19-mm Luger projectile were computationally fired at the glabellar region of the finite element model from a distance of 10 cm, at perpendicular incidence. The results show different morphologies in the entrance holes produced by the three bullets, using the same skull at the same shot distance. The results and traits of the entrance holes are discussed. Finite element models allow feasible computational ballistic research, which may be useful to forensic experts when comparing and analyzing data related to gunshot wounds in the forehead.
PMCID: PMC4208880  PMID: 25343337
3.  Arthroscopic Bullet Removal from the Acetabulum (Hip Joint) 
Hip arthroscopy has been shown to offer minimally invasive access to the hip joint compared with standard open arthrotomy. The use of arthroscopy for diagnosing and treating disorders about the hip continues to evolve. This study describes a case that involves arthroscopic removal of a bullet from a low-velocity gunshot wound. The patient sustained a gunshot wound that entered the abdomen and traversed the small bowel, sigmoid colon then penetrated the urinary bladder before ending up in the medial wall of the acetabulum. After surgical repair of the viscus, the bullet was retrieved from the hip joint using standard arthroscopic portals and a fracture table. A number of issues led to the decision to use arthroscopy. Most importantly was the need to minimize soft tissue dissection, which was required to access the bullet, without interfering with previous wound at the suprapubic area. The risks of potential bullet fragmentation and migration, as well as a possible abdominal compartment syndrome were considered before proceeding. Arthroscopy allowed adequate inspection of the articular surface, irrigation of the joint, and removal of the foreign body while avoiding an invasive arthrotomy with its associated morbidity and soft tissue disruption. This surgical technique afforded a very satisfactory outcome for this patient and serves as a model for others when encountering a similar injury pattern in a trauma patient. It is a procedure that can be performed safely, quickly, and with minimal complications for surgeons with experience in arthroscopy of the hip joint.
PMCID: PMC3673356  PMID: 23741592
Acetabulum; arthroscopy; bullet; foreign body; gunshot; hip
4.  An Elusive Bullet in the Gastrointestinal Tract: A Rare Case of Bullet Embolism in the Gastrointestinal Tract and a Review of Relevant Literature 
Case Reports in Critical Care  2014;2014:689539.
Bullet embolism within the gastrointestinal system is extremely rare. Such bullet injuries are infrequently covered in the general literature, but the surgeon should be aware of the phenomenon. Smaller caliber bullets are more common in civilian gunshot wound (GSW) events. These bullets are able to tumble through the gastrointestinal tract and cause perforation of the intestinal lumen which is small enough to be easily missed. Bullets retained in the abdominal cavity should not be dismissed as fixed and should be carefully monitored to ensure that they do not embolize within the bowel and cause occult lesions during their migration. We present a unique case wherein a bullet caused a minute perforation in the small bowel, before migrating to the distal colon, which resulted in late presentation of sepsis secondary to peritonitis.
PMCID: PMC4009998  PMID: 24829839
5.  Combat-Related Intradural Gunshot Wound to the Thoracic Spine: Significant Improvement and Neurologic Recovery Following Bullet Removal 
Asian Spine Journal  2015;9(1):127-132.
The vast majority of combat-related penetrating spinal injuries from gunshot wounds result in severe or complete neurological deficit. Treatment is based on neurological status, the presence of cerebrospinal fluid (CSF) fistulas, and local effects of any retained fragment(s). We present a case of a 46-year-old male who sustained a spinal gunshot injury from a 7.62-mm AK-47 round that became lodged within the subarachnoid space at T9-T10. He immediately suffered complete motor and sensory loss. By 24-48 hours post-injury, he had recovered lower extremity motor function fully but continued to have severe sensory loss (posterior cord syndrome). On post-injury day 2, he was evacuated from the combat theater and underwent a T9 laminectomy, extraction of the bullet, and dural laceration repair. At surgery, the traumatic durotomy was widened and the bullet, which was laying on the dorsal surface of the spinal cord, was removed. The dura was closed in a water-tight fashion and fibrin glue was applied. Postoperatively, the patient made a significant but incomplete neurological recovery. His stocking-pattern numbness and sub-umbilical searing dysthesia improved. The spinal canal was clear of the foreign body and he had no persistent CSF leak. Postoperative magnetic resonance imaging of the spine revealed contusion of the spinal cord at the T9 level. Early removal of an intra-canicular bullet in the setting of an incomplete spinal cord injury can lead to significant neurological recovery following even high-velocity and/or high-caliber gunshot wounds. However, this case does not speak to, and prior experience does not demonstrate, significant neurological benefit in the setting of a complete injury.
