Penetrating brain injury following an accidental air gunshot through the frontal sinus with retained bullet

Penetrating brain injury caused by air gunshot wounds is uncommon but potentially life-threatening, even when produced by low-velocity projectiles. Management requires individualized surgical decision-making, particularly when retained intracranial bullet fragments are deeply embedded and their removal may endanger surrounding neural tissue. We report a 21-year-old male who was referred to a secondary-level hospital after an accidental air gunshot injury to the face, presenting with headache and nausea but without neurological deficit. Imaging revealed a penetrating trajectory through the left frontal region toward the left mid-occipital area, with multiple retained bullet fragments, pneumocephalus, intracerebral hemorrhage, intraventricular hemorrhage, and frontal sinus involvement. Referral to a tertiary center was declined because of financial constraints. The patient underwent craniectomy for hematoma evacuation, debridement of accessible superficial bullet and bone fragments, and infection control. Deeply embedded intracerebral fragments were intentionally left in place because removal was considered high risk and technically limited by available resources. The postoperative course was uneventful, and the patient was discharged without neurological deficits. At 1-month follow-up, he remained asymptomatic, with no evidence of infection, abscess formation, fragment migration, or new intracranial pathology on computed tomography. This case highlights that in selected patients with penetrating brain injury, retained intracranial bullet fragments may be safely managed without aggressive removal when they are deeply located and clinically silent. Surgical priorities should focus on hemorrhage control, debridement of accessible contaminated material, prevention of infection, and close long-term clinical and radiological surveillance.