Predictors of outcome in civilians with gunshot wounds to the head upon presentation

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Suicide by Gunshot Wound to the Posterior Head and Neck: A Retrospective Case Series and Review of the Literature

ABSTRACT

Suicide by firearm is a significant public health concern in specific regions of the world. Depending on firearm availability, any type of firearm may be used, including handguns, shotguns, and long rifles. Common entrance wound sites in suicidal gunshot wounds include the head, with classic gunshot wound locations including the temple, the forehead, the submental aspect of the chin, and inside the mouth. Occasionally, suicidal gunshot wounds occur in atypical body locations such as the back of the head and neck. Given their relative rarity, suicidal gunshot wounds in these regions may be mistaken for homicides. In this report, we present 5 cases of suicidal gunshot wounds to the back of the head and/or neck. In our series, we focus on differentiating each case from homicides involving gunshot wounds in similar areas of the head and neck.

The role of emergency department thoracotomy in patients with cranial gunshot wounds

BACKGROUND

Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low.

METHODS

We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains.

RESULTS

Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation.

CONCLUSION

Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Traumatic Brain Injury and Traumatic Spinal Cord Injury

OBJECTIVE

This article reviews the mechanisms of primary traumatic injury to the brain and spinal cord, with an emphasis on grading severity, identifying surgical indications, anticipating complications, and managing secondary injury.

LATEST DEVELOPMENTS

Serum biomarkers have emerged for clinical decision making and prognosis after traumatic injury. Cortical spreading depolarization has been identified as a potentially modifiable mechanism of secondary injury after traumatic brain injury. Innovative methods to detect covert consciousness may inform prognosis and enrich future studies of coma recovery. The time-sensitive nature of spinal decompression is being elucidated.

ESSENTIAL POINTS

Proven management strategies for patients with severe neurotrauma in the intensive care unit include surgical decompression when appropriate, the optimization of perfusion, and the anticipation and treatment of complications. Despite validated models, predicting outcomes after traumatic brain injury remains challenging, requiring prognostic humility and a model of shared decision making with surrogate decision makers to establish care goals. Penetrating injuries, especially gunshot wounds, are often devastating and require public health and policy approaches that target prevention.

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.

Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study

Background

Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them.

Methods

We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes.

Results

The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3.

Conclusions

Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries.

Level of Evidence

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Utilization of Ophthalmic Management in Patients with Head-and-Neck Trauma Secondary to Firearms

Introduction

This retrospective cohort study presents the epidemiology of severe firearm-related ophthalmic injury and the level of ophthalmology involvement in the multidisciplinary management of head-and-neck gunshot injuries.

Methods

A retrospective study identified 207 patients with firearm-related injuries involving the head and neck treated at an Academic Tertiary Care Institution from 2010 to 2020.

Results

Ophthalmology consulted on 29% of patients with head-and-neck firearm injuries. At least one of the services managing facial trauma (plastic surgery and otolaryngology) consulted on 71.5% of cases (P < 0.001). Of patients evaluated by ophthalmology, 93.3% survived to discharge; 78.2% of patients who were not evaluated survived to discharge (P = 0.009). Ophthalmology consulted on all patients with open globe injury (10.6%) (P < 0.001), all of which were evaluated by the facial trauma service (P = 0.002), 77.3% by otolaryngology (P = 0.42), 50% by neurosurgery, 36.4% by plastic surgery, 13.6% by orthopedic surgery, and 4.5% by vascular surgery. Ophthalmology consulted on 76.5% of patients with orbital fracture (32.9%) (P < 0.001); 83.8% were evaluated by the facial trauma service (P = 0.006), 69.1% by otolaryngology (P = 0.014), 54.4% by neurosurgery, 27.9% by plastic surgery, 10.3% by orthopedic surgery, and 2.9% by vascular surgery. For patients with orbital fractures, 92.3% survived when ophthalmology was consulted (P = 0.698); 43.8% survived when not consulted (P = 0.001).

Conclusions

Firearm-related injuries of the head and neck frequently involve ocular and orbital structures, often causing serious vision-threatening injuries. Multispecialty management is common and early ophthalmology specialist evaluation and co-management are indicated to best identify ophthalmic injuries.