PMCID: PMC4330208
Gunshot wound; Foreign body; Spinal cord injury; Laminectomy; Recovery of function
6.  Clinical and legal significance of fragmentation of bullets in relation to size of wounds: retrospective analysis 
BMJ : British Medical Journal  1999;319(7207):403-406.
To examine the relation between fragmentation of bullets and size of wounds clinically and in the context of the Hague Declaration of 1899.
Retrospective analysis of prospectively collected data on hospital admissions.
Hospitals of the International Committee of the Red Cross.
5215 people wounded by bullets in armed conflicts (5933 wounds).
Main outcome measures
Grade of wound computed from the Red Cross wound classification and presence of bullet fragments on radiography.
Of the 347 wounds with fragmentation of bullets, 251 (72%) were large wounds (grade 2 or 3)—that is, those with a clinically detectable cavity. Of the 5586 wounds without fragmentation of bullets, 2915 (52.1%) were large wounds. Only 7.9% (251/3166) of large wounds were associated with fragmentation of bullets.
Fragmentation of bullets is associated with large wounds, but most large wounds do not contain bullet fragments. In addition, bullet fragments may occur in wounds that are not defined as large. Fragmentation of bullets is neither a necessary nor sufficient cause of large wounds, and surgeons should not diagnose extensive tissue damage because of the presence of fragments on radiography. Such findings also do not necessarily represent the use of bullets which contravene the law of war. Future legislation should take into account not only the construction of bullets but also their potential to transfer energy to the human body.
Key messagesThe use of certain bullets has been prohibited in warWounds from bullets are caused by transfer of kinetic energy from the bullet to the tissuesThe relation between size of wound and fragmentation of bullets can be examined using the Red Cross wound classification system Fragments of bullets seen on radiographs of wounds sustained in wars do not necessarily represent large wounds or the use of illegal bulletsExisting legislation on the construction of bullets should be supplemented by legislation on how much energy is transferred to tissues
PMCID: PMC28192  PMID: 10445917
7.  Removal of 10-nm contaminant particles from Si wafers using CO2 bullet particles 
Nanoscale Research Letters  2012;7(1):211.
Removal of nanometer-sized contaminant particles (CPs) from substrates is essential in successful fabrication of nanoscale devices. The particle beam technique that uses nanometer-sized bullet particles (BPs) moving at supersonic velocity was improved by operating it at room temperature to achieve higher velocity and size uniformity of BPs and was successfully used to remove CPs as small as 10 nm. CO2 BPs were generated by gas-phase nucleation and growth in a supersonic nozzle; appropriate size and velocity of the BPs were obtained by optimizing the nozzle contours and CO2/He mixture fraction. Cleaning efficiency greater than 95% was attained. BP velocity was the most important parameter affecting removal of CPs in the 10-nm size range. Compared to cryogenic Ar or N2 particles, CO2 BPs were more uniform in size and had higher velocity and, therefore, cleaned CPs more effectively.
PMCID: PMC3349508  PMID: 22494621
Nano-bullet; CO2; Supersonic nozzle; Gas-phase nucleation; Cleaning efficiency
8.  Pattern, presentation and management of vascular injuries due to pellets and rubber bullets in a conflict zone 
Rubber bullets and pellet guns are considered non-lethal low-velocity weapons. They are used to disperse a mob during street protests. The present study was undertaken to analyze the pattern, presentation and management of vascular injuries caused by these weapons.
