1
|
Junior LSB, Ferreira Neto ODC, Araruna Dias AJ, Do Rêgo Aquino PL, Miranda Cavalcante Filho JR, Silva Diniz AM, Gonçalves de Lima LF, Lemos NB, de Alencar Neto JF, Lima Da Silva T, Andrade De Abreu T, De Lima Guerra Barros JG, da Silva Junior EJ, Veiga Silva AC, Faquini IV, Almeida NS, de Azevedo Filho HRC. Pediatric Gunshot Head Injury: Prevalence of Prognostic Factors in Surgical Patients: An Institutional Experience in Ten Years. Neurotrauma Rep 2022; 2:669-675. [PMID: 35018367 PMCID: PMC8742276 DOI: 10.1089/neur.2021.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This article aims to evaluate the predictive factors of morbidity and mortality in pediatric patients who suffered gunshot wounds to the head. We reviewed a series of 43 patients who were admitted to a referential neurosurgical hospital between 2010 and 2019. Data from 43 patients who underwent a surgical treatment in our institution were collected, and the following parameters were considered in the analysis: the initial Glasgow Coma Scale (GCS), age, sex, bullet entry site, and bullet trajectory. Computed tomography (CT) scans at admission, complications, midline crossing, and Glasgow score scale at the time of discharge (Glasgow Outcome Scale; GOS) were also factored in. Male sex corresponded to 90.7% of cases (N = 39), and 16–17 years of age was the most common age (60.5%). The frontal region was the most common entry site (41.9%), followed by the parietal wall and occipital entry. Penetrating trajectory was shown in 48.8% of cases, perforation/transfixing in 39.5%, and tangential in 11.6%. CT showed that sinking is the most common alteration (74.4%), followed by cerebral contusion (44.2%). According to the GOS, 23.3% died, 23.3% were classified by an unfavorable outcome (GOS, 2–3), and 53.5% a favorable outcome (GOS, 4 and 5). In our study, there was a significant association between the low GCS scores on admission and low GOS (1–3; p = 0.001) at time of discharge. Patients with wounds that crossed the midline also had a significant association with low GOS (p = 0.014) in our clinical experience. We concluded that low GCS scores at admission and children with a wound that crosses the midline are predictive factors of high mortality and morbidity, in our clinical experience.
Collapse
Affiliation(s)
- Luiz Severo Bem Junior
- Departament of Neurosurgery, Hospital da Restauração, Recife, Brazil.,College of Medical Sciences, Unifacisa University Center, Campina Grande, Paraíba, Recife, Brazil
| | | | | | | | | | | | | | - Nilson Batista Lemos
- College of Medical Sciences, Unifacisa University Center, Campina Grande, Paraíba, Recife, Brazil
| | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Liu R, Liu Y, Liu W, Liu X, Gong J, Li C, Tian Y. Gunshot penetrating brain injury in children: report of three cases with review of the literature. Childs Nerv Syst 2018; 34:1459-1463. [PMID: 29948135 DOI: 10.1007/s00381-018-3858-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 05/29/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Gunshot penetrating brain injury is common in military conflict area and in urban violence area, but similar incident in pediatric population is rarely reported. CASE REPORT We reported three cases of gunshot penetrating brain injury in children. Two patients had a good recovery after surgery and no significant deficit on his neurologic function, the other patient was not having surgery due to the severity of the condition. CONCLUSIONS We suggest surgery should be performed immediately to prevent further injury and refractory brain edema due to the injury, in any case of penetrating brain injury; a good prognosis can be achieved from early surgery and with appropriate post-operative treatment.
Collapse
Affiliation(s)
- Raynald Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100050, China
| | - Yuhan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Xujun Liu
- State University of New York, Upstate Medical University, New York, NY, 13210-2375, USA
| | - Jian Gong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Yongji Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China.