Neurologically Intact Survival after Bihemispheric Penetrating Head Trauma: A Case Report

BACKGROUND

Patients with penetrating head trauma that crosses the midline of the brain have a high mortality rate; most die in the prehospital setting or during initial resuscitative efforts. However, surviving patients are often neurologically intact and several factors other than bullet path, including post-resuscitation Glasgow Coma Scale, age, and pupillary abnormalities, must be considered in aggregate when prognosticating patients.

CASE REPORT

We present a case of an 18-year-old man who presented unresponsive after a single gunshot wound to the head that traversed the bilateral hemispheres. The patient was managed with standard care and without surgical intervention. He was discharged from the hospital neurologically intact 2 weeks after his injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with such apparently devastating injuries are at risk of premature termination of aggressive resuscitative efforts based on clinician bias that these efforts are futile and that patients cannot recover to a neurologically meaningful outcome. Our case reminds clinicians that patients with severe injury patterns with bihemispheric involvement can recover with good outcomes, and that bullet path is only one variable among multiple that must be considered to predict clinical outcome.

Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond

OBJECTIVE

The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma.

BACKGROUND

While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field.

METHODS

We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners.

RESULTS

Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level.

CONCLUSIONS

Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Racial and Social Determinants of Civilian Gunshot Wounds to the Head

OBJECTIVE

To assess the clinical, racial, and social characteristics of victims of Gunshot wounds (GSWs) to the head and assess for associations between these factors and outcomes.

SUMMARY BACKGROUND DATA

Previous literature has not focused on the association of race and socioeconomic factors with these specific injuries.

METHODS

We identified patients with GSWs to the head who presented to 2 urban academic medical centers between 1998 and 2020, and extracted patient-level demographic data, information about the clinical and surgical course, and outcomes at discharge and follow-up.

RESULTS

The cohort included 250 patients, 90% (n = 226) of whom were male, with a mean age of 28 years. Forty-five percent were white (n = 112), 19% Black (n = 48), 18% Latinx (n = 45), with 6% "other" (n = 16), and 12% "unknown" (n = 29). The majority of patients presented with assault-related trauma (n = 153, 61%) as compared to self-inflicted injuries (n = 97, 39%). Across the entire cohort, sex, age, race, and median income by ZIP code were not significant predictors of outcome. Victims of assault by GSW to the head were more likely to be age 18 or younger (OR 5.26, P = 0.01), between the ages of 19 and 33 years (OR 4.7, P = 0.001), Black (OR 6.66, P < .001), and Latinx (OR 2.65, P = 0.03). Most patients (n = 155, 63%) had a poor functional outcome (modified Rankin Score 3-6) at discharge.

CONCLUSION

Age, race, and income status were not independent predictors of mortality or functional outcome at discharge in our population. Assault-related GSWs to the head mostly involved young Black or Latinx men of lower socioeconomic status, while self-inflicted injuries were largely seen in older white men.

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.

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

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

An independent, external validation and component analysis of the Surviving Penetrating Injury to the Brain score for civilian cranial gunshot injuries

OBJECTIVE

The Surviving Penetrating Injury to the Brain (SPIN) score utilizes clinical variables to estimate in-hospital and 6-month mortality for patients with civilian cranial gunshot wounds (cGSWs) and demonstrated good discrimination (area under the receiver operating characteristic curve [AUC] 0.880) in an initial validation study. The goal of this study was to provide an external, independent validation of the SPIN score for in-hospital and 6-month mortality.

METHODS

To accomplish this, the authors retrospectively reviewed 6 years of data from their institutional trauma registry. Variables used to determine SPIN score were collected, including sex, transfer status, injury motive, pupillary reactivity, motor component of the Glasgow Coma Scale (mGCS), Injury Severity Score (ISS), and international normalized ratio (INR) at admission. Multivariable logistic regression analysis identified variables associated with mortality. The authors compared AUC between models by using a nonparametric test for equality.

RESULTS

Of the 108 patients who met the inclusion criteria, 101 had all SPIN score components available. The SPIN model had an AUC of 0.962. The AUC for continuous mGCS score alone (0.932) did not differ significantly from the AUC for the full SPIN model (p = 0.26). The AUC for continuous mGCS score (0.932) was significantly higher compared to categorical mGCS score (0.891, p = 0.005). Use of only mGCS score resulted in fewer exclusions due to missing data. No additional variable included in the predictive model alongside continuous mGCS score was a significant predictor of inpatient mortality, 6-month mortality, or increased model discrimination.

