Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers

Delayed Posterior Fossa Hemorrhage Following a Tangential Gunshot Wound to the Occiput in a Patient With Chronic Liver Disease: A Case Report

Gunshot wounds (GSWs) to the head and neck are a common etiology of traumatic brain injury. Tangential GSWs (TGSWs) are a subset of GSWs wherein the missile penetrates tissue adjacent to the cranium, causing varying degrees of intracranial injury. Most patients sustaining TGSWs present with relatively benign neurological findings, and while a significant proportion have varying degrees of intracranial hemorrhage (ICH) on computed tomography, these tend to respond well to nonoperative management. We present a case report of a 28-year-old male who sustained a TGSW to the occiput, with a nonfocal neurological examination, small-volume posterior fossa ICH, a blunt vertebral artery injury (BVAI), and hepatic coagulopathy, who rapidly decompensated six hours after presenting due to massive posterior fossa hemorrhage with brainstem compression, requiring emergent cardiopulmonary resuscitation followed by suboccipital decompression and cerebrospinal fluid diversion. We propose that the patient's BVAI led to an unexpected thromboembolic event, precipitating an ischemic stroke that underwent hemorrhagic conversion in the setting of coagulopathy. This case report emphasizes the insidious danger that TGSWs to the head and neck present to patients, and risk factors for poor outcomes, such as BVAI and coagulopathy. This report also highlights potential intraoperative challenges during surgery for acute mass lesions in the posterior fossa, such as neurogenic shock and pulmonary edema, that warrant careful consideration and preparation in neurosurgical cases.

Emergency Anesthesiology Encounters, Care Practices, and Outcomes for Patients with Firearm Injuries: A 9-Year Single-Center US Level 1 Trauma Experience

BACKGROUND

Firearm injuries cause significant morbidity and mortality. Patients with firearm injuries require urgent/emergency operative procedures but the literature incompletely describes how anesthesia care and outcomes differ between high acuity trauma patients with and without firearm injuries. Our objective was to examine anesthesia care, resource utilization, and outcomes of patients with acute firearm injuries compared to nonfirearm injuries.

METHODS

We conducted a retrospective cross-sectional study of patients ≥18 years admitted to a regional Level 1 trauma center between 2014 and 2022 who required operative management within the first 2 hours of hospital arrival. We examined clinical characteristics, anesthesiology care practices, and intra- and postoperative outcomes of patients with firearm injuries compared to patients with nonfirearm injuries.

RESULTS

Over the 9-year study period, firearm injuries accounted for the largest yearly average increase in trauma admissions (firearm 10.1%, blunt 3.2%, other 1.3%, motor-vehicle crash 0.9%). Emergency anesthesiology care within 2 hours of arrival was delivered to 4.7% of injured patients (2124; 541 firearm [25.4%] and 1583 [74.5%] nonfirearm). Patients with firearm injuries were younger (30 [23-40] years vs 41 [29-56] years; P < .0001), male (90% vs 75%; P < .0001), direct admissions from scene (78% vs 62%; P < .0001), had less polytrauma (10% vs 22%; P < .0001), arrived after hours (73% vs 63%; P < .0001), and received earlier anesthesiology care (0.4 [0.3-0.7] vs 0.9 [0.5-1.5] hours after arrival; P < .0001). Patients with firearm injuries more often received invasive arterial (83% vs 77%; P < .0001) and central venous (14% vs 10%; P = .02) cannulation, blood products (3 [0-11] vs 0 [0-7] units; P < .0001), tranexamic acid (30% vs 22%; P < .001), as well as had higher estimated blood loss (500 [200-1588] mL vs 300 [100-1000] mL; P < .0001), and were transferred to the intensive care unit (ICU) more frequently (83% vs 77%; P < .001) than patients with nonfirearm injuries. Intraoperative mortality was comparable (6% firearm vs 4% nonfirearm) but postoperative mortality was lower for patients with firearm injuries who survived the intraoperative course (6% vs 14%; P < .0001). Comparatively, more patients with firearm injuries were discharged to home, or to jail (P < .001).

CONCLUSIONS

Over the study period, anesthesiologists increasingly cared for patients with firearm injuries, who often present outside of daytime hours and require urgent operative intervention. Operating room readiness and high-intensity resuscitation capacity, such as access to hemostatic control measures, are critical to achieving intraoperative survival and favorable postoperative outcomes, particularly for patients with firearm injuries.

Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management

BACKGROUND AND OBJECTIVES

To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI).

METHODS

We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome.

RESULTS

The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05).

CONCLUSION

Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.

Firearm-Related Traumatic Brain Injuries in Adults: A Scoping Review

BACKGROUND AND OBJECTIVES

Firearm-related traumatic brain injury (TBI) has emerged as a significant public health issue in the United States, coinciding with a rapid increase in gun-related deaths. This scoping review aims to update our understanding of firearm-related TBI in adult populations.

METHODS

A comprehensive search of 6 online databases yielded 22 studies that met the inclusion criteria. The reviewed studies predominantly focused on young adult men who were victims of assault, although other vulnerable populations were also affected.

RESULTS

Key factors in evaluating patients with firearm-related TBI included low Glasgow Coma Scale scores, central nervous system involvement, hypotension, and coagulopathies at presentation. Poor outcomes in firearm-related TBIs were influenced by various factors, including the location and trajectory of the gunshot wound, hypercoagulability, hemodynamic instability, insurance status, and specific clinical findings at hospital admission.

CONCLUSION

Proposed interventions aimed to reduce the incidence and mortality of penetrating TBIs, including medical interventions such as coagulopathy reversal and changes to prehospital stabilization procedures. However, further research is needed to demonstrate the effectiveness of these interventions. The findings of this scoping review hope to inform future policy research, advocacy efforts, and the training of neurosurgeons and other treating clinicians in the management of firearm-related TBI.

Association of Cerebrovascular Injury and Secondary Vascular Insult With Poor Outcomes After Gunshot Wound to the Head in a Large Civilian Population

BACKGROUND AND OBJECTIVES

Cerebrovascular injury (CVI) after civilian gunshot wound to the head (GSWH) likely contributes to poor outcomes, but little supporting evidence exists. The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or rehemorrhage) were associated with poor outcomes in a large civilian population.

METHODS

This was a single-institution, retrospective cohort study on patients admitted between January 2014 and July 2022 at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used.

RESULTS

A total of 512 civilian patients presented with GSWH, and a cohort of 172 (33.5%) met inclusion criteria, with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), and that of secondary vascular insult was 32.2% (28/172 patients). Bifrontal trajectories (adjusted odds ratio [aOR] 13.11; 95% CI 2.45-70.25; P = .003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; P < .001) were associated with increased odds of resultant CVI. Patients with CVI suffered higher rate of mortality (34% vs 20%; odds ratio [OR] 2.1; CI 0.78-5.85; P = .015) and were less likely to achieve a good functional outcome with a Glasgow Outcome Score of 4-5 (34% vs 68%; OR 0.24; CI 0.1-0.6; P = .004) at follow-up. Furthermore, patients with CVI and resultant secondary vascular insult had even worse functional outcomes (Glasgow Outcome Score 4-5, 16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, P = .001).

CONCLUSION

Intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying CVI may prove to be critical to improve outcomes by reducing stroke and rehemorrhage incidence.

Penetrating Firearm-Inflicted Injury-The Neglected Traumatic Brain Injury

This Viewpoint discusses penetrating firearm-inflicted brain injury and the current collaborative efforts to perform more penetrating brain injury–specific randomized clinical trials and comparative effectiveness research to identify effective management guidelines.

Firearm injury prevention counseling for patients with traumatic brain injury: a survey of brain injury physicians

Background

Survivors of traumatic brain injury are at increased risk for firearm-related injuries, including suicide.

Aims

To determine current practices of Brain Injury Medicine (BIM) physicians and their rehabilitation teams in assessing patients' access to firearms and in providing firearm safety education, and the impact of having received training on this topic on physicians' likelihood of inquiring about patients' access to firearms.

Methods

14-item web-based cross-sectional survey of 86 U.S. physiatrists board-certified in BIM.

Results

81% of respondents indicated they believe BIM physicians should counsel their patients on firearm safety but only 12.9% reported always doing so. Fifteen percent reported always inquiring about their patients' access to firearms. 88.2% indicated having never received formal training on firearm injury prevention counseling. Physicians who received such training had 7.5 times higher odds of reporting at least sometimes inquiring about patients' access to firearms than those who were not trained [95% confidence interval (1.94, 28.64)]. They also had 5.7 times higher odds for reporting being at least moderately comfortable providing patients firearm safety counseling [95% CI: (1.39, 23.22)].

