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Year : 2016  |  Volume : 7  |  Issue : 1  |  Page : 53-55

Persisting metallic bullet inside the brain: The role of the speech language pathologist in the assessment and management of communication skills in traumatic brain injury based on a single case study

Department of Speech and Hearing, Father Muller College, Mangalore, Karnataka, India

Date of Web Publication21-Jan-2016

Correspondence Address:
Priyanka EM Vas Naik
Department of Speech and Hearing, Father Muller College, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.174649

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To acquire more knowledge on the communication skills after traumatic brain injury (TBI) caused due to gunshot with the bullet sustained in the brain. Formal speech, language, voice, hearing, and swallowing functions were evaluated using several tests and an informal assessment of reading, writing, and arithmetic skills were performed. Results of the evaluation gave a diagnosis as global aphasia with spastic dysarthria. Moderate to severe impairment was observed in the swallowing function. Right hemisphere functions were severely affected except for the music perception. On hearing screening, otoacoustic emissions were present in both the ears suggesting a normal outer hair cell function. The present study hence outlined the speech and language characteristics secondary to TBI with a persisting metallic bullet in the brain. Therefore, it is important that a speech language pathologist plays a role in the comprehensive assessment and management of individuals with TBI to provide a better quality of life.

Keywords: Frenchay dysarthria assessment (FDA), metallic bullet, traumatic brain injury (TBI), Western Aphasia Battery (WAB)

How to cite this article:
Vas Naik PE, Zacharia T, Kuniyil JG, Sada S. Persisting metallic bullet inside the brain: The role of the speech language pathologist in the assessment and management of communication skills in traumatic brain injury based on a single case study. Muller J Med Sci Res 2016;7:53-5

How to cite this URL:
Vas Naik PE, Zacharia T, Kuniyil JG, Sada S. Persisting metallic bullet inside the brain: The role of the speech language pathologist in the assessment and management of communication skills in traumatic brain injury based on a single case study. Muller J Med Sci Res [serial online] 2016 [cited 2022 Jun 25];7:53-5. Available from: https://www.mjmsr.net/text.asp?2016/7/1/53/174649

  Introduction Top

Traumatic brain injury (TBI) is a form of acquired brain injury that occurs when a sudden trauma causes damage to the brain. Symptoms of TBI can be mild, moderate, or severe, being dependent on the extent of the damage to the brain. TBI due to gunshot is a complex injury from a variety of symptoms and high rates of mortality and morbidity. [1] According to an estimate at the National Institute of Mental Health and Neuro Sciences, the incidence of TBI in India is 2,000,000. [2] The study and treatment of bullet wounds have been the subject of a considerable amount of medical thought and writing since the introduction of gun powder in Europe in the 14th century. [3] On reviewing earlier studies, it is expected to be very rarely reported as an individual surviving with a persisting foreign body such as a metallic bullet in his brain. Yet, surviving individuals with TBI have vast effects on their sensory and motor functions of daily living. A retrospective review conducted on 116 patients having complications due to TBI revealed aphasia and dysarthria in 19% and 30.2% of the patients, respectively, and dysphagia in 17.2% and posttraumatic seizures in 21.6% of the patients. [4] A foreign body causing TBI can hence, have numerous effects on the individual's daily living depending on the extent of the injury. Therefore, the current study was taken up to outline the communication and swallowing characteristics in an individual with TBI having persisting metallic bullet in the brain, which will help to plan a comprehensive assessment and management for individuals affected by such injuries.

  Case Report Top

Mr. xxx was brought to the hospital with a history of bullet shot injury on August 17, 2011 having a 3-mm stellate wound over the forehead and trifurcate entry wound 2.2 × 1.2 cm in the center of the forehead just above the nasion; the exit wound was not observed and no other wound was observed on the scalp while bleeding was present from the left ear, and there were restlessness and disorientation with a Glasgow Coma Scale of 8/15 representing severe injury. Reports of computed tomography (CT) scan revealed the metallic bullet in the right temporal lobe, extensive area of intraparenchymal hemorrhage involving the right temporal and frontal lobes, few metallic fragments in the right inferior frontal lobe, evidence of subarachnoid and intraventricular hemorrhages, acute extradural hemorrhage in the left temporal fossa, diffused cerebral edema, and descending transtentorial herniation on the right side. The patient was diagnosed with bullet (visible) injury with extensive right contusions, small frontal contusions, and severe brain edema. Following the injury, the patient underwent large right frontotemporoparietal craniotomy, evacuation of temporal intracerebral hematoma, debridement of contused frontal lobe, and removal of bone flap. The final medical diagnosis was gunshot injury (allegedly suicidal) with the right frontotemporal contusion and intracerebral hematoma. The bullet was lodged in the torcular region and there were diffuse axonal injury, severe dysphonia, and spasticity. Further, CT scan report on September 28, 2011 revealed migration of the metallic bullet posteriorly into the posterior aspects of the occipital lobe, minimal hydrocephalus, focal infarct in the right thalamus and genu, and extradural hematoma in the left temporal lobe. The patient also underwent right frontotemporal cranioplasty using polyetheretherketone (PEEK) plate on June 7, 2012.

Evaluation of Communication Skills

The assessment of speech and language skill was performed on January 18, 2012 by an experienced speech language pathologist. Language characteristics were assessed using Western Aphasia Battery (WAB). Speech characteristics were rated using Frenchay Dysarthria Assessment (FDA) and perceptual evaluation of the voice was performed using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale. Also, informal assessment of the cognitive, motor, self-help skills, reading, writing, arithmetic, and right hemisphere functions was performed. Swallowing function was assessed using Swallowing Ability and Function Evaluation (SAFE). A distortion-product otoacoustic emission (DPOAE) screening needed to be performed to rule out peripheral hearing problems.

