Civilian craniocerebral gunshot injuries in a developing country: presentation, injury characteristics, prognostic indicators, and complications

Analysis of ballistic trajectories and its association with clinical outcomes in civilian penetrating brain injury

PURPOSE

Civilian penetrating brain injuries (PBI) caused by firearms are a medical emergency with high rates of morbidity and mortality. The aim of this study was to evaluate the association between trajectory vectors in CT brain angiography and clinical outcomes in patients with civilian gunshots.

METHODS

This is a retrospective analytical cross-sectional study that includes patients over 15 years of age with PBI due to firearms, admitted from January 2019 to December 2021 at a University Hospital in Cali, Colombia. A brain CT with angio-CT was performed the first day of admission. An XYZ coordinate system centered on the Turk's saddle was developed. Trajectories of projectiles were plotted and compared to a patient 0 in a 3D-Slicer software. A bivariate analysis of the clinical and geometric characteristics of the trajectory was performed. Primary outcomes include mortality and disability at 6 months.

RESULTS

Twenty-eight patients with a mean age of 27.39 ± 11.66 years were included. The vectors of non-survivors show a trend, crossing at a specific area. This area was designated as a "potential lethal zone" and inside this area, injuries around 25.3 mm from the circle of Willis, were associated with greater mortality (p < 0.005).

CONCLUSIONS

In our study PBI avoiding the ventricular system, brain stem, dorsum sellae and the circle of Willis were associated with more survivability. A "potential lethal zone" was detected and associated with poor outcome after civilian PBI due to firearms. A better evaluation of the performance of this "potential lethal zone" in larger studies will be required.

Advancing dementia care in Pakistan: challenges and the way forward

Dementia encompasses a wide range of cognitive and psychological impairments that hinder individuals' ability to carry out daily tasks effectively. In the context of Pakistan, the prevalence of dementia patients currently stands at ~150,000-200,000, reflecting the impact of the country's significant population size. This increase in numbers poses a substantial socioeconomic challenge, emphasizing the need to prioritize dementia within Pakistan's healthcare system. However, the allocation of resources and attention to dementia remains relatively low, leading to considerable difficulties in both diagnosing and treating affected individuals. The provision of comprehensive dementia care faces numerous obstacles, including limited public awareness, insufficient research initiatives, inadequate infrastructure, and a lack of specialized training programs. To address these challenges, the Pakistani government must acknowledge and address the stringent regulations governing the neuroscience industry, with a specific emphasis on catering to the unique needs of dementia patients. By doing so, they can ensure the delivery of high-quality care, essential support, and necessary resources for individuals living with dementia in the country.

The history of antibiotic irrigation and prophylaxis in operative neurotrauma: perpetuation of military care in civilian settings

The benefit of antibiotic irrigation for prophylaxis against wound infections, not only for traumatic cranial injuries but also in elective neurosurgical care, has recently been called into question. Several articles have cast doubt on the utility of topical antibiotics, and recently, bacitracin irrigation was made unavailable in some US markets. The pervasive nature of antibiotic irrigation, considering the lack of evidence supporting its use, led the authors to question when and how neurosurgeons started using antibiotic irrigation in cranial neurosurgery. Through a review of historical literature, they highlight the adoption of antibiotic irrigation as it began in battlefield surgical practice, gradually leading to the modern concept of antibiotic prophylaxis in civilian and military care.

Assessing fetal human neural stem cells tumorigenicity potential in athymic rats with penetrating traumatic brain injury (pTBI)

