Arterial missile embolism is a rare complication of penetrating vascular trauma. We report a case of middle cerebral artery pellet embolism and delayed appearance of a carotid artery pseudoaneurysm following a shotgun wound of the neck. The pseudoaneurysm was repaired. Because the patient had no associated neurologic deficits, the pellet embolus was left within the patient middle cerebral artery. He remains well 4 years after injury. A selective approach to the management of a pellet embolus to the middle cerebral artery based on clinical signs or symptoms and status of arterial patency is recommended. In addition, several principles are suggested to improve the reliability of arteriography for shotgun wounds of the neck.