Computed tomography angiography-guided conservative management of a penetrating ballistic neck injury involving the carotid sheath: A case report

Penetrating ballistic neck injury carries a high risk of vascular injury, particularly to the common carotid artery (CCA), due to its superficial location and critical role in cerebral perfusion. While surgical intervention is indicated in the presence of "hard signs" of vascular injury, the role of conservative management in asymptomatic patients remains debated. We report the case of a 45-year-old male who sustained a penetrating ballistic injury while seated and cleaning his 5-shot hunting rifle (shotgun). The accidental discharge occurred at less than 1 meter, producing a short-range, low-velocity dispersion of 42 metallic pellets across the craniofacial, cervical, and thoracoabdominal regions. The trajectory was oblique, consistent with the patient's seated position. Computed tomography angiography (CTA) revealed multiple pellets adjacent to the carotid sheath without evidence of vascular disruption, active bleeding, or neurological deficit. The patient was managed conservatively with close clinical and imaging surveillance. This case highlights the feasibility and safety of nonoperative management in carefully selected, hemodynamically stable patients with penetrating ballistic cervical injury, even when projectiles are located near major vascular structures. CTA was pivotal for initial assessment, surgical decision‑making, and follow‑up planning. A structured surveillance protocol incorporating serial neurological examinations and repeat imaging is proposed to detect delayed complications such as pseudoaneurysm, thrombosis, or dissection. In the absence of clinical or radiological signs of vascular injury, CTA-guided conservative management can be a safe alternative to surgery, provided rigorous monitoring is ensured. This approach may reduce unnecessary surgical morbidity while maintaining patient safety.