Conclusion

While most BIM specialists who responded to this survey believe they should counsel patients on firearm safety, few always or usually do so. Moreover, most do not routinely inquire about their patients' access to firearms. The provision of firearm injury prevention training to BIM physicians was strongly associated with an increased likelihood they will inquire about their patients' access to guns and with an improved comfort level in providing counseling on this subject matter.

Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients

Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.

Firearm-Related Traumatic Brain Injury Homicides in the United States, 2000-2019

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of homicide-related death in the United States. Penetrating TBI associated with firearms is a unique injury with an exceptionally high mortality rate that requires specialized neurocritical trauma care.

OBJECTIVE

To report incidence patterns of firearm-related and nonfirearm-related TBI homicides in the United States between 2000 and 2019 by demographic characteristics to provide foundational data for prevention and treatment strategies.

METHODS

Data were obtained from multiple cause of death records from the National Vital Statistics System using Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for the years 2000 to 2019. Number, age-adjusted rates, and percent of firearm and nonfirearm-related TBI homicides by demographic characteristics were calculated. Temporal trends were also evaluated.

RESULTS

During the study period, there were 77 602 firearm-related TBI homicides. Firearms were involved in the majority (68%) of all TBI homicides. Overall, men, people living in metro areas, and non-Hispanic Black persons had higher rates of firearm-related TBI homicides. The rate of nonfirearm-related TBI homicides declined by 40%, whereas the rate of firearm-related TBI homicides only declined by 3% during the study period. There was a notable increase in the rate of firearm-related TBI homicides from 2012/2013 through 2019 for women (20%) and nonmetro residents (39%).

CONCLUSION

Firearm-related violence is an important public health problem and is associated with the majority of TBI homicide deaths in the United States. The findings from this study may be used to inform prevention and guide further research to improve treatment strategies directed at reducing TBI homicides involving firearms.

Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis

BACKGROUND

Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures.

OBJECTIVES

The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries.

METHODS

A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers.

RESULTS

Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01-1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98-1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of -1.63 (95% CI, -2.89 to -0.36) and -0.21 (95% CI, -1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78-1.09).

CONCLUSION

Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care.

LEVEL OF EVIDENCE

Systematic review and meta-analysis; Level III.

The Cost of Gunshot Wounds to the Head: An Unevenly Distributed Burden

BACKGROUND

Despite the significant clinical consequences and socioeconomic costs of gunshot wounds to the head (GSWH), studies examining prehospital risk factors, geospatial patterns, and economic cost are lacking.

METHODS

A retrospective analysis was performed for patients with GSWH (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami-Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. In addition, ME data were queried from the previous decade (2008-2017) to analyze longitudinal trends.

RESULTS

A total of 402 consecutive patients met the inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly affecting males, whites, and individuals who committed suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be black males from low socioeconomic status (SES) regions involved in assault. Older white males were overrepresented in patients attempting and completing suicide and thus comprised a higher percentage of ME cases. Geospatial analysis of hospital patient injury zip codes shows that GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total health care costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498, respectively.

CONCLUSIONS

In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings show prehospital risk factors and the unequal distribution of the significant economic costs of GSWH.

Civilian penetrating traumatic brain injury: A 5-year single-center experience

Background

The aim of this study was to report the demographics and clinical features of patients with penetrating traumatic brain injury (PTBI) during the past 5 years in Rajaee Hospital, a tertiary referral trauma center in Shiraz, southern Iran.

Methods

We conducted a 5-year retrospective evaluation of all patients diagnosed with PTBI who were referred to Rajaee Hospital. We retrieved the following items from the hospital's database and PACS system: patients' demographics, on-admission Glasgow Coma Scale (GCS), presence of trauma to other organs, duration of the hospital and ICU stay, the neurosurgical interventions, any necessity of tracheostomy, duration of ventilator dependency, the entrance point of the trauma in the skull, type of assault, length of trajectory in the brain parenchyma, the number of remaining objects in the brain, the occurrence of any hemorrhagic phenomenon, the cross of the bullet from the midline or coronal suture, and the presence of the pneumocephalus.

