MILITARY MEDICINE, 176, 2:228, 2011
Delayed Diagnosis of Intracerebral Foreign Body From
the Vietnam War
David B. FitzGerald, MD*†‡; Joseph M. Gullett, BS†; Charles E. Levy, MD§; Bruce A. Crosson, PhD†||
ABSTRACT We report on a 22-year-old infantryman who sustained a right frontal wound to his head. He was treated
and returned to duty immediately. During a computed tomography scan, 38 years after the incident, a metallic foreign
body and disruption of the brain consistent with a projectile track were discovered in his brain. In this report, we review
similar cases of delayed discovery of unsuspected foreign bodies and the probable nature of the wound.
INTRODUCTION
Computed tomography (CT) and roentgenograms (X-rays)
are low-risk tools that have become widely available. These
tools are considered routine components of standard evalua-
tions for head wounds and suspected brain injury. Thus, it is
commonly assumed that foreign bodies in the brain will be
detected as part of a routine evaluation after injury. However,
injuries may be incurred in austere environments where these
imaging modalities are not available. This lack of imaging
may result in delayed discovery of intracerebral foreign bod-
ies to the potential detriment of the patients’ health. We pres-
ent here such a case.
CASE REPORT
A 22-year-old, left-handed U.S. infantryman was engaged in
a firefight in Vietnam when he experienced a loud flash. His
subsequent loss of consciousness was not witnessed, but was
estimated by him to be of several seconds in duration. After
recovering consciousness, he realized that he had a wound
in his right temple and a corpsman came and assisted him.
He was treated with a field dressing and then told to return
to battle. He did not have noticeable deficits at that time and
was able to continue his duties as a squad leader. After several
days, the wound on his temple had healed sufficiently for him
to discard his battle dressing. No X-rays were performed. He
did not experience a headache or an alteration of vision after
the initial flash.
The soldier eventually became aware of a small, palpable
stationary mass underneath the well-healed area of the original
injury. He attributed this to a retained fragment of bullet or
*Neurology Service and †Brain Rehabilitation Research Center,
Rehabilitation Research and Development Service (RR&D), Office of
Research and Development, Department of Veteran Affairs, North Florida/
South Georgia Veterans Health System, 1601 SW Archer Road, Gainesville,
FL 32608-1197.
‡Department of Neurology, University of Florida, PO Box 100236,
Gainesville, FL 32610-0236.
§Physical Medicine and Rehabilitation Service, North Florida/South
Georgia Veterans Health System, 1601 SW Archer Road, Gainesville, FL
32608-1197.
||Department of Clinical and Health Professions, University of Florida,
PO Box 100185, Gainesville, FL 32610-0185.
228
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shrapnel. He remained on active duty for 8 years after return-
ing to the United States and then retired. Following retirement,
he worked as a truck driver, security guard, and bodyguard,
supporting himself, his wife, and children. He was diagnosed
with posttraumatic stress disorder (PTSD) and alcohol abuse
as a civilian.
He had a syncopal episode and underwent a noncontrast
head CT in 2006, which was considered to be an unremark-
able study with the exception of a finding, “a metallic foreign
body in the medial aspect of the right frontal lobe.” The dis-
covery of a foreign body in his head was not communicated to
him until an office visit in 2010 for an unrelated matter. The
retention of the metallic foreign body was not considered to be
related to his syncopal episode.
His examination in the office in 2010 showed no neuro-
logical deficits, including full visual field of view to confron-
tation. The level of lead in the patient’s serum was found to
be <3 mcg/dL, which is considered to be within normal lim-
its. Neurosurgical intervention was deferred indefinitely. The
patient’s electronic medical record was flagged for a metallic
foreign body to prevent magnetic resonance imaging (MRI)
scans being performed in the future.
Imaging
Images of the patient’s CT scan are shown in Figures 1 and 2.
The single metallic object measures 0.70 cm in the longitudi-
nal direction of the object, which is in line with the object’s
apparent trajectory in the brain. The short dimension of the
object in the axial plane is 0.47 cm. The object is seen in 2
slices; thus, the inferior–superior length of the object is less
than 9 mm (CT slice thickness is 4.5 mm in this study).
DISCUSSION
The discovery of unsuspected intracerebral foreign bodies
years after injury has been rarely reported, yet the lack of
detection may have clinical consequences even for an appar-
ently intact survivor. Several case reports exist documenting
the late discovery of such bodies in symptomatic children and
adults (Table I).
During evaluation for tonic-clonic seizures of 6 months
duration, a wooden fragment from a child’s toy was found in
MILITARY MEDICINE, Vol. 176, February 2011
 Intracerebral Foreign Body
FIGURE 1. CT scout display of the patient shows a single metallic foreign
object measuring approximately 0.66 cm from the anterior tip to the posterior
tip of the object.
a 4-year-old girl in her right temporal lobe. This discovery
was made 3 years after a transtemporal penetrating injury. The
purulent material surrounding the piece of wood was found to
be sterile on aerobic and anaerobic cultures. Immediately after
the initial injury, the child’s neurological examination was
considered normal.1 One year after the removal of the piece
of wood, the child was seizure-free and had no neurological
deficits (Ravi Dadlani, personal communication).
Two cases of penetrating injuries with delays in removal of
the retained foreign bodies were reported by Orszagh et al.2
In one case, a wooden branch was found to have entered a
2-year-old child’s brain via a transorbital route after a fall onto
a hedge. The entry wound was below the right lower eyelid,
with the object in the mediobasal aspect of the right tempo-
ral lobe. Her neurological examination was considered normal
with the exception of ptosis and a mydriatic right pupil. The
development of exophthalmos triggered additional investiga-
tions, and an MRI was performed on day 10 after the accident.
The MRI definitively determined the presence of a foreign
body, which was then removed.
In the second case, a skiing accident resulted in tran-
sorbital penetration of an 8 cm × 0.6 cm tree branch to the
parenchyma. The entry site was located below the right lower
eyelid, with the tree branch extending across the midline to
the left basal ganglia. No neurological deficits were seen dur-
ing examination at the time of the accident and the patient was
discharged on the same day. He was readmitted the next morn-
ing after being found comatose at home. Chronic meningitis
triggered the search for a cause of infection, with discovery of
the retained tree branch in the right orbital roof extending to
the left basal ganglia 64 days after the accident.2
Liu et al3 reported on a bamboo stick that penetrated the
left upper eyelid after a fall by an 18-month-old boy. The pres-
ence of a retained portion of the bamboo stick was recognized
1 month after the accident during evaluation for severe orbital
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FIGURE 2. Axial CT scan image showing the apparent entry trajectory in
the right frontal lobe with loss of tissue extending to the right lateral ventricle.
Slice thickness is 4.5 mm, with radiological convention used. The long axis of
the object is 1.05 cm, and the short axis of the object is 0.59 cm.
swelling and slight headache. The bamboo stick remnant was
found in the left frontal lobe and was removed.3
A 30-year-old bicyclist crashed his bicycle and sustained a
mildly depressed left frontal skull fracture. Two months later,
a retained bicycle wheel valve cap was discovered in his left
frontal lobe after evaluation for mild but persistent headache,
followed by neurosurgery to remove the object.4
A case of 2 retained objects in the brain were identified as
a result of psychiatric symptoms by Yamakawa et al.5 They
reported a case of a 69-year-old gentleman with seizures,
sometimes accompanied by visual hallucinations. Evaluation
of the seizures led to the discovery of a bullet (34 mm × 10 mm
in size) and a metal fragment. The bullet was found to be in
the right occipital lobe and the fragment was found in the left
extracranial temporal lobe. Both objects were thought to have
penetrated his brain 45 years earlier during the Sino–Japanese
War. The objects were removed and the patient’s symptoms
resolved after a 14-day course of penicillin.5
Jennett and Teasdale6 pointed out that puncture wounds
can be deceptive in their severity. Removal of the penetrating
agent may reduce the suspicion that penetration of the skull
has occurred. They noted that this is particularly true in the
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TABLE I. A Summary of Historical Cases of Delayed Diagnosis of Intracerebral Foreign Bodies