Patients and Methods:
This was a prospective study of patients with features of vascular injuries due to pellets and rubber bullets from June 2010 to November 2010. All patients with features of vascular injuries due to these non-lethal weapons were included in the study. Vascular injuries caused by other causes were excluded from the study.
A total of 35 patients who presented with features of vascular injury during this period were studied. All of them were males. The mean age was 22 years. Fifteen patients were revascularized primarily, 19 patients needed reverse saphenous vein graft and, in one, patient lateral repair was done. There were two mortalities in our series. Wound infection was the most common complication. The amputation rate was around 6%.
Pellet and rubber bullets can cause serious life-threatening injuries. Vascular injury caused by these weapons need no different approach than other vascular injuries. Early revascularization and prompt resuscitation prevents the loss of limb or life.
PMCID: PMC3746434  PMID: 23960369
Pellet; rubber bullet; vascular injury
9.  Bullet embolization to the external iliac artery after gunshot injury to the abdominal aorta: a case report 
Abdominal vascular trauma is fairly common in modern civilian life and is a highly lethal injury. However, if the projectile is small enough, if its energy is diminished when passing through the tissue and if the arterial system is elastic enough, the entry wound into the artery may close without exsanguination and therefore may not be fatal. A projectile captured may even travel downstream until it is arrested by the smaller distal vasculature. The occurrence of this phenomenon is rare and was first described by Trimble in 1968.
Case presentation
Here we present a case of a 29-year-old Albanian man who, due to a gunshot injury to the back, suffered fracture of his twelfth thoracic and first lumbar vertebra, injury to the posterior wall of his abdominal aorta and then bullet embolism to his left external iliac artery. It is interesting that the signs of distal ischemia developed several hours after the exploratory surgery, raising the possibility that the bullet migrated in the interim or that there was a failure to recognize it during the exploratory surgery.
In all cases where there is a gunshot injury to the abdomen or chest without an exit wound and with no projectile in the area, there should be a high index of suspicion for possible bullet embolism, particularly in the presence of the distal ischemia.
PMCID: PMC3169494  PMID: 21819587
10.  Gunshot Wound of the Thoracic Aorta with Right Popliteal Artery Embolization: A Case Report of Bullet Embolism with Review of Relevant Literature 
Bullet embolism is a well-known but relatively uncommon complication of gunshot injuries. Their rarity and the potential lack of early symptoms lead to delays in diagnosis and often in inadequate early management that can potentially result in the loss of a limb or life. We present an interesting case in which a small caliber bullet to the upper anterior abdomen penetrated the thoracic aorta and traveled to the right popliteal artery embolizing the vessel. The exploratory laparotomy failed to locate neither the bullet nor the trajectory resulting in sudden deterioration and eventual death 5 hours into the postoperative period.
PMCID: PMC3639690  PMID: 23662217
11.  Bullet Embolism into the Cardiovascular System 
Texas Heart Institute Journal  1982;9(1):75-80.
Two clinical case reports of bullet embolism into the cardiovascular system are reported. The patient in the first case sustained a gunshot wound at the right clavicular area with embolism resulting in the right ventricle. In the second case, the patient received a projectile wound to the anterior right shoulder with eventual bullet embolism in the left iliac artery. In both cases, the bullets were removed successfully. Surgical intervention with the aid of extracorporeal circulation is recommended for similar cases.
PMCID: PMC341476  PMID: 15226816
12.  Gunshot bullet embolus with pellet migration from the left brachiocephalic vein to the right ventricle: a case report 
We report the case of a 16 year old male who was the victim of a drive by shooting sustaining the rare but recognised complication of cardiovascular bullet embolism. He was seen as a trauma call in the emergency department and CT scanning revealed 70 shotgun pellets scattered throughout left sided sub-cutaneous tissues of the head and neck, and more significantly a single pellet within the right atrium. It is believed to have got there via injury to the left brachiocephalic vein which was demonstrated by extravasation of contrast on the CT scan. He remained stable throughout admission and the injury was managed conservatively. Serial scanning showed the pellet had subsequently migrated into the right ventricle where it has remained since, presumably having become epithelialised. This case report highlights the importance of repeated scanning for the possibility of projectile migration within the cardiovascular system in similar cases of penetrating injury.