Traumatic brain injuries (TBI) often produce disability in survivors due to unresolved inflammation and progressive neurodegeneration. The central nervous system in mammals is incapable of self-repair. Two decades of preclinical studies and clinical trials have provided insights into TBI pathophysiology that could be utilized to develop clinically relevant therapy. Our laboratory recently reported efficacy of clinical trial grade fetal human neural stem cells (hNSCs) in immunosuppressed rats with penetrating traumatic brain injury (pTBI). Next, in compliance with the United States Food and Drug Administration (USFDA) guidance, this study explores safety by assessing the tumorigenicity potential of intracranial hNSC transplants in athymic rats with pTBI. First, the maximum tolerated dose (MTD) was determined. Then, forty athymic pTBI rats were randomized to either: Group A. pTBI + vehicle or Group B. pTBI + hNSCs at MTD one week after injury with 6-months survival, sufficient time to uncover transplant associated tumorigenicity. A board-certified Pathologist examined hematoxylin-eosin (H&E), Ki67 immunostained brain and spinal cord, serial sections along with several abnormal peripheral masses for evidence of lesion, transplant, and oncogenesis. There was no evidence of transplant derived tumors or oncogenic tissue necrosis. Consistent with athymic literature, the lesion remained unchanged even after robust hNSC engraftment. This safety study supports the conclusion that hNSCs are safe for transplantation in pTBI. The differences in lesion expansion between immunosuppressed and athymic rats in the presence of hNSCs suggests an unexpected role for thymus derived cells in resolution of trauma induced inflammation.

Simple Wound Closure for Civilian Cranial Gunshot Wounds: A Systematic Literature Review

Civilian cranial gunshot wounds are common injuries associated with significant morbidity and mortality. Simple wound closure has been previously proposed as an alternative treatment option for a small subset of patients, but the exact outcomes of this strategy are not well-defined. The objective of this paper was to describe the scientific literature reporting simple wound closure of civilian cranial gunshot wounds, its effect on short-term and long-term neurologic outcomes, and rates of seizures and infections. A systematic literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The strength of evidence was assessed using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria. Seventeen studies were found that met inclusion criteria. There was very low strength of evidence that patients treated with simple wound closure can achieve good short and long-term neurologic outcomes. There was very low strength of evidence that simple wound closure has a higher incidence of mortality compared to operative intervention, especially in patients with initial low Glasgow Coma Scale (GCS) scores. There was very low strength of evidence that patients treated with simple wound closure have a small risk of subsequently developing infections or seizures. In conclusion, under most circumstances, neurosurgical operative intervention should be viewed as the optimal treatment for salvageable civilian cranial gunshot wound patients. However, our literature review showed that simple wound closure is safe and viable. More data are needed to determine the appropriate clinical scenario for using this alternative option.

Factors associated with hospital outcomes of patients with penetrating craniocerebral injuries in armed conflict areas of the Democratic Republic of the Congo: a retrospective series

INTRODUCTION

Penetrating craniocerebral injuries (PCCI) are types of open head injuries caused by sharp objects or missiles, resulting in communication between the cranial cavity and the external environment. This condition is deemed to be more prevalent in armed conflict regions where both civilians and military are frequently assaulted on the head, but paradoxically their hospital outcomes are under-reported. We aimed to identify factors associated with poor hospital outcomes of patients with PCCI.

METHODS

This was a retrospective series of patients admitted at the Regional Hospital of Bukavu, DRC, from 2010 to 2020. We retrieved medical records of patients with PCCI operated in the surgical departments. A multivariate logistic regression model was performed to find associations between patients' admission clinico-radiological parameters and hospital outcomes. Poor outcome was defined as a Glasgow Outcomes Score below 4.

RESULTS

The prevalence of PCCI was 9.1% (91/858 cases) among admitted TBI patients. More than one-third (36.2%) of patients were admitted with GCS < 13, and 40.6% of them were unstable hemodynamic. Hemiplegia was found in 23.1% on admission. Eight patients had an intracerebral hemorrhage. Among the 69 operated patients, complications, mainly infectious, occurred in half (50.7%) of patients. Poor hospital outcomes were observed in 30.4% and associated with an admission GCS < 13, hemodynamic instability, intracerebral hemorrhage, and hemiplegia (p < 0.05).

CONCLUSION

The hospital poor outcomes are observed when patients present with hemodynamic instability, an admission GCS < 13, intracerebral hemorrhage, and hemiplegia. There is a need for optimizing the initial care of patients with PCCI in armed conflict regions.

Ballistic lobar trajectory outcomes in civilian firearm penetrating brain injury

OBJECTIVE

Penetrating brain injury (PBI) is the most lethal of all firearm injuries, with reported survival rates of less than 20%. The projectile trajectory (PT) has been shown to impact mortality, but the significant lobar tracks have not been defined. The aim of this retrospective case-control study was to test for associations between distinct ballistic trajectories, missile types, and patient outcomes.