Age at Trauma Time From Injury to

(years) Location of Foreign Body Nature of Foreign Body Symptoms Nature of Symptoms References
1 Right Temporal Lobe via Wood From a Toy 3 years Generalized Tonic-clonic 1
Right Squama Temporalis Seizures
2 Lateral to Right Oculomotor Wooden Branch Within Few hours, Meningitis, Followed by 2
Nerve to Parapontine Cistern Meningitis; Then 4 Exophthalmos of
via the Right Superior or More Days Later, Right Eye
Orbital Fissure Exophthalmos
35 Right Medial Orbit to Left Wooden Branch Next Morning Comatose 2
Basal Ganglia (8.0 cm × 0.6 cm)

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1.5 Left Frontal Lobe With Entry at Bamboo Stick >1 cm 1 month Severe Orbital Swelling and 3
Left Orbital Roof in Length Slight Headache
30 Left Frontal Lobe via Left Bicycle Wheel Valve Cap 2 months Mild, Persistent Headache 4
Frontal Bone (approximately
1 cm × 1 cm)
24 Right Occipital Lobe Near Bullet (35 mm × 10 mm) 4 months Minimum, Epileptic Seizures Sometimes 5
the Right Tentorium With Definitive Accompanied by Visual
Diagnosis 45 years Hallucinations With Todds
Later Palsy on the Left Side