PMCID: PMC2898681  PMID: 20565913
13.  Bullet Embolization: Multidisciplinary Approach by Interventional Radiology and Surgery 
Bullet embolization after penetrating trauma is an infrequent but important phenomenon. It presents an unexpected sequelae to the otherwise predictable injury pattern of penetrating missile injury mechanism and poses a challenging diagnostic and therapeutic dilemma. Bullets from penetrating wounds can gain access to the vasculature and migrate to nearly every large vascular bed. Patients can be asymptomatic, but the potential complications can be devastating including limb-threatening ischemia, sepsis, endocarditis, cardiac valvular incompetence, pulmonary embolism, stroke, and even death. The exact incidence of bullet embolization is unknown, but it was estimated to be 0.3% during the Vietnam War and 1.1% in the recent conflict in Afghanistan and Iraq. The scarcity of the condition and the lack of concentrated experience at any single institution contribute to the controversies pertaining to the management approach. Traditionally, surgical extraction of embolized bullets may involve difficult and invasive surgical exposures. Recent advancement in endovascular techniques provides an additional option in this treatment algorithm. In this article, we describe a case of venous bullet embolization from the left iliac vein treated by a combined endovascular and surgical approach.
PMCID: PMC3577595  PMID: 23997411
penetrating trauma; bullet embolization; endovascular retrieval; interventional radiology
14.  Is estimated bullet trajectory a reliable predictor of severe injury? Case report of a thoraco-abdominal gunshot with a protracted trajectory managed nonoperatively 
BMC Research Notes  2013;6:63.
Operative management of all gunshot’s traumas carries a high rate of unwarranted interventions that are known to cause serious complications. Selective nonoperative management is thus being increasingly practiced which has reduced these avoidable interventions. Physical examination and computed tomography scans are most sensitive in assessing need of laparotomy. Assessment of internal injuries on the basis of an estimated bullet trajectory is often practiced but has seldom been studied. We report a case of conservative management of a thoraco abdominal gun shot patient where an estimated bullet trajectory was indicative of serious injuries. To the best of our knowledge this is the first report of a thoraco abdominal gunshot that, despite of a protracted trajectory, had no sequelae and was thus managed nonoperatively.
Case presentation
A 30 year old male patient having height of 180 cm and weight of 70 kg (Body Mass Index 21.6) presented with complaint of a penetrating injury at left side of upper torso. The patient had no symptoms or obvious bleeding and was vitally stable. On examination a 1 cm × 1 cm entry wound at the left 3rd intercostal space in the mid clavicular line was identified. The chest and abdomen were otherwise unremarkable on examination. The chest radiograph displayed clear lung fields. The abdominal radiographs displayed a bullet in the upper left quadrant of the abdomen lateral to the spine. The bullets estimated trajectory from 3rd intercostal space and its lodgment in the abdomen lateral to the spine indicated severe visceral injury. The computed tomography scan showed that the bullet was lodged postero-medially to the left kidney. All thoracic, intra peritoneal and retroperitoneal visceral structures were identified to be normal. The patient remained clinically and vitally stable, hence was managed nonoperatively being discharged after 48 h of observation.
From this case we conclude that decision for managing gun shot patients should be based on objective clinical and diagnostic findings. We recommend further investigation of the predictability of estimated trajectory for visceral injuries and consequent operative intervention as we found it to be misleading in this case.
PMCID: PMC3598892  PMID: 23414905
15.  Bronchoscopic retrieval of a bullet using a Dormia basket: a case report 
Penetrating bullet injury to the trachea is a rarity, and therefore standardized procedure for injury management and foreign body removal has not been established. This is a case report describing retrieval of a bullet from the bronchus intermedius using flexible bronchoscopy and a Dormia basket.
Case presentation
A 19-year-old African American woman presented with a gunshot wound to her right neck just lateral to the sternal head of the sternocleidomastoid muscle and just superior to the clavicle. Imaging showed a bullet lodged within her right bronchus with no evidence of vascular injury. Fiberoptic flexible bronchoscopy in combination with biopsy forceps and a Dormia basket were used for bullet removal.