| |
Collapse
|
3
|
Shahlaie K, Keachie K, Hutchins IM, Rudisill N, Madden LK, Smith KA, Ko KA, Latchaw RE, Muizelaar JP. Risk factors for posttraumatic vasospasm. J Neurosurg 2011; 115:602-11. [PMID: 21663415 DOI: 10.3171/2011.5.jns101667] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Posttraumatic vasospasm (PTV) is an underrecognized cause of ischemic damage after severe traumatic brain injury (TBI) that independently predicts poor outcome. There are, however, no guidelines for PTV screening and management, partly due to limited understanding of its pathogenesis and risk factors. METHODS A database review of 46 consecutive cases of severe TBI in pediatric and adult patients was conducted to identify risk factors for the development of PTV. Univariate analysis was performed to identify potential risk factors for PTV, which were subsequently analyzed using a multivariate logistic regression model to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Fever on admission was an independent risk factor for development of PTV (OR 22.2, 95% CI 1.9-256.8), and patients with hypothermia on admission did not develop clinically significant vasospasm during their hospital stay. The presence of small parenchymal contusions was also an independent risk factor for PTV (OR 7.8, 95% CI 0.9-69.5), whereas the presence of subarachnoid hemorrhage or other patterns of intracranial injury were not. Other variables, such as age, sex, ethnicity, degree of TBI severity, or admission laboratory values, were not independent predictors for the development of clinically significant PTV. CONCLUSIONS Independent risk factors for PTV include parenchymal contusions and fever. These results suggest that diffuse mechanical injury and activation of inflammatory pathways may be underlying mechanisms for the development of PTV, and that a subset of patients with these risk factors may be an appropriate population for aggressive screening. Further studies are needed to determine if treatments targeting fever and inflammation may be effective in reducing the incidence of vasospasm following severe TBI.
Collapse
Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California Davis School of Medicine, Sacramento, California 95817, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Bell RS, Ecker RD, Severson MA, Wanebo JE, Crandall B, Armonda RA. The evolution of the treatment of traumatic cerebrovascular injury during wartime. Neurosurg Focus 2010; 28:E5. [PMID: 20568945 DOI: 10.3171/2010.2.focus1025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.
Collapse
Affiliation(s)
- Randy S Bell
- Department of Neurosurgery, National Naval Medical Center, Bethesda, Maryland 20889, USA.
| | | | | | | | | | | |
Collapse
|
5
|
Shahlaie K, Boggan JE, Latchaw RE, Ji C, Muizelaar JP. Posttraumatic vasospasm detected by continuous brain tissue oxygen monitoring: treatment with intraarterial verapamil and balloon angioplasty. Neurocrit Care 2008; 10:61-9. [PMID: 18807219 DOI: 10.1007/s12028-008-9138-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 08/14/2008] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Posttraumatic vasospasm (PTV) is a relatively common event following traumatic brain injury (TBI) that has been strongly correlated with worse neurological outcome in many studies. However, vasospasm continues to be an under-recognized source of secondary injury following TBI, and currently published guidelines do not address screening or management strategies for PTV. Brain tissue oxygen (P(bt)O(2)) monitoring probes allow for continuous screening for cerebral hypoxia following TBI, but their use as a monitor for PTV has not been previously described. METHODS Case report and literature review. RESULTS We present a case of PTV identified by persistent low P(bt)O(2) despite aggressive medical therapy. Computed tomography and digital subtraction angiography confirmed severe cerebral arterial vasospasm involving both anterior and posterior circulations. The patient was successfully treated with serial intraarterial therapy including balloon angioplasty and verapamil infusion. CONCLUSION Posttraumatic vasospasm should be included in the differential diagnosis of cerebral hypoxia (e.g., low P(bt)O(2)) following TBI. Management strategies for PTV may include early, aggressive intraarterial therapies including drug infusion and balloon angioplasty.
Collapse
Affiliation(s)
- Kiarash Shahlaie
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, CA 95817, USA.
| | | | | | | | | |
Collapse
|
6
|
Abstract
Patients who have penetrating head injury all too often present with some of the most devastating and challenging intracranial injuries. The mechanisms of injury and associated neuropathology affect every body system and require a multidisciplinary approach. Evidence-based guidelines have been developed to offer some direction to clinicians involved in their care. Much remains scientifically unsubstantiated, however. Optimal management of critically ill patients who have penetrating head injury requires clinical expertise and care of the highest quality.
Collapse
Affiliation(s)
- Patricia A Blissitt
- Neuroscience Intensive Care Unit, Duke University Hospital, Durham, NC, USA.