CONCLUSIONS

Given these findings, continuous 6-point mGCS score may be sufficient as a generalizable predictor of inpatient and 6-month mortality in patients with cGSW, demonstrating excellent discrimination and reduced bias due to missing data.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

BACKGROUND

The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.

DISCUSSION

The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.

TRIAL REGISTRATION

Nederlands Trial Register (NTR), Trial NL9012 .

CLINICALTRIALS

gov, Trial NCT04648436 .

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.

The value of simplicity: externally validating the Baylor cranial gunshot wound prognosis score

OBJECTIVE

Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population.

METHODS

Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance.

RESULTS

A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome.

CONCLUSIONS

The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.

Incorporating conditional survival into prognostication for gunshot wounds to the head

OBJECTIVE

Several scores estimate the prognosis for gunshot wounds to the head (GSWH) at the point of hospital admission. However, prognosis may change over the course of the hospital stay. This study measures the accuracy of the Baylor score among patients who have already survived the acute phase of hospitalization and generates conditional outcome curves for the duration of hospital stay for patients with GSWH.

METHODS

Patients in whom GSWH with dural penetration occurred between January 2009 and June 2019 were identified from a trauma registry at a level I trauma center in the southeastern US. The Baylor score was calculated using component variables. Conditional overall survival and good functional outcome (Glasgow Outcome Scale score of 4 or 5) curves were generated. The accuracy of the Baylor score in predicting mortality and functional outcome among acute-phase survivors (survival > 48 hours) was assessed using receiver operating characteristic curves and the area under the curve (AUC).

RESULTS

A total of 297 patients were included (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male), and 129 patients survived the initial 48 hours of admission. These acute-phase survivors had a decreased mortality rate of 32.6% (n = 42) compared to 68.4% (n = 203) for all patients, and an increased rate of good functional outcome (48.1%; n = 62) compared to the rate for all patients (23.2%; n = 69). Among acute-phase survivors, the Baylor score accurately predicted mortality (AUC = 0.807) and functional outcome (AUC = 0.837). However, the Baylor score generally overestimated true mortality rates and underestimated good functional outcome. Additionally, hospital day 18 represented an inflection point of decreasing probability of good functional outcome.

CONCLUSIONS

During admission for GSWH, surviving beyond the acute phase of 48 hours doubles the rates of survival and good functional outcome. The Baylor score maintains reasonable accuracy in predicting these outcomes for acute-phase survivors, but generally overestimates mortality and underestimates good functional outcome. Future prognostic models should incorporate conditional survival to improve the accuracy of prognostication after the acute phase.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ballistic lobar trajectory outcomes in civilian firearm penetrating brain injury

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Spontaneous migration of a falling bullet in the cerebellum reveals the importance of intraoperative skull X-ray

Cranial gunshot wounds (CGSWs) are the most lethal types of the cranial traumas and they are usually mortal. Falling bullets or gravitational bullets are the ones that move under the effect of the gravity force after the muzzle force diminished. CGSWs constitute a major clinical challenge for neurosurgeons dealing with trauma in both the military and civil experience. We report the case of a 21-year-old man with a falling bullet wound to the head. The decision of surgical treatment of a bullet injury is difficult if it is in close proximity to vital structures; removal of the bullet may cause significant neurological damage; however, migration can lead to a worsening of the neurological status of the patient. Before surgical removal of any intracranial bullet, as valuable information, it is recommended that a plain skull X-ray be obtained after final positioning of the head.

Civilian gunshot wounds to the head: a case report, clinical management, and literature review

BACKGROUND

Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion. Gunshot wounds to the head are the deadliest of all gun injuries. According to literature statistics, the survival rate of patients with gunshot wounds to the head is only 9%. Due to the strict management of various types of firearms, they rarely occur, so the injury mechanism, injury and trauma analysis, clinical management, and surgical standards are almost entirely based on military experience, and there are few related reports, especially of the head, in which an individual suffered a fatal blow more than once in a short time. We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time.

CASE PRESENTATIONS

We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score of 6, was unable to communicate, and had loss of consciousness. The first bullet penetrated the right frontal area and finally reached the right occipital lobe. When the patient reflexively shielded his head with his hand, the second bullet passed through the patient's right palm bone, entered the right frontotemporal area, and came to rest deep in the lateral sulcus. The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan. After two foreign body removals and skull repair, the patient recovered completely.

CONCLUSIONS

Gunshot wounds to the head have a high mortality rate and usually require aggressive management. Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital, followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is usually necessary, and its key points include the timing, method, and scope of the operation.