METHODS

A total of 243 patients who presented with a PBI to the Saint Louis University emergency department from 2008 through 2019 were identified from the hospital registry. Conventional CT scans combined with 3D CT reconstructions and medical records were reviewed for each patient to identify distinct PTs.

RESULTS

A total of 65 ballistic lobar trajectories were identified. Multivariable regression models were used, and the results were compared with those in the literature. Penetrating and perforating types of PBI associated with bitemporal (t-statistic = -2.283, p = 0.023) or frontal-to-contralateral parietal (t-statistic = -2.311, p = 0.025) projectile paths were universally found to be fatal. In the group in which the Glasgow Coma Scale (GCS) score at presentation was lower than 8, a favorable penetrating missile trajectory was one that involved a single frontal lobe (adjusted OR 0.02 [95% CI 0.00-0.38], p = 0.022) or parietal lobe (adjusted OR 0.15 [95% CI 0.02-0.97], p = 0.048). Expanding or fragmenting types of projectiles carry higher mortality rates (OR 2.53 [95% CI 1.32-4.83], p < 0.001) than do nondeformable missiles. Patient age was not associated with worse outcomes when controlled by other significant predictive factors.

CONCLUSIONS

Patients with penetrating or perforating types of PBI associated with bitemporal or frontal-to-contralateral parietal PTs should be considered as potential donor candidates. Trauma patients with penetrating missile trajectories involving a single frontal or parietal lobe should be considered for early neurosurgical intervention, especially in the circumstances of a low GCS score (< 8). Surgeons should not base their decision-making solely on advanced patient age to defer further treatment. Patients with PBIs caused by nondeformable types of projectiles can survive multiple simultaneous intracranial missile trajectories.

Prognosis and futility in neurosurgical emergencies: A review

A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.

Brain Injury and Dementia in Pakistan: Current Perspectives

Alzheimer's disease (AD) is the most common form of dementia, accounting for 50-75% of all cases, with a greater proportion of individuals affected at older age range. A single moderate or severe traumatic brain injury (TBI) is associated with accelerated aging and increased risk for dementia. The fastest growth in the elderly population is taking place in China, Pakistan, and their south Asian neighbors. Current clinical assessments are based on data collected from Caucasian populations from wealthy backgrounds giving rise to a "diversity" crisis in brain research. Pakistan is a lower-middle income country (LMIC) with an estimated one million people living with dementia. Pakistan also has an amalgamation of risk factors that lead to brain injuries such as lack of road legislations, terrorism, political instability, and domestic and sexual violence. Here, we provide an initial and current assessment of the incidence and management of dementia and TBI in Pakistan. Our review demonstrates the lack of resources in terms of speciality trained clinician staff, medical equipment, research capabilities, educational endeavors, and general awareness in the fields of dementia and TBI. Pakistan also lacks state-of-the-art assessment of dementia and its risk factors, such as neuroimaging of brain injury and aging. We provide recommendations for improvement in this arena that include the recent creation of Pakistan Brain Injury Consortium (PBIC). This consortium will enhance international collaborative efforts leading to capacity building for innovative research, clinician and research training and developing databases to bring Pakistan into the international platform for dementia and TBI research.

Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: A decision-tree algorithm based on a single trauma center

Gunshot wounds (GSW) are one of the most lethal forms of head trauma. The lack of clear guidelines for civilian GSW complicates surgical management. We aimed to develop a decision-tree algorithm for mortality prediction and report long-term outcomes on survivors based on 15-year data from our level 1 trauma center. We retrospectively reviewed 96 consecutive patients who presented with cerebral GSWs between 2003 and 2018. Clinical information from our trauma database, EMR, and relevant imaging scans was reviewed. A decision-tree model was constructed based on variables showing significant differences between survivors and non-survivors. After excluding patients who died at arrival, 54 patients with radiologically confirmed intracranial injury were included. Compared to survivors (51.9%), non-survivors (48.1%) were significantly more likely to have perforating (entry and exit wound), as opposed to penetrating (entry wound only), injuries. Bi-hemispheric and posterior fossa involvement, cerebral herniation, and intraventricular hemorrhage were more commonly present in non-survivors. Based on the decision-tree, Glasgow Coma Scale (GCS) > 8 and penetrating, uni-hemispheric injury predicted survival. Among patients with GCS ≤ 8 and normal pupillary response, lack of 1) posterior fossa involvement, 2) cerebral herniation, 3) bi-hemispheric injury, and 4) intraventricular hemorrhage, were associated with survival. Favorable long-term outcomes (mean follow-up 34.4 months) were possible for survivors who required neurosurgery and stable patients who were conservatively managed. We applied clinical and radiological characteristics that predicted survival to construct a decision-tree to facilitate surgical decision-making for GSW. Further validation of the algorithm in a large patient setting is recommended.