| |
Collapse
|
7
|
Gunshot injuries to the head and brain caused by low-velocity handguns and rifles. Forensic Sci Int 2004; 146:111-20. [DOI: 10.1016/j.forsciint.2004.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
8
|
Abstract
The principles of management of civilian gunshot wounds (GSWs) to the head and spine have evolved directly from the experience gained in war by military neurosurgeons. The type of craniocerebral wounds being produced in urban gang warfare and suicide at tempts using handguns or rifles at close range vary considerably from the lower velocity fragment injuries which are common in modern warfare. Civilian craniocerebral GSWs are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52-95% depending on the proportion of suicide victims in the series. The most important predictive factor is the post-resuscitation Glasgow Coma Score (GCS). Many civilian victims (47%) present with GCS 3-5 and only approximately 8.1% survive. Of these survivors, 1.4% will have nil, mild or moderate disability without surgery and 4.8% with surgery. Higher post-resuscitation GCS is associated with a significantly improved survival: GCS 6-8, 35.6% and GCS 9-15, 90.5%. A selective treatment policy is recommended for the patients with GCS 3-5. There are many clinical and radiological correlates with poor outcome that help the neurosurgeon decide on operative versus supportive treatment. Early aggressive resuscitation, surgery and vigorous control of intracranial pressure offers the best chance of achieving a satisfactory outcome. Spinal GSWs are uncommon and the neurosurgeon should be aware of the principles of management and prognosis. The indication for acute spinal cord decompression is deteriorating neurological status. Steroids are not indicated for these injuries. Neurosurgeons should take an active role in formulating and supporting public policy which aims to reduce possession and usage of firearms and therefore the prevalence of gunshot injuries.
Collapse
Affiliation(s)
- Jeffrey V Rosenfeld
- Department of Neurosurgery, the Alfred Hospital and Monash University, Australia
| |
Collapse
|
9
|
Oehmichen M, Meissner C, König HG. Brain injury after survived gunshot to the head: reactive alterations at sites remote from the missile track. Forensic Sci Int 2001; 115:189-97. [PMID: 11074174 DOI: 10.1016/s0379-0738(00)00335-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Gunshot wounds to the brain usually lead to acute respiratory arrest or death after a brief survival period, even in cases involving only slight direct tissue damage. It can be assumed therefore that the damage extends beyond the zone of recognizable destruction and hemorrhages. To determine the true extent of the tissue injury resulting from gunshot wounds to the brain, we carried out microscopic investigations for reactive changes (emigration of leukocytes and macrophages, axonal expression of beta-amyloid precursor protein (beta-APP) in 10 cases of gunshot wound to the narrow channel of the brain with survival times >2h. Demonstration of leukocytes expressing naphthol AS-D chloroacetate esterase activity in the brain tissue at the border of the missile track established the vitality of the gunshot effect. The presence of macrophages (CD68-epitope) allowed demarcation of a 1-2mm wide necrotic zone around the permanent cavity. Within this zone and beyond, beta-APP showed an initial increase followed by a decline in the number of injured axons. Three types of beta-APP positive staining could be differentiated. In the immediate vicinity of the missile track beta-APP positive neurons were present at a distance of 2-4mm from the margin of the permanent cavity (type 1) as a result of primary injured neuronal tissue by the gunshot itself. At longer distances from the narrow channel and the permanent cavity single beta-APP positive axons or axon fragments and two additional types were found; type 2 shows a parallel, wave-like arrangement of the damaged fibers, which suggests that the injury was produced by mechanical acceleration of the brain tissue created by the energy the projectile expended within the brain; irregular aggregation of beta-APP positive axons or axon fragments within a local edema represents type 3, which may be attributed to secondary ischemia or edema.
Collapse
Affiliation(s)
- M Oehmichen
- Department of Legal Medicine, Medical University of Lübeck, Kahlhorststrasse 31-35, D-23562, Lübeck, Germany.
| | | | | |
Collapse
|
10
|
Zubkov AY, Lewis AI, Raila FA, Zhang J, Parent AD. Risk factors for the development of post-traumatic cerebral vasospasm. SURGICAL NEUROLOGY 2000; 53:126-30. [PMID: 10713189 DOI: 10.1016/s0090-3019(99)00178-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Post-traumatic vasospasm is a well-recognized sequela of head injury. The risk factors associated with post-traumatic vasospasm have not been well defined. We studied 119 consecutive patients with head injury to determine the risk factors for post-traumatic vasospasm. METHODS Twenty-nine (27.1%) patients were excluded from the study because of poor insonation (n = 12) or a hospital stay of less than 72 hours (n = 17). Seventy (77.8%) of 90 patients suffered severe head injury. Sixteen (17.8%) patients sustained moderate head injury and four (4.4%) patients sustained mild head injury. All patients were monitored with transcranial Doppler (TCD) ultrasonography daily. RESULTS Post-traumatic vasospasm was detected in 32 (35.6%) of 90 patients. Among these patients, 29 (90.6%) had severe head injury, and three (9.4%) had moderate head injury. None of the patients with mild head injury suffered post-traumatic vasospasm. In most cases, the onset of post-traumatic vasospasm began on the fifth day and lasted 1 to 9 days. In 8 (25%) patients, post-traumatic vasospasm began within the first three days of the head injury. Among 32 patients with post-traumatic vasospasm, 10 (31.2%) patients had mild vasospasm, 20 (65.5%) had moderate vasospasm, and 2 (6.3%) had severe post-traumatic vasospasm. Clinical deterioration was documented in two (2.5%) patients. CONCLUSIONS Development of post-traumatic vasospasm correlated only with severe subarachnoid hemorrhage on initial computed tomographic scan. There was an increased incidence of post-traumatic vasospasm in patients with epidural hematomas, subdural hematomas, and intracerebral hemorrhages. The Glasgow Coma Scale (GCS) score on admission was inversely related to the development of post-traumatic vasospasm. In most cases, the period of vasospasm was short and clinical deterioration was rare. Probably, two varieties of post-traumatic vasospasm exist, one that lasts a shorter time and does not correlate with the presence of SAH, and a second that correlates with the presence of SAH, lasts longer, and resembles aneurysmal vasospasm.
