IN A suicide attempt using an air rifle, a 49-year-old man suffered an oral gunshot. The bullet ended up close underneath the skull base and the patient survived (Figure 1, A). He was taken to the hospital where the projectile was surgically removed. Soon after the trauma he noticed a deviation of his tongue to the left. Two days later he developed a right-sided hemiparesis, Broca's aphasia, and a right homonymous hemianopia. On physical examination he also showed dysarthria, an incomplete left-sided Horner's syndrome, and a hypoglossal paresis without any wasting of the tongue (Figure 1 B). Cranial magnetic resonance imaging (MRI) revealed a left middle cerebral artery and a posterior cerebral artery infarction. The only abnormality seen on MRI was the fetal origin of the posterior cerebral artery. T1-weighted, fat-suppressed axial MRI scan as well as duplex ultrasound images confirmed a dissection of the left internal carotid artery (Figure 1 C). In addition, a small extravascular hematoma anterior to the internal carotid artery was seen. The gunshot wounds were allowed to heal before the patient was started on a temporary regimen of oral anticoagulants.
Hagemann G, Willig V, Fitzek C, Witte OW. Gunshot-Induced Artery Dissection With Twelfth Nerve Palsy. Arch Neurol. 2003;60(2):280-281. doi:10.1001/archneur.60.2.280