Civilian gunshot wounds to the brain

From Henry Shrapnel (1761–1842) to today’s neurosurgery: how antipersonnel weapons have laid the foundation of clinical and surgical management of head injury fractures and penetrating brain injuries

Henry Shrapnel invented an antipersonnel weapon capable of defragmenting with the explosion of charge. Modern grenades or improvised explosive devices may be seen as an evolution of Shrapnel’s ammunition. Starting by analyzing the ballistics of these weapons, it is possible to understand the historical evolution of the management of skull fractures and penetrating brain injuries (PBIs).

A circular crack line with a splinter at the center, depressed in bone, was a characteristic feature of fractures due to Shrapnel’s bullet. Three longitudinal fissures, one medial and two lateral, may be present due to tangential blows. Craniectomy and/or fracture reduction were almost always necessary in these cases.

The first document describing medical examination and therapeutic strategies for head-injured patients dates back to 1600 bc (the Edwin Smith Papyrus). Several doctors from the past century, such as Puppe, Matson, and Cushing, proposed different theories about skull fractures and the management of craniocerebral injuries, paving the way for diagnosing and treating these injuries.

Shrapnel fractures required wider craniotomies and in the past surgeons had to deal with more severe injuries. Based on past military experiences during what could be called the postshrapnel age, guidelines for the management of PBIs were introduced in 2001. In these guidelines various concepts were reviewed, such as the importance of antibiotics and seizure prevention; included as well were prognostic factors such as hypotension, coagulopathy, respiratory distress, and Glasgow Coma Scale score. Furthermore, they highlight how it has not been possible to reach a common viewpoint on surgical management. Nevertheless, in contrast with the past, it is preferable to be less aggressive regarding retained fragments if there is no intracranial mass effect.

Although military situations were useful in building basic principles for PBI guidelines, civilian PBIs differ noticeably from military ones. Therefore, there is a need to review modern guidelines in order to apply them in every situation.

Wound vacuum-assisted closure as a bridge therapy in the treatment of infected cranial gunshot wound in a pediatric patient: illustrative case

BACKGROUND

The authors reported the first pediatric case of a craniocerebral gunshot injury successfully treated with a wound vacuum-assisted closure (VAC) device after dehiscence and infection of the initial cranial wound.

OBSERVATIONS

A 17-year-old boy suffered several gunshots to the left hemisphere, resulting in significant damage to the scalp, calvaria, and brain. Emergency hemicraniectomy was performed, with reconstruction of a complicated scalp wound performed at the initial surgery. The scalp was devitalized and ultimately dehisced, resulting in a cranial infection. It was treated first with a repeated attempt at primary closure, which failed because of persistent devitalized tissue, and was then treated with aggressive debridement followed by placement of a wound VAC device over the exposed brain as a bridge therapy to reconstruction. This procedure was deemed necessary given the active infection.

LESSONS

The patient received delayed reconstruction with a free split-thickness skin graft and made a remarkable recovery, with cranioplasty performed 6 months later. The authors reviewed the literature on wound VAC use in cranial wound treatment and proposed it as a legitimate bridge therapy to definitive reconstruction in the setting of dirty wounds, active infection, or even hemodynamically unstable patients.

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.

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.

Attempted suicide leading to acquired brain injury: a scoping review

Objective: Conduct a scoping review of literature surrounding acquired brain injury (ABI) sustained secondary to a suicide attempt to establish the current body of research on injury outcomes and rehabilitative needs for this population.Methods: A systematic search of the literature was conducted. Searches were conducted using terms relating to this injury etiology and search results with original or secondary data on individuals with an ABI were included for review.Results: Thirty-two articles were reviewed. Limited data characterizing this population exists in the literature. Findings indicate that this population have generally poorer injury outcomes compared with ABI sustained through other means. Rehabilitative needs are rarely addressed, but limited commentary suggests that extensive pre-morbid conditions, severity of injuries and psychosocial support needs of this population present implications for rehabilitative supports.Conclusion: There is a relative dearth of research examining ABI sustained secondary to a suicide attempt. Collated findings suggest these individuals are rarely recognized in the literature as a distinct ABI population with rehabilitative needs specific to this etiology. Future research should aim to address the gaps identified in the literature, including characterizing the population, establishing pre-morbid conditions and developing tailored rehabilitative support to address complex needs.

Full Recovery After a Bihemispheric Gunshot Wound to the Head: Case Report, Clinical Management, and Literature Review

BACKGROUND

Nearly 33,600 people die each year in the United States as a result of gunshot wounds (GSWs). Penetrating craniocerebral GSWs are often fatal with a nearly 70% death rate at the scene of the trauma. Overall combined mortality rate for patients who die at the scene or at the hospital is almost 91%. Poor outcome is associated with initial low Glasgow Coma Scale score and bihemispheric and transventricular gunshot trajectory. We summarize current understanding in management, prognostic factors, and survival outcomes in patients with a penetrating GSWs to the head. We report a patient with return to full function despite bihemispheric, multilobar involvement. Full function is defined here as ability to return to previous work and perform activities of daily living.