Collapse
Affiliation(s)
- A Y Zubkov
- Department of Neurosurgery, The University of Mississippi Medical Center, Jackson 39216-4505, USA
| | | | | | | | | |
Collapse
|
11
|
Valadka AB, Gopinath SP, Mizutani Y, Chacko AG, Robertson CS. Similarities between civilian gunshot wounds to the head and nongunshot head injuries. THE JOURNAL OF TRAUMA 2000; 48:296-302. [PMID: 10697090 DOI: 10.1097/00005373-200002000-00017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This investigation compared the cerebral pathophysiologic status of gunshot wounds to the head (GSWH) with that of severe head injury of other causes (non-GSWH). METHODS Data were collected prospectively from 71 GSWH and 541 non-GSWH patients. The two groups had similar demographic characteristics and injury severities. Cerebral metabolic parameters for each patient were averaged for the entire period of monitoring. These per-patient averages were compared between GSWH and non-GSWH groups. RESULTS Median intracranial pressure was 21.4 mm Hg in GSWH patients vs. 16.7 mm Hg in non-GSWH patients (p < 0.001). Mean arterial pressures were similar, but the higher intracranial pressure in GSWH patients produced a lower median cerebral perfusion pressure. Cerebral blood flow, cerebrovascular resistance, cerebral metabolic rate of oxygen, average jugular venous oxygen saturation, and number of jugular venous desaturations did not differ significantly between the groups. Three-month outcome was death in 43% of GSWH patients and 32% of non-GSWH patients, persistent vegetative state or severe disability in 33% and 32%, respectively, and moderate disability or good recovery in 24% and 36%, respectively. These outcomes were not significantly different (p = 0.11). CONCLUSION GSWH patients suffer global cerebral metabolic disturbances that are at least as severe as those seen in non-GSWH patients with injuries of comparable severity. This selected population of GSWH patients may enjoy outcomes comparable to those of non-GSWH patients if they are treated by the same aggressive protocols.
Collapse
Affiliation(s)
- A B Valadka
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | | | | | | | |
Collapse
|
12
|
Zubkov AY, Pilkington AS, Bernanke DH, Parent AD, Zhang J. Posttraumatic cerebral vasospasm: clinical and morphological presentations. J Neurotrauma 1999; 16:763-70. [PMID: 10521136 DOI: 10.1089/neu.1999.16.763] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Head injury is one of the leading causes of morbidity and mortality in the young population. Many factors complicate head injury and worsen an outcome. One of these factors is posttraumatic cerebral vasospasm. We studied 75 patients admitted to the University of Mississippi Medical Center with head injury. Their ages ranged from 14 to 67 years (mean 30 years, SD 11.63). Eighty percent of the patients were men, and 20% were women. Of these patients, 53 (70.6%) suffered severe blunt trauma, and 4 patients suffered gunshot wounds to the head. Four patients had mild head injury, and 14 had moderate head injury. Posttraumatic vasospasm was detected in 24 (32%) patients. Among these patients, 19 (79.2%) had severe closed head injury, 3 patients had moderate head injury, and 2 suffered gunshot wounds. The severity of the patient's respective condition was correlated with the development of posttraumatic cerebral vasospasm: 50% of the patients with Glasgow Coma Scale (GCS) 3-4 developed PTV, and only 30% with GCS 9-11, and none of the patients with GCS > 12 developed PTV. Overall, posttraumatic vasospasm started earlier and had a shorter course than did aneurysmal vasospasm. Morphologically, posttraumatic vasospasm resembled the features of aneurysmal vasospasm. We found increased corrugation of the internal elastic lamina and increased amounts of connective tissue in the subendothelial layer. These findings show that posttraumatic vasospasm, although clinically more mild, demonstrates the same morphological changes as aneurysmal vasospasm.