With the exception of the case we report on, all foreign bodies were discovered after the presentation of new symptoms. All foreign bodies were in noncritical
structures, e.g., not in the diencephalon, the brain stem, the cerebellum, or the major motor pathways.

case of eyelid or sclera. In our review, 2 of the 6 cases had
entry through the orbital fissure or the orbital roof.
Infection is a major medical complication of gunshot
wounds.7 However, in a study of missile wounds that pene-
trated to the brain, in Vietnam, only 5 of the brain wound sites
in 45 patients showed bacterial contamination. Contamination
was also observed in 44 of the skin wounds. In-driven bone
chips were estimated to be sterile in up to 75% of the wounds,
suggesting that in rare cases penetrating head wounds might
not result in infection.8
Karger9 suggests in a review of wound ballistics that
either hunting or military rifles cause comminution of bone
and laceration of the brain in penetrating head injury. In a
companion review article of gunshot wounds and preserved
capacity to act, he also suggests that wounds limited to the
frontal lobes, which avoid the brain stem, diencephalon,
major motor paths of conduction, and cerebellum, may be
survivable and not incapacitating.10 All the cases of delayed
diagnosis that we have listed earlier and in Table I avoid the
brain stem, the diencephalon, the major motor paths of con-
duction, and the cerebellum, although some do involve the
temporal lobes.
North Vietnamese forces typically used AK-47 rifles in
the Vietnam war. The standard cartridge in an AK-47 is a
7.62 mm × 39 mm cartridge. The bullet dimensions for this
size cartridge are approximately 23 mm long with a 7.92 mm
diameter. The dimensions of the foreign body in our case are
smaller than this, suggesting that the foreign body is either a
bullet fragment or a piece of shrapnel.
In addition, the lack of penetration through the opposite
side of the skull suggests that a spent bullet fragment or a
piece of shrapnel was responsible for the wound rather than
a full-sized bullet from a military rifle.9 Hammon11 found that
many more penetrating wounds were fragment wounds in con-
trast to bullet wounds. Of 2,187 admissions in his study, 1,790
were attributed to fragment wounds and 351 were attributed
to bullet wounds. Forty six of the admissions were for other
causes.11
In our case, the discovery of the foreign body was inci-
dental. Using the standard clinical guidelines for diagnosing
traumatic brain injury (TBI), this veteran would be diagnosed
with a mild TBI (no focal deficits and loss of consciousness
for less than 30 minutes).12 However, the extensive dam-
age caused by the foreign object with loss of parenchyma
changes the classification of his injury to moderate or severe
TBI.
Although the veteran appeared to be without major deficits
following the initial injury, he was later diagnosed with PTSD
and alcoholism. It is speculative, but we wonder if the dam-
age to the veteran’s right temporal lobe might have contrib-
uted to his PTSD and alcoholism. As noted by Damasio and
Anderson,13 there can be a wide set of symptoms associated
with frontal lobe dysfunction, including cognitive deficits,
impairments of social behavior, impulse control, and decision
making. For this patient, the ability to estimate his premor-
bid functioning is complicated as he was left-handed; thus,
the lateralization of his language is not easily predicted. The
preservation of speech suggests that he was left hemisphere
language–dominant, but this is difficult to prove. The patient
has never received neuropsychological testing.
Early detection of the brain injury might have led to a more
nuanced appraisal of the veteran’s limitations, to a differ-
ent course of treatment, and to provide some explanation for
symptoms attributed at the time to PTSD. In addition, ear-
lier diagnosis might have affected the veteran’s compensation
entitlement and vocational choices.

230 MILITARY MEDICINE, Vol. 176, February 2011

 Intracerebral Foreign Body
CONCLUSION
Delayed recognition of retained intracerebral foreign bod-
ies can occur. Usually, these cases come to light as part of
the diagnostic process for determining the source of infec-
tion, seizure, or headache. However, not all retained foreign
objects trigger infection or other symptoms. Survival after a
penetrating head injury is more likely with shrapnel or bullet
fragments as opposed to intact bullets. Shrapnel or bullet frag-
ments are of lower velocity and, thus, are less likely to affect
critical structures. Physicians should be cautious in assuming
that apparent superficial wounds are truly only superficial and
should obtain screening films before ordering MRI-based pro-
cedures in patients with head wounds.
ACKNOWLEDGMENTS
We thank the staff of the Malcom Randall Veterans Affairs Medical Center
Library for their help in obtaining reference materials. Dr. FitzGerald is spon-
sored by Veterans Health Administration RR&D grant B6698W. Dr. Crosson
is sponsored by Veterans Health Administration RR&D grant B6364S and
NIH grants R21-DC009247 and R01-DC007387.
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