Results

A total of 59 patients with a mean age of 28.75 ± 9.40 had PTBI over the 5 years. The mortality rate was 8.5%. Stab wounds, shotguns, gunshots, and airguns were the cause of injury in 33 (56%), 14 (23.7%), 10 (17%), and 2 (3.4%) patients, respectively. The median initial GCS of patients was 15 (3-15). Intracranial hemorrhage was observed in 33 cases, subdural hematoma in 18 cases, intraventricular hemorrhage in eight cases, and subarachnoid hemorrhage in four cases. The mean duration of hospitalization was 10.05 ± 10.75 (ranging from 1 to 62 days). Furthermore, 43 patients experienced ICU admission with mean days of 6.5 ± 5.62 (1-23). The temporal and frontal regions were the most common entrance points, in 23 and 19 patients, respectively.

Conclusion

The incidence of PTBI is relatively low in our center, possibly due to the prohibition of possession or using warm weapons in Iran. Further, multicenter studies with larger sample sizes are needed to determine prognostic factors associated with worse clinical outcomes after PTBI.

Surviving the Scene in Civilian Penetrating Brain Injury: Injury Type, Cause and Outcome in a Consecutive Patient Series in Austria

Background

Penetrating brain injury (PBI) is a heterogeneous condition with many variables. Few data exist on civilian PBI. In some publications, PBI differentiation between low-velocity injury (LVI) and high-velocity injury (HVI) is made, but exact definitions are not given yet. The incidence of PBI depends heavily on the country of origin. Furthermore, captive bolt pistol (CBP) injuries represent a rare type of LVI and almost no reports exist in the human medical literature. Treatment of PBI has been controversially discussed due to high morbidity and mortality with results varying considerably between series. Prognostic factors are of utmost importance to identify patients who presumably benefit from treatment.

Methods

A retrospective, single-center analysis of a consecutive patient series was performed from September 2005 to May 2018. We included all patients with PBI who reached our hospital alive and received any neurosurgical operative procedure.

Results

Of 24 patients, 38% died, 17% had an unfavourable outcome, and 46% had a favourable outcome. In total, 58% of patients with PBI were self-inflicted. Leading causes of injury were firearms, while captive bolt pistols were responsible for 21% of injuries. LVI represented 54%, and HVI represented 46%. The outcome in HVI was significantly worse than that in LVI. A favourable outcome was achieved in 69% of LVI and 18% of HVI. Low GCS and pathological pupillary status at admission correlated significantly with an unfavourable outcome and death.

Conclusions

PBI is a heterogeneous injury with many variables and major geographical and etiological differences. Differentiation between LVI and HVI is crucial for decision-making and predicting outcomes. In patients presenting with object trajectories crossing the midline, no favourable outcome could be achieved. Nevertheless, in total, a favourable outcome was possible in almost half of the patients who succeeded in surgery.

Persistent coagulopathy after gunshot traumatic brain injury: the importance of INR and the SPIN score

INTRODUCTION

Penetrating ballistic brain injury (gunshot traumatic brain injury or GTBI) is associated with a high mortality. Admission Glascow Coma Scale (GCS), injury severity score and neurological findings, cardiopulmonary instability, coagulopathy and radiological finding such as bullet trajectory and mass effect are shown to predict survival after GTBI. We aimed to examine the dynamics of the observed coagulopathy and its association with outcome.

METHODS

In this single-centered retrospective cohort study, we examined 88 patients with GTBI between 2015 and 2021. Variables analyzed include patient age; temperature, hemodynamic and respiratory variables, admission Glasgow Coma Scale (GCS); injury severity score (ISS); head abbreviated injury scale (AIS); Marshall, Rotterdam, SPIN and Baylor scores, and laboratory data including PTT, INR and platelet count. Receiver operating characteristic analysis was conducted to evaluate the performance of the predictive models.

RESULTS

The average age of our sample was 28.5 years and a majority were male subjects (92%). Fifty-four (62%) of the patients survived to discharge. The GCS score, as well as the motor, verbal, and eye-opening sub-scores were higher in survivors (P < 0.001). As was expected, radiologic findings including the Marshall and Rotterdam Scores were also associated with survival (P < 0.001). Although the ISS and Head AIS scores were higher (P < 0.001), extracranial injuries were not more prevalent in non-survivors (P= 0.567). Non-survivors had lower platelet counts and elevated PTT and INR (P < 0.001) on admission. PTT normalized within 24 h but INR continued to increase in non-survivors. SPIN score, which includes INR, was a better predictor for mortality than Rotterdam, Marshall, and Baylor etc. CONCLUSION: Progressively increasing INR after GTBI is associated with poor outcome and may indicate consumption coagulopathy from activation of the extrinsic pathway of coagulation and metabolic derangements that are triggered and sustained by the brain injury. The SPIN score, which incorporates INR as a major survival score component, outperforms other available prediction models for predicting outcome after GTBI.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Management of migrating intracranial bullet fragments in a 13-year-old female after firearm brain injury: technical and surgical nuances

INTRODUCTION

We present the challenges and nuances of management in a rare case of multiple migrating intracranial fragments after pediatric gunshot wound to the head (GSWH).