Removal of foreign bodies from the airway is essential in order to avoid complications such as tracheal stenosis, pneumonia, bronchiectasis and foreign body migration. To the best of our knowledge, this case is one of only several cases reporting the use of flexible bronchoscopy for bullet removal, and this is the only case to describe the use of a Dormia basket. This case demonstrates bronchoscopy as a safe and effective means of minimally invasive removal of a bullet fragment from the bronchus in a trauma setting.
PMCID: PMC4234521  PMID: 25362866
Bronchoscopic foreign body retrieval; Dormia basket; Penetrating neck trauma
16.  Potential Hazard to Human Health from Exposure to Fragments of Lead Bullets and Shot in the Tissues of Game Animals 
PLoS ONE  2010;5(4):e10315.
Lead is highly toxic to animals. Humans eating game killed using lead ammunition generally avoid swallowing shot or bullets and dietary lead exposure from this source has been considered low. Recent evidence illustrates that lead bullets fragment on impact, leaving small lead particles widely distributed in game tissues. Our paper asks whether lead gunshot pellets also fragment upon impact, and whether lead derived from spent gunshot and bullets in the tissues of game animals could pose a threat to human health.
Methodology/Principal Findings
Wild-shot gamebirds (6 species) obtained in the UK were X-rayed to determine the number of shot and shot fragments present, and cooked using typical methods. Shot were then removed to simulate realistic practice before consumption, and lead concentrations determined. Data from the Veterinary Medicines Directorate Statutory Surveillance Programme documenting lead levels in raw tissues of wild gamebirds and deer, without shot being removed, are also presented. Gamebirds containing ≥5 shot had high tissue lead concentrations, but some with fewer or no shot also had high lead concentrations, confirming X-ray results indicating that small lead fragments remain in the flesh of birds even when the shot exits the body. A high proportion of samples from both surveys had lead concentrations exceeding the European Union Maximum Level of 100 ppb w.w. (0.1 mg kg−1 w.w.) for meat from bovine animals, sheep, pigs and poultry (no level is set for game meat), some by several orders of magnitude. High, but feasible, levels of consumption of some species could result in the current FAO/WHO Provisional Weekly Tolerable Intake of lead being exceeded.
The potential health hazard from lead ingested in the meat of game animals may be larger than previous risk assessments indicated, especially for vulnerable groups, such as children, and those consuming large amounts of game.
PMCID: PMC2859935  PMID: 20436670
17.  Cervical spinal cord bullet fragment removal using a minimally invasive surgical approach: a case report 
We present a case of penetrating gunshot injury to the high-cervical spinal cord and describe a minimally invasive approach used for removal of the bullet fragment. We present this report to demonstrate technical feasibility of a minimally invasive approach to projectile removal.
Case presentation
An 18-year-old African-American man presented to our hospital with a penetrating gunshot injury to the high-cervical spine. The bullet lodged in the spinal cord at the C1 level and rendered our patient quadriplegic and dependent on a ventilator. For personal and forensic reasons, our patient and his family requested removal of the bullet fragment almost one year following the injury. Given the significant comorbidity associated with quadriplegia and ventilator dependency, a minimally invasive approach was used to limit the peri-operative complication risk and expedite recovery. Using a minimally invasive expandable retractor system and the aid of a microscope, the posterior arch of C1 was removed, the dura was opened, and the bullet fragment was successfully removed from the spinal cord.
Here we describe a minimally invasive procedure demonstrating the technical feasibility of removing an intramedullary foreign object from the high-cervical spine. We do not suggest that the availability of minimally invasive procedures should lower the threshold or expand the indications for the removal of bullet fragments in the spinal canal. Rather, our objective is to expand the indications for minimally invasive procedures in an effort to reduce the morbidity and mortality associated with spinal procedures. In addition, this report may help to highlight the feasibility of this approach.
