Epistaxis from Aneurysm of the Internal Carotid Artery Due to a Gunshot Wound

An 18-year-old white man was admitted to Barnes Hospital on April 16, 1966, 5 89 hours after having been shot through the right side of the forehead with a 22 caliber bullet. There was no loss of consciousness, and he remained well oriented. First Examination. On physical examination the patient was drowsy and bleeding from the nose. Blood pressure was 190/105, and pulse rate was 75. A small wound of entry was present just to the fight of the glabella; there was no exit wound. The right eye was proptosed without visible pulsations of the globe. There was total opthalmoplegia with a dilated and fixed pupil. Funduscopic examination disclosed elevation of the retina about a recessed optic disc, edema of the macular area, and subretinal hemorrhage. The patient was blind in this eye. A lateral rectus paralysis was present on the left, otherwise examination of this eye was normal. There was diminished pinprick sensation in all three sensory divisions of the fight trigeminal nerve, and the jaw deviated to the right when he opened his mouth. An extensor response to plantar stimulation was present bilaterally. The remainder of the neurological examination was normal. Skull films showed multiple missile fragments along a tract through the right orbit, ethmoid and sphenoid regions with total opacification of the ethmoid, sphenoid, and