CASE DESCRIPTION

A 33-year-old man sustained a GSW to the head under unknown circumstances. On initial presentation, he had a Glasgow Coma Scale score of 15. He was verbalizing and communicating but was amnestic for the event. From a left frontal entry wound, the bullet traversed both frontal lobes of the brain reaching the right frontal-parietal junction. Physical examination and vital signs were normal. Appropriate surgical and medical management resulted in complete recovery.

CONCLUSIONS

Craniocerebral GSWs have a high mortality rate and usually require aggressive management. Evaluation of most GSWs requires appropriate imaging studies followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is often necessary and ranges from local wound débridement to craniectomy, decompression, and wound exploration.

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.

Civilian Penetrating Gunshot Injury to the Neurocranium in Enugu

Introduction:

Civilian penetrating gunshot injuries to the neurocranium are no longer uncommon in Nigeria. Such injuries are however poorly reported. They are associated with poor outcome and, at close range, are frequently fatal, especially when inflicted by high-velocity weapons. Prompt transfer to neurosurgical service and urgent intervention may improve outcome in those that are not mortally wounded.

Materials and Methods:

Fifty-two patients with civilian penetrating gunshot wounds seen over a 10-year period (2004–2014) at the University of Nigeria Teaching Hospital and Memfys Hospital for Neurosurgery Enugu were reviewed retrospectively, and their data were analyzed to evaluate factors that impacted on outcome. Only patients with clinical and imaging evidence of cranial gunshot injuries who reached hospital alive were included in the study. The overall mortality and Glasgow outcome score were analyzed.

Results:

Fifty-two patients with isolated civilian penetrating gunshot wounds were identified (M:F = 7.7:1); mean (standard deviation) age was 32.8 (11.9) years. There was a high correlation (0.983) between the sex of the patients and the outcome. The overall mortality was 30.8%, whereas the mortality for patients with postresuscitation Glasgow coma scale (GCS) score ≤8 was 57%, as against 12.9% in those in whom postresuscitation GCS was >8; meaning that 87.1% of patients in whom postresuscitation GCS was >8 survived. Thirty-one patients (59.6%) had papillary abnormalities. Majority of patients with monohemispheric lesions survived while all those with diencephalic, transventricular, and posterior fossa involvement had 100% mortality.

Conclusions:

Admitting GCS and bullet trajectory were predictive of outcome.

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.

Factors affecting dural penetration and prognosis in patients admitted to emergency department with cranial gunshot wound

PURPOSE

To explore the effect of admission physical examination findings, anamnesis, and computed tomography on dural penetration and prognosis in patients with cranial gunshot wound (CGW).

METHODS

In this study, the medical data of 56 subjects who were admitted to the Emergency Department of Dicle University Hospital with CGWs between January 2011 and December 2013 were retrospectively reviewed. The effects of type of incident (suicidal vs non-suicidal), pupil diameter and light reflex, hemodynamic status, type (bullet or pellet), velocity, trajectory of foreign material, trauma scores, and imaging findings on dural penetration and mortality were explored.

RESULTS

The mean age of the study population was 24.8 ± 13.50 years. Thirty (53.6 %) patients had penetrating injuries and 26 (46.4 %) had non-penetrating injuries; 9 (16.1 %) patients died and 47 (83.9 %) survived. Suicidal injury, pupil diameter and light reflex, bullet as foreign material, and high velocity and lateral trajectory of foreign material significantly affected dural penetration and mortality (p < 0.05). In addition, dural penetration, bilobar, multilobar, or bihemispheric involvement of brain parenchyma, presence of intracranial hemorrhage, subarachnoid hemorrhage, ventricular hemorrhage, fracture, shift, edema, and trauma scores significantly affected mortality (p < 0.05).

CONCLUSIONS

In CGWs, dural penetration and prognosis can be predicted by physical examination findings and patient characteristics on initial admission.

Penetrating shrapnel injuries of the posterior fossa

BACKGROUND

Gunshot injuries of the posterior fossa are rare and may follow a fatal course. In posterior fossa gunshot injuries, cerebellar hematoma, contusion, obstruction of cerebrospinal fluid (CSF) circulation by the shrapnel, and intracranial hypertension caused by autoregulation loss lead to mortality in the early stage.

METHODS

In this study, four cases of patients who underwent surgical intervention after penetrating shrapnel injuries of the pure posterior fossa were evaluated.

RESULTS

All of the patients were male; their mean age was 26.5 ± 5 years. The lowest and highest Glasgow Coma Scale scores were 4 and 12, respectively. Neural injury was detected by computed tomography performed after systemic and neurological examination following admission to the emergency service. The shrapnel was found in the cerebellar tissue in three cases and in the fourth ventricle in one case. Following preoperative procedures, surgery was performed with the patient in the prone position. Postoperative monitoring revealed no CSF fistula, meningitis, or hydrocephalus. None of the patients required revision surgery. There were no postoperative mortalities.

