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Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: A decision-tree algorithm based on a single trauma center. J Clin Neurosci 2020; 75:71-79. [PMID: 32241644 DOI: 10.1016/j.jocn.2020.03.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/20/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Lily H Kim
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Jennifer L Quon
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Tene A Cage
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Marco B Lee
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Lan Pham
- Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Santa Clara Valley Medical Center, 751 S Bascom Ave, San Jose, CA 95128, USA.
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Maragkos GA, Papavassiliou E, Stippler M, Filippidis AS. Civilian Gunshot Wounds to the Head: Prognostic Factors Affecting Mortality: Meta-Analysis of 1774 Patients. J Neurotrauma 2018; 35:2605-2614. [DOI: 10.1089/neu.2018.5682] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Georgios A. Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aristotelis S. Filippidis
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts
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Kong VY, Weale RD, Sartorius B, Bruce JL, Laing GL, Clarke DL. Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience. Emerg Med Australas 2018; 30:773-776. [PMID: 29693313 DOI: 10.1111/1742-6723.12985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/01/2018] [Accepted: 03/04/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). METHODS A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. RESULTS During the 5 year study period, 102 patients were included. Ninety-two per cent (94/102) were male and the mean age was 29 years. Ninety-eight per cent of the injuries were secondary to low velocity GSWs. Twenty-seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty-five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. CONCLUSION Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs.
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Affiliation(s)
- Victor Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Ross D Weale
- Department of Surgery, Wessex Deanery, Wessex, UK
| | - Benn Sartorius
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - John L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Grant L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Damian L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
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Kong VY, Odendaal J, Sartorius B, Clarke DL, Bruce JL, Laing GL, Esterhuizen T. Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score. Ann R Coll Surg Engl 2018; 100:97-100. [PMID: 29022788 PMCID: PMC5838685 DOI: 10.1308/rcsann.2017.0141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. Materials and methods A retrospective study was undertaken over a 5-year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. Results A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88-100%, P < 0.001). Conclusions The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non-survivors of cerebral gunshot wounds. Further study is required to validate this score.
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Affiliation(s)
- V Y Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - J Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - B Sartorius
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal , Durban , South Africa
| | - D L Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
- Department of Surgery, University of the Witwatersrand , Johannesburg , South Africa
| | - J L Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - G L Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal , Durban , South Africa
| | - T Esterhuizen
- Centre for Evidence Based Health Care, Department of Global Health, University of Stellenbosch , Stellenbosch , South Africa
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Kong VY, Oosthuizen GV, Sartorious B, Bruce JL, Laing GL, Weale R, Clarke DL. Validation of the Baragwanath mortality prediction score for cerebral gunshot wounds: the Pietermaritzburg experience. Eur J Trauma Emerg Surg 2017; 44:615-620. [DOI: 10.1007/s00068-017-0835-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 09/07/2017] [Indexed: 11/30/2022]
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Kong V, Odendaal J, Sartorius B, Clarke D, Brysiewicz P, Jerome E, Bruce J, Laing G. Civilian cerebral gunshot wounds: a South African experience. ANZ J Surg 2016; 87:186-189. [PMID: 27871133 DOI: 10.1111/ans.13846] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 09/30/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cerebral gunshot wounds represent one of the most lethal forms of traumatic brain injury, but there is a paucity of literature on the topic, especially from the developing world. We reviewed our experience and describe the spectrum and outcome of civilian cerebral gunshot wounds in a major metropolitan trauma centre in South Africa. METHODS This was a retrospective study of all patients with isolated cerebral gunshot wounds managed by the Pietermaritzburg Metropolitan Trauma Service over a 5-year period from 2010 to 2014. RESULTS One hundred and two patients were included, 92% (94/102) were male and the mean age was 29 years. Fifty-four per cent (55/102) of all patients were from urban areas. The mean time from injury to arrival was 6 h (standard deviation: 5) for urban patients and 15 h (standard deviation: 5.2) for rural patients (P < 0.001). Ninety-four per cent (94/102) of all injuries were related to interpersonal violence and involved low velocity firearms. Twenty per cent of all patients (20/102) had a Glasgow Coma Scale 3-8, 20% (20/102) 9-12 and 61% (61/102) 12-15. All 102 patients underwent computed tomography scans. Thirty per cent (31/102) required neurosurgical interventions. The overall mortality rate was 22% (22/102). There was a significant difference in mortality between urban and rural patients (9% versus 36%, P < 0.001). CONCLUSIONS Cerebral gunshot wounds are associated with significant mortality and protracted delay to definitive care is common in our setting. Those who survive the delayed transfer to definitive care generally do well and have reasonably good clinical outcomes.
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Affiliation(s)
- Victor Kong
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Jocinta Odendaal
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- Department of Public Health Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Damian Clarke
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Petra Brysiewicz
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Ellen Jerome
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - John Bruce
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Grant Laing
- Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
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Doll D, Vassiliu P. Single gunshot wound head - Link between mortality and admission systolic blood pressure. Injury 2014; 45:1802. [PMID: 24360077 DOI: 10.1016/j.injury.2013.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/17/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Dietrich Doll
- Department of Surgery, St. Marys Hospital Vechta, Marienstr. 6-8, D-49377 Vechta, Germany.
| | - Pantelis Vassiliu
- Department of Surgery, 4th Surgical Clinic, "Attikon" University Hospital, Athens, Greece
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