Prognostic performance of computerized tomography scoring systems in civilian penetrating traumatic brain injury: an observational study

Background

The prognosis of penetrating traumatic brain injury (pTBI) is poor yet highly variable. Current computerized tomography (CT) severity scores are commonly not used for pTBI prognostication but may provide important clinical information in these cohorts.

Methods

All consecutive pTBI patients from two large neurotrauma databases (Helsinki 1999–2015, Stockholm 2005–2014) were included. Outcome measures were 6-month mortality and unfavorable outcome (Glasgow Outcome Scale 1–3). Admission head CT scans were assessed according to the following: Marshall CT classification, Rotterdam CT score, Stockholm CT score, and Helsinki CT score. The discrimination (area under the receiver operating curve, AUC) and explanatory variance (pseudo-R²) of the CT scores were assessed individually and in addition to a base model including age, motor response, and pupil responsiveness.

Results

Altogether, 75 patients were included. Overall 6-month mortality and unfavorable outcome were 45% and 61% for all patients, and 31% and 51% for actively treated patients. The CT scores’ AUCs and pseudo-R²s varied between 0.77–0.90 and 0.35–0.60 for mortality prediction and between 0.85–0.89 and 0.50–0.57 for unfavorable outcome prediction. The base model showed excellent performance for mortality (AUC 0.94, pseudo-R² 0.71) and unfavorable outcome (AUC 0.89, pseudo-R² 0.53) prediction. None of the CT scores increased the base model’s AUC (p > 0.05) yet increased its pseudo-R² (0.09–0.15) for unfavorable outcome prediction.

Conclusion

Existing head CT scores demonstrate good-to-excellent performance in 6-month outcome prediction in pTBI patients. However, they do not add independent information to known outcome predictors, indicating that a unique score capturing the intracranial severity in pTBI may be warranted.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04074-1) contains supplementary material, which is available to authorized users.

Successful Surgical Treatment of Severe Perforating Diametric Craniocerebral Gunshot Wound Sustained during Combat: A Case Report

Many researchers classify perforating diametric craniocerebral gunshot wounds as fatal because mortality exceeds 96% and the majority of patients with such injuries die before hospitalization. A 23-year-old Ukrainian male soldier was admitted to a regional hospital with a severe perforating craniocerebral wound in a comatose state (Glasgow Coma Scale score, 5). Following brain helical computed tomography, the patient underwent primary treatment of the cerebral wound with primary duraplasty and inflow/outflow drainage. After 18 days of treatment in the intensive care unit, he was transferred to a military hospital for further rehabilitation. This report details our unusual case of successful treatment of a perforating diametric craniocerebral gunshot wound.

Combination of drug and stem cells neurotherapy: Potential interventions in neurotrauma and traumatic brain injury

Traumatic brain injury (TBI) has been recognized as one of the major public health issues that leads to devastating neurological disability. As a consequence of primary and secondary injury phases, neuronal loss following brain trauma leads to pathophysiological alterations on the molecular and cellular levels that severely impact the neuropsycho-behavioral and motor outcomes. Thus, to mitigate the neuropathological sequelae post-TBI such as cerebral edema, inflammation and neural degeneration, several neurotherapeutic options have been investigated including drug intervention, stem cell use and combinational therapies. These treatments aim to ameliorate cellular degeneration, motor decline, cognitive and behavioral deficits. Recently, the use of neural stem cells (NSCs) coupled with selective drug therapy has emerged as an alternative treatment option for neural regeneration and behavioral rehabilitation post-neural injury. Given their neuroprotective abilities, NSC-based neurotherapy has been widely investigated and well-reported in numerous disease models, notably in trauma studies. In this review, we will elaborate on current updates in cell replacement therapy in the area of neurotrauma. In addition, we will discuss novel combination drug therapy treatments that have been investigated in conjunction with stem cells to overcome the limitations associated with stem cell transplantation. Understanding the regenerative capacities of stem cell and drug combination therapy will help improve functional recovery and brain repair post-TBI. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