PMCID: PMC3438077  PMID: 22876811
Bullet; Gunshot wound; Intramedullary; Minimally invasive spine surgery; Spinal cord
18.  Atypical gunshot injury to the right side of the face with the bullet lodged in the carotid sheath: a case report 
Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet’s trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering’; a first of its kind in East Africa.
Case presentation
A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering’) of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering’ bullet was successfully removed surgically. It had caused no damage to any part of her neck structure.
AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the important decision to extract the entrapped bullet from the patient’s neck because it had started to 'wander’ and could have caused grave injury over time with further migration. Maxillofacial, plastic, trauma, general and military surgeons, otorhinolaryngologists and emergency physicians can gain from this experience because it calls for a multidisciplinary team approach.
PMCID: PMC3917526  PMID: 24467784
AK-47 rifle; Carotid sheath; Facial injuries; Mandibular fracture; Middle ear injury; Nerve damage; Surgical extraction; Wandering bullet
19.  Pulmonary artery bullet embolism—Case report and review 
Bullet embolism, an uncommon but serious complication of penetrating vascular trauma, poses a unique clinical challenge for the trauma physician. Migration of bullets can lead to infection, thrombosis, ischemia, hemorrhage and death.
We report a patient in whom a bullet embolized from the left femoral vein to the right pulmonary artery, a situation ultimately managed by observation alone.
Bullet embolism should be suspected when the number of penetrating entry wounds exceeds the number of exit wounds. Patients with radiographic studies showing a bullet outside the established trajectory require further evaluation. Most bullet emboli are arterial, and are generally symptomatic presenting with early signs of ischemia. Venous emboli are less common, and they are generally asymptomatic. Most venous bullet emboli travel in the direction of the blood flow and may lodge in the pulmonary arterial tree causing serious complications. Management of bullet emboli in the pulmonary arterial tree remains controversial and specific guidelines have not been clearly established. However, the available data in the literature suggest that pulmonary artery embolism can be observed in the asymptomatic patient.
Symptomatic pulmonary bullet emboli should be managed with endovascular retrieval when available or operative therapy. Asymptomatic intravascular bullet emboli may be managed conservatively as seen in our patient.
PMCID: PMC3731686  PMID: 23567547
Bullet embolism; Penetrating vascular injury; Femoral vein injury; Pulmonary artery bullet embolism
20.  A firearm bullet lodged into the thoracic spinal canal without vertebral bone destruction: a case report 
Firearm injuries account for 13% to 17% of all spinal cord injuries, and are generally caused during warfare or assault with intent to kill. Spinal cord injuries caused by firearms are usually observed in patients aged 15 to 34 years old, and are especially common among men.
Case presentation
We report the case of a 28-year-old Iraqi man who was referred to our radiology department with lower limb paraplegia secondary to a gunshot wound. We performed 64-slice computerized tomography with two-dimensional and three-dimensional reconstruction of the thoracolumbar spine. On the two-dimensional and three-dimensional reconstructed axial images of the thoracolumbar spine, an intra-canalicular bullet nucleus was found at the mid-spinal cord at the T8 level, with no evidence of vertebral bone destruction.
To the best of our knowledge, there is only one previous report in the literature describing a case of a bullet nucleus lodged into the inferior epidural spinal canal without destruction of the vertebral bone. With the rise of violence worldwide the incidence of gunshot injuries continues to increase, and, thus, it is essential for radiologists to have a clear understanding of gunshot injuries and the findings on radiographic images.
PMCID: PMC3142520  PMID: 21733154
21.  Bullet embolization from an aorto-caval fistula to the heart 
Bullet emboli to the heart as a result of penetrating trauma are rare. We report a case of a 19-year old male who suffered a gunshot wound to the abdomen, resulting in an aorto-caval fistula and subsequent venous embolization of the bullet to the right ventricle. Successful surgical removal of the foreign body under cardiopulmonary bypass was performed.
PMCID: PMC3630424  PMID: 23355649
Aorto-caval fistula; Venous embolization
22.  The Wandering Bullet 
The phenomenon of bullet embolization has been documented in various organs or major organ systems. A case report of a gunshot wound injury to the left hemithorax with penetration of the esophagus and embolization to the stomach is presented. Diagnostic evaluation and therapy are discussed.
