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This was one of our Midnight Warriors

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in East Baltimore, Baltimore City.

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And one had a history of gunshot wound

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to the left neck. So on these images,

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when we start from below and try

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to track the carotid arteries,

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we'll start with the left common carotid

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artery and just follow it up.

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And what we're seeing is some subcutaneous and neck

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space air, which is likely from the

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entry wound of the bullet.

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And here we have our carotid bifurcation.

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Well, at this carotid bifurcation,

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we're already seeing irregularity to the lumen of the

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vessel, and we're seeing a thrombus in the vessel, and

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we're seeing all the air around the carotid sheath on

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the left side. If we continue further superiorly,

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we have a portion of the bullet in the subcutaneous

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fat posterior to the sternocleidomastoid muscle,

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and we have all this air tracking along the

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parapharyngeal space and carotid sheath structures.

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Up at this level,

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you notice that we're seeing the internal

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carotid artery on the right side,

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but we don't see the internal carotid

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artery on the left side.

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All this is fractured bone that has come through the

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space. In fact, you have some in the masticator space,

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you have some in the prestyloid parapharyngeal space,

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and you have some in the poststyloid parapharyngeal

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space or the carotid space.

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So this is an example of direct injury to the internal

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carotid artery secondary to a gunshot wound to the

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face leading to thrombosis of the internal carotid

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artery. Notice that we're not seeing the jugular vein.

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This is because the timing of this

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study was for an arteriogram.

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So this is a CT arteriogram, and it's normal for the

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jugular vein not to be seen because of the

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timing of the bolus for the imaging in this case.

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Let's look at this case with bone windows. Here's

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the thin section bone.

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And we just get a better sense of how much of this is

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metallic artifact or metallic component of the

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bullet versus bone fracture fragments.

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And you can see that the patient has had

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extensive fracture of the facial bones.

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And some of the density here represents

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bone from the fractures,

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some of it represents metal from the bullet itself.

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And strange as it may seem,

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this bullet went from the anterior face.

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He was shot in the face,

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and the bullet lodged posteriorly here in

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the subcutaneous fat, superficially.

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This is the 3D reconstruction of the

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examination put into the bone algorithm, and as you can

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see, you have the normal right side with the mandible,

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the zygomatic arch, and the orbit.

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Let's look on the left side.

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So here on the left side, we see the bullet.

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We sort of see the trajectory of the bullet.

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We see the fractures involving the anterior

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facial structures. But in addition,

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I think nicely demonstrated, is the stump of the left

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internal carotid artery just above the carotid

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bifurcation where the bullet had

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injured the carotid artery,

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dissected it, and led to thrombosis. Notice on the

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contralateral side, you see the internal carotid artery

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going above and behind the mandible

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in the normal fascia.