  Result Top

On speech and language evaluations that were performed, WAB scores represented global aphasia. On FDA, those subsystems, which had a task that did not require patient cooperation and comprehension were assessed and were graded from "c" to "e" representing no function and spastic dysarthria. GRBAS scale revealed a rating of 3 (severe degree) for grade, rough, asthenic, strained and 2 (moderate degree) for breathy. The cognitive, self-help, reading, writing, and arithmetic skills were grossly affected. Motor skills were affected due to spasticity of the muscles. The right hemisphere functions were grossly affected except for music perception. On SAFE, severe impairment on physical examination of oropharyngeal mechanism and oral phase of swallowing, and moderate impairment on the pharyngeal phase of swallowing with consistency of thick liquids were noted. DPOAE screening suggested normal outer hair cell function.

  Discussion Top

The present study focused on the assessment and management of speech and language skills of an individual having a persisting metallic bullet due to TBI secondary to gunshot that was rarely reported before in studies. The major effects of penetrating brain injury or an injury due to gun shot depends on several factors, including the projectile velocity, size of the missile, amount of missile fragmentation, and number of wounds. The primary effects of TBI include lacerations, diffuse axonal injury and diffuse vascular injury, primary focal lesion, and primary brainstem injury. Depending on each factor, the effects may include an increase in intracranial pressure, death, reduced cerebral blood flow, destruction of brain tissue, and hydrocephalus. [5] The neurobehavioral deficits, speech deficits, language deficits, cognitive deficits, and physical deficits are those major short- and long-term effects that require extensive rehabilitation.

Following the initial assessment, the patient also underwent speech and language therapy for 8 months and a posttherapy assessment was performed that included evaluations of the initial assessment, along with evaluation of the voice using Praat software (By Paul Boersma & David Weenink (2011): Praat: doing phonetics by computer version 5.2.26), evaluation of articulation using Kannada Articulation Test (KAT), and speech intelligibility rating using the Ali Yavar Jung National Institute for the Hearing Handicapped (AYJNIHH) rating scale. Following speech and language therapy, WAB score revealed transcortical sensory aphasia. A marked improvement was noted on Food and Drug Administration (FDA) grades. There was a marked improvement in the cognitive, self-help, motor, reading, writing, arithmetic, and right hemisphere functions. Music perception and responsiveness for musical stimulus were preserved even though the right temporal lobe was damaged. Writing was used as an alternate mode in complicated situations of communication. On SAFE, "moderate impairment" on physical examination of oropharyngeal mechanism and the oral phase of swallowing, and the pharyngeal phase of swallowing was "within normal limits" with "regular consistency." The values obtained from Praat were mean F0 = 155.081 Hz, standard deviation (SD) F0 = 6.215 Hz, voice breaks = 1, jitter = 0.374%, shimmer = 3.477%, and harmonics-to-noise ratio (HNR) = 17.119 dB. KAT revealed distortion of velar, lingua palatal, lingua alveolar, lingua dental, labial sounds, and the omission of /∫/, /s/, /h/, and /ļ/ sounds. Intelligibility was rated as 3 on AYJNIHH rating scale. Along with the reported characteristics, the patient had several exaggerated pathological reflexes, repetitive stereotypic movements, and palilalia. There was an episode of seizures following which the patient was lethargic and irresponsive for 1 week but there was no regression of any skill that had improved. A study conducted by Sherman reported that cerebrospinal fluid fistulas and seizures were the complications of TBI and seizures were seen within the first week of injury in seven patients out of 79 patients. [6] The patient's motivation, personal interest, and restricted body movements were the hindrance factors that affected the administration of more formal tests.

  Conclusion Top

The current study outlines the deficits in speech and language skills that are due to a persisting metallic bullet, which was moving from the lodged position in the brain. Since this is a rarely reported study, considering the effects on speech and language skills due to TBI with a persisting foreign body in the brain, it becomes important on the part of a speech language pathologist to assess, apprehend, and manage the affected skills, and to provide a better quality of life to the affected individuals.


The authors would like to thank the participant and his family for their cooperation. The authors also wish to express their deepest gratitude to the management officials, Father Muller Charitable Institution for permitting to conduct the study; additionally, the authors express their sincere thanks to the principal Mr. Akhilesh PM, all the staff, and friends for their valuable support and information for the paper.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

Solmaz I, Kural C, Temiz C, Seçer HI, Düz B, Gönül E, et al. Traumatic brain injury due to gunshot wounds: A single institution′s experience with 442 consecutive patients. Turk Neurosurg 2009;19 216-23.  Back to cited text no. 1
Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 2002;24:24-8.  Back to cited text no. 2
Crockard HA. Bullet injuries of the brain. Ann R Coll Surg Engl 1974;55:111-23.  Back to cited text no. 3
Safaz I, Alaca R, Yasar E, Tok F, Yilmaz B. Medical complications, physical function and communication skills in patients with traumatic brain injury: A single centre 5-year experience. Brain Inj 2008;22:733-9.   Back to cited text no. 4
Hegde MN. Traumatic brain injury: Causes and consequences. In: Hegde MN, editor. A Course Book on Aphasia and Other Neurogenic Language Disorders. 3 rd ed. Clifton Park, New York: Delmar Cengage Learning; 2006. p. 358-9.  Back to cited text no. 5
Sherman WD, Apuzzo ML, Heiden JS, Petersons VT, Weiss MH. Gunshot wounds to the brain - A civilian experience. West J Med 1980;132:99-105.  Back to cited text no. 6


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