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.

Craniocerebral nail gun injuries: a definitive review of the literature

AIM

Nail guns are important time saving devices but are associated with morbidity and mortality. Specifically, craniocerebral injuries have been reported in the literature since 1963 and have increased in frequency as the use of these tools has become commonplace. There remains a paucity of literature comprehensively assessing nail gun injuries, as compared with other penetrating craniocerebral injuries like those from firearms.

METHOD

A literature review of PubMed, Medline (Ovid), Cochrane library, and Google Scholar for articles published between 1960 and 2018 reporting craniocerebral nail gun injuries.

RESULTS

In total, 96 individual cases were identified, with 80 meeting inclusion criteria. These were categorized as accidental and intentional injuries. The demographic was overwhelmingly young males (97.5%), and intentional self-inflicted injuries (54%) was the most frequent mechanism of injury. Overall mortality was 10%. Mortality was more common in patients with intentional injuries, but morbidity rates were similar between the accidental and intentional injury cohorts. Post-operative complications rate was 23.8%.

CONCLUSION

Craniocerebral nail gun injuries are associated with lower rates of both mortality and residual neurological deficits than craniocerebral firearms injuries. There is limited data to inform clinical prognostication about long-term neurological impairments and the time to recovery which should be addressed in future studies.

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.

Blast-Induced Traumatic Brain Injuries: Experience from the Deadliest Double Suicide Bombing Attack in Iraq

INTRODUCTION

Blast-induced traumatic brain injuries (bTBIs) are increasingly frequent in civilian settings. We present the first study of individuals with bTBI in Iraq. The study focuses on one of the deadliest suicide car bomb attacks in Iraq and uses it to show the devastating nature of bTBIs.

METHODS

This study was conducted at the Neurosurgery Teaching Hospital in Baghdad, Iraq. A retrospective chart analysis of patients with bTBI admitted to the Neurosurgery Teaching Hospital was performed. Measured parameters included patients' demographics, initial presentation, injury patterns, hospital course, surgical management, and outcomes.

RESULTS

A total of 75 patients with bTBI were included in this study, 19 of whom died in the emergency room. The remaining 56 patients were admitted to the hospital. Of those patients, 68.6% (n = 39) underwent surgery, and 30.4% were managed conservatively. A modified, tailored triaging system was implemented. All surgery was guided by the principles of damage control neurosurgery. In addition, 76.9% and 46.2% of patients underwent corticectomy and decompressive craniectomy, respectively. Dural venous sinus repair was performed in 17.9% of patients, and 30.7% of the operations entailed additional steps to control major (arterial) cerebrovascular bleeding. The net bTBI-related complication rate was 76%. The total mortality was 48%. Of survivors, 10.7% (n = 8) were discharged with a severe disability. Overall, good outcomes were achieved in 41.3% of the patients.

CONCLUSIONS

This study sheds light on the devastating nature of bTBIs. Neurosurgeons worldwide need to be mindful of the unique triaging, diagnostic, and management requirements of these injuries.

Bullet fragments spontaneously migrating in opposite directions after a cardiac arrest treated with extracorporeal cardiopulmonary resuscitation following a gunshot wound to the head: A case report

Gunshot injuries to the head are associated with a poor neurological prognosis, have a high risk of mortality, and make the return of spontaneous breathing and circulation after cardiopulmonary arrest difficult. Bullets or bullet fragments can cause penetrating injuries to the brain tissue and sometimes remain in the skull, potentially migrating within the skull. Herein, we describe a rare patient who achieved a return of spontaneous circulation after cardiopulmonary (ROSC) arrest caused by a gunshot wound, following extracorporeal cardiopulmonary resuscitation. After ROSC, repeated computed tomography (CT) identified spontaneously migrating bullets/fragments in the right hemisphere and the metal fragment was excreted from the skull, while another fragment had moved from the left temporal to the occipital fossa. The patient died on the 15th day of hospitalization. The present case had a rare clinical course, suggesting that ROSC may be achieved under adequate respiratory and circulation management in cases of cardiac arrest with a head injury. The scans showed differing movements of the bullet fragments at each lesion, which was difficult to predict from the first CT scan. When surgical treatment is required to remove bullet fragments remaining in the skull (due to lead poisoning, or infection, among others), it may be useful to be aware that fragments may move in various directions, even out of the skull. Furthermore, we recognized the usefulness of CT scanning for detecting the location of the foreign body in cases of gunshot injury to the head.