Collapse
Affiliation(s)
- A Y Zubkov
- Department of Neurosugery, The University of Mississippi Medical Center, Jackson 39216-4505, USA.
| | | | | | | | | |
Collapse
|
13
|
Koszyca B, Blumbergs PC, Manavis J, Wainwright H, James R, Gilbert J, Jones N, Reilly PL. Widespread axonal injury in gunshot wounds to the head using amyloid precursor protein as a marker. J Neurotrauma 1998; 15:675-83. [PMID: 9753215 DOI: 10.1089/neu.1998.15.675] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In order to determine whether axonal injury (AI) is a factor in cases of penetrating head injury, the brains of 14 patients who died shortly after sustaining a fatal gunshot wound (GSW) to the head were examined, and the presence of AI determined using immunohistochemical staining for amyloid precursor protein (APP). The distribution of AI was mapped throughout the cerebral hemispheres and brain stem. AI was present in all cases in a diffuse distribution distant to the missle track with severe involvement of the brain stem in all cases. There was no axonal APP immunoreactivity in the direct region of the missle track at the point of primary axotomy. The APP-positive AI in these cases is likely to be a mixture of primary and secondary AI as APP immunostaining is unable to distinguish primary AI due to mechanical deformation from AI secondary to hypoxic-ischemic damage.
Collapse
Affiliation(s)
- B Koszyca
- Department of Pathology, University of Adelaide, South Australia, Australia
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Kordestani RK, Counelis GJ, McBride DQ, Martin NA. Cerebral arterial spasm after penetrating craniocerebral gunshot wounds: transcranial Doppler and cerebral blood flow findings. Neurosurgery 1997; 41:351-9; discussion 359-60. [PMID: 9257302 DOI: 10.1097/00006123-199708000-00003] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE The goals of the study were to determine the incidence and time course of cerebral arterial spasm in patients with penetrating craniocerebral gunshot wounds, to study the relationship between vasospasm and subarachnoid hemorrhage (SAH) in these patients, and to evaluate the effects of vasospasm on outcome. METHODS Thirty-three patients with craniocerebral gunshot wounds underwent computed tomography at admission and then underwent transcranial doppler ultrasonography (TCD). Velocities in the middle cerebral artery and the extracranial internal carotid artery were measured. Vasospasm was defined as a middle cerebral artery velocity greater than 120 cm per second and a hemispheric index (ratio of middle cerebral artery to internal carotid artery velocity) greater than 3. Intravenous xenon-133 cerebral blood flow (CBF) studies were performed for 10 patients. RESULTS TCD was initiated, on average, 1.1 days after injury; 205 studies (mean, 6.3 studies/patient) were performed 0 to 33 days after injury. TCD showed vasospasm in 14 patients (42.4%). Xenon-133 studies performed within 24 hours of TCD measurements indicating spasm demonstrated normal or low CBF in three of five patients with spasm, ruling out hyperemia as the cause of elevated flow velocities in these three patients. Seven patients had unilateral vasospasm, and seven had bilateral spasm. Vasospasm was most prominent from Days 5 through 11. Vasospasm was distributed across all levels of injury severity, as defined by the Glasgow Coma Scale. Initial computed tomographic scans demonstrated SAH in all 14 patients with vasospasm but in only 9 of 19 without spasm (100 versus 47%, P < 0.0001, binomial distribution probability test). Outcomes for patients with vasospasm were slightly worse than for those without spasm (35.7 versus 47.4% good outcomes, respectively); however, this difference did not reach statistical significance (P = 0.12). CONCLUSION These findings demonstrate that delayed cerebral arterial spasm is a frequent complication in patients with craniocerebral gunshot wounds and is strongly associated with SAH. The frequency, time course, and severity of spasm are comparable with those observed with aneurysmal SAH and traumatic SAH caused by closed head injury. This study offers new insights into the hemodynamic pathophysiology after gunshot wounds to the brain and suggests that increased vigilance for vasospasm may be of benefit.
Collapse
Affiliation(s)
- R K Kordestani
- Division of Neurosurgery, School of Medicine, University of California, Los Angeles, USA
| | | | | | | |
Collapse
|