Bullet fragment embolisation to posterior cerebral artery from a gunshot wound to the left shoulder

A male patient in his late 40s presented after a single high-velocity gunshot injury to the left shoulder. He was haemodynamically unstable on arrival with no evidence of neurological deficit. CT of the thorax and abdomen showed multiple bullet fragments throughout the posterior left thorax with evidence of an acute aortic injury. Following resuscitation, the patient stabilised, and his aortic injury was managed conservatively. Two days postinjury, postextubation, the patient reported a homonymous hemianopia. CT brain and angiography showed a subacute left posterior cerebral artery (PCA) territory infarct. A metallic bullet fragment was identified within the lumen of the left PCA vessel segment, compatible with an arterial bullet fragment embolus causing occlusion of the left PCA. The patient was managed conservatively. Full head to toe (scout) imaging should be considered during initial work-up of low- and high-velocity firearm injuries to exclude distant embolisation of bullet fragments.