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.

Diagnostic and predictive value of white blood cell count, erythrocyte sedimentation rate, and coagulation tests in patients with blunt head trauma

Introduction: Head trauma is the third leading cause of death and one of the most common causes of referral to the emergency department. Prognosis in these patients identifies individuals at higher risk and provides them with faster and more complete treatment, so it is of particular importance. The aim of this study is to evaluate the diagnostic and predictive value of white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and coagulation tests in the outcome of patients with blunt head trauma. Methods: In this retrospective study, 91 patients referred to the emergency department of Imam Reza hospital of Tabriz, with a complaint of DAI type of blunt head trauma, were enrolled in a complete and sequential study during the first six months of the year 2017. The patientswere divided into two groups according to good or poor prognosis and their association with leukocytosis status and other paraclinical factors at the baseline. Results: The final outcome in high consciousness group was 13.3% need for intubation,26.7% need for surgery, 50% improvement without complications, and 10% mortality. In the low consciousness group, 16.7% required intubation, 20.0% required surgery, 10% had no complications, and 53.3% experienced mortality. The significance level of the chi-squaretest was 0.001. Independent t test results showed that the WBC and ESR values in the lowconsciousness group were significantly higher than the high consciousness group. But the international normalized ratio (INR) in the high consciousness group was significantly higher than the low consciousness group (P<0.05). Conclusion: There is a significant relationship between severity of injury and leukocytosis, ESRelevation, and related coagulopathy after major trauma.

Cortical lesions causing loss of consciousness are anticorrelated with the dorsal brainstem

Brain lesions can provide unique insight into the neuroanatomical substrate of human consciousness. For example, brainstem lesions causing coma map to a specific region of the tegmentum. Whether specific lesion locations outside the brainstem are associated with loss of consciousness (LOC) remains unclear. Here, we investigate the topography of cortical lesions causing prolonged LOC (N = 16), transient LOC (N = 91), or no LOC (N = 64). Using standard voxel lesion symptom mapping, no focus of brain damage was associated with LOC. Next, we computed the network of brain regions functionally connected to each lesion location using a large normative connectome dataset (N = 1,000). This technique, termed lesion network mapping, can test whether lesions causing LOC map to a connected brain circuit rather than one brain region. Connectivity between cortical lesion locations and an a priori coma-specific region of brainstem tegmentum was an independent predictor of LOC (B = 1.2, p = .004). Connectivity to the dorsal brainstem was the only predictor of LOC in a whole-brain voxel-wise analysis. This relationship was driven by anticorrelation (negative correlation) between lesion locations and the dorsal brainstem. The map of regions anticorrelated to the dorsal brainstem thus defines a distributed brain circuit that, when damaged, is most likely to cause LOC. This circuit showed a slight posterior predominance and had peaks in the bilateral claustrum. Our results suggest that cortical lesions causing LOC map to a connected brain circuit, linking cortical lesions that disrupt consciousness to brainstem sites that maintain arousal.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Development and Validation of a Nomogram for Predicting the Mortality after Penetrating Traumatic Brain Injury

Objective:

To determine the factors associated with mortality in penetrating brain injury (PTBI) and proposed the nomogram predicting the risk of death.

Methods:

A retrospective cohort study was conducted on all patients who had sustained PTBI between 2009 and 2018. Collected data included clinical characteristics, neuroimaging findings, treatment, and outcomes. Prognostic factors analysis was conducted using a forest plot. Therefore, the nomogram was developed and validated. For the propose of evaluation, the nomogram’s sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Receiver Operating Characteristic (ROC) curve and the area under the receiver operating characteristic (AUC) were determined for validating the optimal cut-off point of the total scores.

Results:

During the study period, 62 individuals enrolled. In the univariate analysis, factors associated with the morality were normal pupils’ reactivity to light (OR 0.04, p < 0.001), hypotension (OR 9.91, p<0.001), hypoxia (OR 10.2, p=0.04), bihemispheric injuries (OR 19.0, p=0.001), multilobar injuries (OR 21.5, p< 0.001), subarachnoid hemorrhage (OR 6.9, p= 0.02), intraventricular hemorrhage (OR 26.6, p= 0.006), basal cistern effacement (OR 28.8, , p<0.001), midline shift >5 mm (OR 0.19, p<0.001) were significantly associated with death. In multivariable analysis, hypotension (OR 8.82, p=0.03), normal pupils’ reactivity to light (OR 0.07, p =0.01), midline shift >5 mm (OR 18.23, p<0.007) were significantly associated with death. The nomogram’s sensitivity, specificity, PPV, NPV, and AUC for predicting mortality (total score ≥ 100) were 80%, 92.6%, 72.7%, 95.0%, and, 0.86 respectively.