PMCID: PMC2625665  PMID: 3292777
23.  Matrix Protein of Rabies Virus Is Responsible for the Assembly and Budding of Bullet-Shaped Particles and Interacts with the Transmembrane Spike Glycoprotein G 
Journal of Virology  1999;73(1):242-250.
To elucidate the functions of rhabdovirus matrix (M) protein, we determined the localization of M in rabies virus (RV) and analyzed the properties of an M-deficient RV mutant. We provide evidence that M completely covers the ribonucleoprotein (RNP) coil and keeps it in a condensed form. As determined by cosedimentation experiments, not only the M-RNP complex but also M alone was found to interact specifically with the glycoprotein G. In contrast, an interaction of G with the nucleoprotein N or M-less RNP was not observed. In the absence of M, infectious particles were mainly cell associated and the yield of cell-free infectious virus was reduced by as much as 500,000-fold, demonstrating the crucial role of M in virus budding. Supernatants from cells infected with the M-deficient RV did not contain the typical bullet-shaped rhabdovirus particles but instead contained long, rod-shaped virions, demonstrating severe impairment of the virus formation process. Complementation with M protein expressed from plasmids rescued rhabdovirus formation. These results demonstrate the pivotal role of M protein in condensing and targeting the RNP to the plasma membrane as well as in incorporation of G protein into budding virions.
PMCID: PMC103828  PMID: 9847327
24.  Nanobody: The “Magic Bullet” for Molecular Imaging? 
Theranostics  2014;4(4):386-398.
Molecular imaging involves the non-invasive investigation of biological processes in vivo at the cellular and molecular level, which can play diverse roles in better understanding and treatment of various diseases. Recently, single domain antigen-binding fragments known as 'nanobodies' were bioengineered and tested for molecular imaging applications. Small molecular size (~15 kDa) and suitable configuration of the complementarity determining regions (CDRs) of nanobodies offer many desirable features suitable for imaging applications, such as rapid targeting and fast blood clearance, high solubility, high stability, easy cloning, modular nature, and the capability of binding to cavities and difficult-to-access antigens. Using nanobody-based probes, several imaging techniques such as radionuclide-based, optical and ultrasound have been employed for visualization of target expression in various disease models. This review summarizes the recent developments in the use of nanobody-based probes for molecular imaging applications. The preclinical data reported to date are quite promising, and it is expected that nanobody-based molecular imaging agents will play an important role in the diagnosis and management of various diseases.
PMCID: PMC3936291  PMID: 24578722
Nanobody; molecular imaging; cancer; arthritis; atherosclerosis; positron emission tomography (PET)
25.  Vagoglossopharyngeal-Associated Syncope Due to a Retained Bullet in the Jugular Foramen 
Skull Base  2010;20(2):105-109.
Gunshot wounds (GSWs) to the head are frequently fatal. Rarely, the bullet may lodge in the skull base and not cause significant brain injury. Typically, the bullet fragments are felt to be inert and do not require operative extirpation if they are within the bony confines of the skull base. We report the case of a bullet in the jugular foramen causing recurrent syncope that resolved after surgical removal of the bullet. The medical records from a patient who suffered a GSW to the head were retrospectively reviewed and the treatment and outcome documented. In 2000, a 20-year-old man suffered a GSW to the head. Immediate evaluation revealed the bullet in the right skull base at the jugular foramen, but no parenchymal brain injury. One year after the GSW, he began to experience stereotypical spells resulting in loss of consciousness. Extensive cardiovascular workup was normal. In 2002, the patient underwent removal of the bullet. He has been syncope-free since the operation and returned to his career in the military. We believe the retained bullet in this patient was irritating the IX–X cranial nerves, resulting in syncope, similar to the mechanism in vagoglossopharyngeal neuralgia. Removing the bullet relieved the irritation and stopped the syncopal spells.
PMCID: PMC2853077  PMID: 20808535
Gunshot wounds; jugular foramen; Syncope; vagoglossopharyngeal neuralgia

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