Microglial Inflammasome Activation in Penetrating Ballistic-Like Brain Injury

Penetrating traumatic brain injury (PTBI) is a significant cause of death and disability in the United States. Inflammasomes are one of the key regulators of the interleukin (IL)-1β mediated inflammatory responses after traumatic brain injury. However, the contribution of inflammasome signaling after PTBI has not been determined. In this study, adult male Sprague-Dawley rats were subjected to sham procedures or penetrating ballistic-like brain injury (PBBI) and sacrificed at various time-points. Tissues were assessed by immunoblot analysis for expression of IL-1β, IL-18, and components of the inflammasome: apoptosis-associated speck-like protein containing a caspase-activation and recruitment domain (ASC), caspase-1, X-linked inhibitor of apoptosis protein (XIAP), nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (NLRP3), and gasdermin-D (GSDMD). Specific cell types expressing inflammasome proteins also were evaluated immunohistochemically and assessed quantitatively. After PBBI, expression of IL-1β, IL-18, caspase-1, ASC, XIAP, and NLRP3 peaked around 48 h. Brain protein lysates from PTBI animals showed pyroptosome formation evidenced by ASC laddering, and also contained increased expression of GSDMD at 48 h after injury. ASC-positive immunoreactive neurons within the perilesional cortex were observed at 24 h. At 48 h, ASC expression was concentrated in morphologically activated cortical microglia. This expression of ASC in activated microglia persisted until 12 weeks following PBBI. This is the first report of inflammasome activation after PBBI. Our results demonstrate cell-specific patterns of inflammasome activation and pyroptosis predominantly in microglia, suggesting a sustained pro-inflammatory state following PBBI, thus offering a therapeutic target for this type of brain injury.

Characterization of 95 patients with traumatic brain injury due to gunshot wounds at a referral center in Cali, Colombia

OBJECTIVE

This study aims to describe cases of traumatic brain injury due to gunshot wounds in civilian population over 18 years of age, treated at a referral hospital in Cali, Colombia and compare the clinical outcomes at discharge.

METHODS

An observational, descriptive cross-sectional study was conducted by retrospectively collecting clinical data related to adult patients that presented traumatic brain injury due to civil gunshot-wounds and that consulted to the emergency room at Fundación Valle del Lili Hospital in Cali, Colombia between January 2010 and February of 2016. A univariate analysis was performed to determine factors associated with death and adverse clinical outcomes.

RESULTS

A total of 95 patients older than 18 years, with traumatic brain injury by gunshot were included in the civil context. The 91.6% were male. The main context was interpersonal violence with 54.7%. The most common method of transportation was by ambulance (79%). The Glasgow score at admission was 3-8 in 64.2% of cases; 9-12 in 6.32% and 13-15 in 28.4%. On admission, head CT scan was performed in 82 (86.3%) patients within the first hour, finding a Marshall-Score between I-III in 60.9%, of IV in 17.8% of cases and a score between V-VI and in 4.1%. The trajectory was non-transfixing penetrating in 43.2%, transfixing in 27.3% and tangential in 9.5%. Mortality was 45.3% in total, 39% died within the first 24hours.

CONCLUSIONS

A major compromise on admission determines an overall poorer prognosis and a high likelihood of death in the first 24-hours.