CASE PRESENTATION

A 13-year-old girl suffered left parietal GSWH, with new neurologic decline 3 days after initial debridement. Serial imaging showed the largest intracranial fragments had migrated into the left trigone, and descended further with head of bed (HOB) elevation. HOB was iteratively decreased, with concurrent intracranial pressure monitoring. After extubation, with an alert and stable neurologic exam, HOB was decreased to -15 degrees, allowing gravity-assisted migration of the fragments to an anatomically favorable position within the left occipital horn. The patient underwent occipital craniotomy for fragment retrieval on hospital day 27. Two large and >20 smaller fragments were retrieved using neuronavigation and intraoperative ultrasound. Forensics showed these to be .45 caliber handgun bullet fragments. The patient recovered well after 2-months of intensive inpatient rehabilitation.

DISCUSSION

During new neurologic decline after GSWH, bullet migration must be considered and serial cranial imaging is requisite. Surgical retrieval of deep fragments requires judicious planning to minimize further injury. Tightly controlled HOB adjustments with gravity assistance for repositioning of fragments may have utility in optimizing anatomic favorability prior to surgery.

Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis

BACKGROUND

Redlining was a racialized zoning practice in the U.S. that blocked fair access to home loans during the 1930s, and recent research is illuminating health problems in the current residents of these historically redlined areas. However, this work has not yet been holistically summarized. Here, we present the first systematic review and meta-analysis comparing health outcomes in redlined versus non-redlined neighborhoods in U.S. cities.

METHODS

We extracted relevant articles in PubMed, Web of Science, Cochrane and Science Direct databases published from January 2010 to September 2021.

RESULTS

The search revealed 12 studies on preterm births (n = 3), gunshot-related injuries (n = 2), cancer (n = 1), asthma (n = 1), self-rated health (n = 1), multiple health outcomes (n = 2), heat-related outcomes (n = 1) and COVID-19 incidence and mortality (n = 1). A meta-analysis of three studies found the odds of having preterm birth was significantly higher (OR = 1.41, 95% CI: 1.05, 1.88; p = 0.02) among women living in redlined areas compared to those in non-redlined areas. Review of other outcomes revealed that gunshot-related injuries, asthma, heat-related outcomes, and multiple chronic conditions were worse in redlined areas, while associations with cancer varied by cancer type. In terms of cause-specific mortality, one study revealed no link between residential redlining and infant mortality rate, while one study on COVID-19 outcomes was inconclusive.

CONCLUSIONS

Overall, this review presents evidence that living in historically redlined areas is associated with increased risk of multiple serious adverse health outcomes. Further research on mechanisms, remediation, and neighborhood-level interventions is needed to strengthen the understanding of the impacts of redlining on health.

Civilian Firearm-Inflicted Brain Injury: Coagulopathy, Vascular Injuries, and Triage

PURPOSE OF REVIEW

Civilian firearm-inflicted penetrating brain injury (PBI) carries high morbidity and mortality. Concurrently, the evidence base guiding management decisions remains limited. Faced with large volume of PBI patients, we have made observations in relation to coagulopathy and cerebrovascular injuries. We here review this literature in addition to the question about early prognostication as it may inform neurosurgical decision-making.

RECENT FINDINGS

The triad of coagulopathy, low motor score, and radiographic compression of basal cisterns comprises a phenotype of injury with exceedingly high mortality. PBI leads to high rates of cerebral arterial and venous injuries, and projectile trajectory is emerging as an independent predictor of outcome. The combination of coagulopathy with cerebrovascular injury creates a specific endophenotype. The nature and role of coagulopathy remain to be deciphered, and consideration to the use of tranexamic acid should be given. Prospective controlled trials are needed to create clinical evidence free of patient selection bias.

