Migration of missile fragments into the heart via the cerebral venous sinuses: A report of 3 cases and a comprehensive review of the literature.

Vascular injury from projectiles can lead to the migration of missile fragments, resulting in arterial or venous missile embolism. In the context of penetrating craniocerebral trauma, this complication is exceedingly rare. This can only occur when a missile breaches a dural venous sinus or the jugular vein, leading to subsequent embolization into the right cardiac chambers or the pulmonary arteries. We present 2 cases of right ventricular missile embolism and 1 case of pulmonary artery missile embolism via dural sinuses and provide a comprehensive review of 7 additional cases from the literature. A 25-year-old male was admitted on day 7 after a penetrating missile head injury. Initial head CT showed a complex wound channel but no intracranial fragment; however, a chest X-ray revealed the metal fragment in the right ventricle. After multidisciplinary consultation, he was managed conservatively with close monitoring for 21 days without complications before transfer for rehabilitation. A 30-year-old male presented on post-injury day 1 with a diametrical penetrating brain injury and a wound track terminating at the right transverse sinus. No fragment was found intracranially, but imaging confirmed its location in the right ventricle. The patient underwent emergency neurosurgical intervention and was subsequently lost to follow-up after transfer. A 26-year-old male presented on day 7 after a transorbital penetrating craniocerebral injury with a right carotid-cavernous fistula and missile embolism to the right pulmonary artery. Endovascular treatment achieved complete fistula occlusion, and the patient received prophylactic anticoagulation. Follow-up imaging demonstrated regression of the fistula with stable positioning of the pulmonary artery fragment, and the patient was transferred to rehabilitation after 14 days. This report highlights venous missile embolism as a rare but critical complication of penetrating craniocerebral trauma. Our analysis, including 3 new cases and a review of the literature, demonstrates that conservative management is a viable and often preferred strategy for stable patients with intracardiac or pulmonary missiles. The decision-making process should be multidisciplinary, individualized, and guided by patient-specific factors.