Amelioration of Penetrating Ballistic-Like Brain Injury Induced Cognitive Deficits after Neuronal Differentiation of Transplanted Human Neural Stem Cells

Penetrating traumatic brain injury (PTBI) is one of the major cause of death and disability worldwide. Previous studies with penetrating ballistic-like brain injury (PBBI), a PTBI rat model revealed widespread perilesional neurodegeneration, similar to that seen in humans following gunshot wound to the head, which is unmitigated by any available therapies to date. Therefore, we evaluated human neural stem cell (hNSC) engraftment to putatively exploit the potential of cell therapy that has been seen in other central nervous system injury models. Toward this objective, green fluorescent protein (GFP) labeled hNSC (400,000 per animal) were transplanted in immunosuppressed Sprague-Dawley (SD), Fisher, and athymic (ATN) PBBI rats 1 week after injury. Tacrolimus (3 mg/kg 2 days prior to transplantation, then 1 mg/kg/day), methylprednisolone (10 mg/kg on the day of transplant, 1 mg/kg/week thereafter), and mycophenolate mofetil (30 mg/kg/day) for 7 days following transplantation were used to confer immunosuppression. Engraftment in SD and ATN was comparable at 8 weeks post-transplantation. Evaluation of hNSC differentiation and distribution revealed increased neuronal differentiation of transplanted cells with time. At 16 weeks post-transplantation, neither cell proliferation nor glial lineage markers were detected. Transplanted cell morphology was similar to that of neighboring host neurons, and there was relatively little migration of cells from the peritransplant site. By 16 weeks, GFP-positive processes extended both rostrocaudally and bilaterally into parenchyma, spreading along host white matter tracts, traversing the internal capsule, and extending ∼13 mm caudally from transplantation site reaching into the brainstem. In a Morris water maze test at 8 weeks post-transplantation, animals with transplants had shorter latency to platform than vehicle-treated animals. However, weak injury-induced cognitive deficits in the control group at the delayed time point confounded benefits of durable engraftment and neuronal differentiation. Therefore, these results justify further studies to progress towards clinical translation of hNSC therapy for PTBI.

Management of Craniocerebral Gunshot Injuries: A Review

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately this is a prevalent condition in developing countries, with major armed conflicts which is not very likely to achieve a high rate of prevention. Management goals should focus on early aggressive, vigorous resuscitation and correction of coagulopathy; those with stable vital signs undergo brain computed tomography scan. Neuroimaging is vital for surgical purposes, especially for determine type surgery, size and location of the approach, route of extraction of the foreign body; however not always surgical management is indicated, there is also the not uncommon decision to choose non-surgical management. The treatment consist of immediate life salvage, through control of persistent bleeding and cerebral decompression; prevention of infection, through extensive debridement of all contaminated, macerated or ischemic tissues; preservation of nervous tissue, through preventing meningocerebral scars; and restoration of anatomic structures through the hermetic seal of dura and scalp. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients; classic studies in military and civil environment have identified that this is a highly lethal or devastating violent condition, able to leave marked consequences for the affected individual, the family and the health system itself. Various measures have been aimed to lower the incidence of CGI, especially in civilians. It is necessarily urgent to promote research in a neurocritical topic such as CGI, looking impact positively the quality of life for those who survive.

Surgical management of chronic traumatic pseudomeningocele of the craniocervical junction: case report

PURPOSE

Chronic traumatic pseudomeningocele (PM) is a rare complication of gunshot injuries of the craniocervical junction in pediatric patients. Impairment of the CSF dynamics may cause severe symptoms and should be treated.

METHODS

We report the case of a 6-year-old girl who was accidentally shot in the neck during tribal clashes. On being admitted, she was neurologically intact with cerebrospinal fluid (CSF) leakage through the wounds. She underwent primary closure of the wounds in a rural medical facility. After two episodes of meningitis, CSF leakage resolved spontaneously. Nine months later, the patient was presented with a disfiguring mass growing in the posterior neck, severe headaches, and constitutional symptoms such as loss of appetite and a failure to thrive.

RESULTS

Neurosurgical intervention was performed with the patient in the prone position. Occipital pericranium graft was used to repair the defect, and the cavity of the PM was obliterated with muscle layers. The patient's symptoms improved at 1 year follow-up without PM recurrence.

CONCLUSION

This is a rare presentation of gunshot injuries in an environment with limited neurosurgical resources. Restoring the normal pattern of CSF circulation should be the aim of any neurosurgical intervention.