Coagulopathy as a Surrogate of Severity of Injury in Penetrating Brain Injury

Penetrating brain injury (PBI) is the most devastating type of traumatic brain injury. Development of coagulopathy in the acute setting of PBI, though common, remains of unclear significance as does its reversal. The aim of this study is to investigate the relationship between coagulopathy and clinical presentation, radiographical features, and outcome in civilian patients with PBI. Eighty-nine adult patients with PBI at a Level I trauma center in Chicago, Illinois who survived acute resuscitation and with available coagulation profile were analyzed. Coagulopathy was defined as international normalized ratio [INR] >1.3, platelet count <100,000 /μL, or partial thromboplastin time >37 sec. Median age (interquartile range; IQR) of our cohort was 27 (21-35) years, and 74 (83%) were male. The intent was assault in 74 cases (83%). The mechanism of PBI was gunshot wound in all patients. Forty patients (45%) were coagulopathic at presentation. In a multiple regression model, coagulopathy was associated with lower Glasgow Coma Scale (GCS)-Motor score (odds ratio [OR], 0.67; confidence interval [CI], 0.48-0.94; p = 0.02) and transfusion of blood products (OR, 3.91; CI, 1.2-12.5; p = 0.02). Effacement of basal cisterns was the only significant radiographical features associated with coagulopathy (OR, 3.34; CI, 1.08-10.37; p = 0.04). Mortality was found to be significantly more common in coagulopathic patients (73% vs. 25%; p < 0.001). However, in our limited sample, reversal of coagulopathy at 24 h was not associated with a statistically significant improvement in outcome. The triad of coagulopathy, low post-resuscitation GCS, and radiographical effacement of basal cisterns identify a particularly ominous phenotype of PBI. The role, and potential reversal of, coagulopathy in this group warrants further investigation.

Neuroendocrine Dysfunction in the Acute Setting of Penetrating Brain Injury: A Systematic Review

BACKGROUND

Data on neuroendocrine dysfunction (NED) in the acute setting of penetrating brain injury (PBI) are scarce, and the clinical approach to diagnosis and treatment remains extrapolated from the literature on blunt head trauma.

METHODS

Three databases were searched (PubMed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale, or the methodological quality of case series and case reports, as indicated. This systematic review was registered in PROSPERO (42020172163).

RESULTS

Six relevant studies involving 58 patients with PBI were included. Two studies were prospective cohort analyses, whereas 4 were case reports. The onset of NED was acute in all studies, by the first postinjury day. Risk factors for NED included worse injury severity and the presence of cerebral edema on imaging. Dysfunction of the anterior hypophysis involved the hypothalamic-pituitary-thyroid axis, treated with hormonal replacement, and hypocortisolism, treated with hydrocortisone. The prevalence of central diabetes insipidus was up to 41%. Most patients showed persistent NED months after injury. In separate reports, diabetes insipidus and hypocortisolism showed an association with higher mortality. The available literature for this review is poor, and the studies included had overall low quality with high risk of bias.

CONCLUSIONS

NED seems to be prevalent in the acute phase of PBI, equally involving both anterior and posterior hypophysis. Despite a potential association between NED and mortality, data on the optimal management of NED are limited. This situation defines the need for prospective studies to better characterize the clinical features and optimal therapeutic interventions for NED in PBI.

Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience

BACKGROUND

Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns.

METHODS

Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up.

RESULTS

Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours.

CONCLUSIONS

CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

Cranial Vault Reconstruction and Evacuation of Hemorrhage After a Bifrontal Gunshot Wound to the Brain

Civilian gunshot wounds to the brain are associated with high overall mortality; however, outcomes can vary significantly depending on bullet trajectory. This report details the outcome of a patient who sustained a bifrontal gunshot wound with multiple associated calvarial and frontal sinus fractures. Although surgery for penetrating brain injury is most frequently employed for relief of mass effect and decompression of vital structures, this case report describes a more comprehensive technique involving duroplasty, obliteration of the frontal sinus, and cranial vault reconstruction with the aim of decreasing the rate of cerebrospinal fluid leak, infection, reoperation, and readmission.

Pediatric firearm-related traumatic brain injury in United States trauma centers

OBJECTIVE

Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death.

METHODS

All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003-2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at α < 0.001 accounting for multiple comparisons.

RESULTS

In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 ± 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3-8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 ± 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3-8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7-3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2-5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2-0.5, p < 0.001).

CONCLUSIONS

From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.