CONCLUSION

Due to the small volume of the posterior fossa, acute pathologies may lead to rapid neurological deterioration and death. Early surgical intervention and close postoperative follow-up after penetrating shrapnel injuries of the posterior fossa play a significant role in reducing mortality and morbidity.

Image guided surgery in the management of craniocerebral gunshot injuries

Background:

A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option?

Methods:

We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge.

Results:

Five of the eight “stereotactic cases” had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine “neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery.

Conclusion:

Conventional craniotomy isn’t indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these treatment modalities for CCGSI.

"Time is brain" the Gifford factor - or: Why do some civilian gunshot wounds to the head do unexpectedly well? A case series with outcomes analysis and a management guide

Background:

Review of intracranial gunshot wounds (GSWs) undergoing emergent neurosurgical intervention despite a very low Glasgow Coma Scale (GCS) score on admission in order to identify predictors of good outcome, with correlates to recent literature.

Methods:

A retrospective review of select cases of GSWs presenting to our trauma center over the past 5 years with poor GCS requiring emergent neurosurgical intervention and a minimum of 1-year follow-up.

Results:

Out of a total of 17 patients who went to the operating room (OR) for GSW to the head during this period, 4 cases with a GCS < 5 on admission were identified. All cases required a hemicraniectomy to alleviate cerebral swelling. Two cases presented with a unilaterally blown pupil due to raised intracranial pressure. The remaining 2 cases had equal and reactive pupils. One patient with a GCS of 3 and a significant bilateral pattern of parenchymal bullet injury was initially assessed in moribund status but rallied and received a delayed hemicraniectomy on day 7. Three out of 4 patients are functionally independent at 1-year follow-up. The fourth patient who received a delayed decompression remains wheelchair dependent.

Conclusion:

Victims of GSWs can have good outcomes despite having a very poor admission GCS score and papillary abnormalities. Factors predicting good outcomes include the following: time from injury to surgical intervention of < 1 h; injury to noneloquent brain; and absence of injury to midbrain, brainstem, and major vessels.

Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries

OBJECTIVE

To examine the functional status of persons surviving a severe penetrating traumatic brain injury (TBI) resulting from a gunshot wound who require inpatient rehabilitation.

DESIGN

Data were collected prospectively at 4 different time periods: rehabilitation admission and discharge and year 1 and year 2 postinjury.

SETTING

Rehabilitation hospital within a Traumatic Brain Injury Model System.

PARTICIPANTS

Forty-five persons with severe penetrating brain injury and 45 persons involved in a motor vehicle crash (MVC).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability Rating Scale (DRS), FIM instrument, and Community Integration Questionnaire (CIQ).

RESULTS

Results indicated functional improvements for both the penetrating and motor vehicle severe TBI groups on the DRS and the FIM from rehabilitation admission to discharge. Follow-up data at 1 and 2 years postinjury revealed continued improvements on the DRS and FIM measures for both groups, with the greatest improvement in recovery during the first year. In addition, improved community reintegration emerged between 1 and 2 years postinjury for both groups, as measured by the CIQ. There was a small significant difference on the outcome measures between the 2 groups in the course of their recovery.

CONCLUSIONS

Persons who survive severe penetrating brain injuries and who require inpatient rehabilitation may show continuing improvement in functioning over time. For persons receiving inpatient rehabilitation services, initial improvement is most likely to occur during the hospital stay and continue postinjury, with the largest improvement in the first year after injury. Community reintegration can also be expected over time. One can expect similar outcomes for individuals who sustain a severe penetrating brain injury and a severe brain injury ensuing from an MVC.

Endonasal transsphenoidal endoscopy-assisted removal of a shotgun pellet in the sphenoid sinus: a case report

BACKGROUND

Gunshot accidents are not uncommon in Taiwan, but involvement limited to the ocular region and sphenoid sinus is rare. Minimal invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure should be considered if there are no additional injuries in the craniocerebral region.

CASE DESCRIPTION

A 39-year-old man had severe pain in the left eye with resulting blindness after being accidentally hit in the left eye by a gunshot pellet while walking in a wooded area. He was referred from another hospital with the impression of left eyeball rupture. There was no severe neurologic deficit except for blindness of the left eye when he arrived at the emergency department of our hospital. Brain and orbits CT scans showed a round metallic foreign body at the right sphenoid sinus without predominant damages of brain parenchyma. Endonasal transsphenoidal endoscopy-assisted procedure was used to remove the shotgun pellet, and the patient had good clinical outcomes.

CONCLUSION

Herein we present this rare case to show the possibility of a shotgun pellet injury remaining in the sphenoid sinus. The role of radiological studies such as CT scans and intraoperative C-arm fluoroscope plain films in diagnosis and management of this case is affirmed. The strategy of minimally invasive treatment by endonasal transsphenoidal endoscopy-assisted procedure for those limited injuries is a good choice for treatment.