Conclusions:

PTBI is the fatal injury depend on both clinical and neuroimaging parameters. The nomogram is the alternative method providing prognostic parameters toward implication for clinical decision making.

Air gun wound: bihemispheric penetrating brain injury in a paediatric patient

Air guns are classified as low-velocity missiles and they usually considered safe and harmless. Despite that fact, air guns still can make serious or life-threatening injuries. Most of air gun injuries occur in paediatric population. A 2-year-old boy was shot in the forehead withan air gun accidentally. Skull radiography and non-contrast CT scan of the head were performed and showed penetrating bihemispheric brain injury from the left frontal to right occipital lobes at the level of the lateral ventricle with a metal-density foreign body at the right occipital. A projectile was successfully extracted via craniotomy, without complications. Air guns have the potential to cause fatal, life-threatening injury especially in children. Imaging is crucial for the evaluation of wound ballistics. Understanding about the mechanism of projectiles and wound ballistics is very helpful for radiologists to conceptualize these injuries when interpreting these cases. The role of radiology in ballistic wound cases is critical and important, both for clinical and forensic settings.

Survival After a Transcranial Bihemispheric Stabbing with a Knife: Case Report and Literature Review

Low-velocity penetrating brain injuries (PBIs), also referred to as nonmissile brain injuries, typically result from stabbings, industrial or home accidents, or suicide attempts. A great deal of literature has focused on the injury patterns and management strategies of high-velocity PBIs. However, there are substantially fewer large, contemporary studies focused solely on low-velocity PBIs. Here, we present an interesting and uncommon case of a patient who suffered a bihemispheric stab wound involving the basal ganglia. A 22-year-old man presented to the hospital with a stab wound to the left calvarium. His initial Glasgow Coma Scale (GCS) score was 13, but he rapidly declined to a six and was intubated. He was emergently taken to the operating room for craniectomy, knife removal, and external ventricular drain placement. On the first postoperative day, the patient was following commands with all extremities. He was discharged to a rehabilitation facility 13 days postinjury. One year after the injury, the patient was free of major neurologic sequelae. This report illustrates a rare case of a good functional outcome after a transcranial stabbing with multiple imaging and exam findings usually associated with poor outcomes.

The assassination of Robert F. Kennedy: an analysis of the senator's injuries and neurosurgical care

On June 5, 1968, having won the Democratic Party presidential primary in California, Senator Robert F. Kennedy delivered a victory speech to supporters at the Ambassador Hotel in downtown Los Angeles. Just after 12:15 am (Pacific daylight savings time), a lone assassin shot Kennedy 3 times at point-blank range. One of the bullets struck Kennedy in the right posterior auricular region. Within the ensuing 26 hours, Kennedy was transported to 2 hospitals, underwent emergency surgery, and eventually died of severe brain injury. Although this story has been repeated in the press and recounted in numerous books, this is the first analysis of the senator's injuries and subsequent surgical care to be reported in the medical literature. The authors review eyewitness reports on the mechanism of injury, the care rendered for 3 hours prior to the emergency craniotomy, the clinical course, and, ultimately, the autopsy.

Intracranial Pressure Monitoring in Experimental Traumatic Brain Injury: Implications for Clinical Management

Traumatic brain injury (TBI) is often associated with long-term disability and chronic neurological sequelae. One common contributor to unfavorable outcomes is secondary brain injury, which is potentially treatable and preventable through appropriate management of patients in the neurosurgical intensive care unit. Intracranial pressure (ICP) is currently the predominant neurological-specific physiological parameter used to direct the care of severe TBI (sTBI) patients. However, recent clinical evidence has called into question the association of ICP monitoring with improved clinical outcome. The detailed cellular and molecular derangements associated with intracranial hypertension (IC-HTN) and their relationship to injury phenotype and neurological outcomes are not completely understood. Various animal models of TBI have been developed, but the clinical applicability of ICP monitoring in the pre-clinical setting has not been well-characterized. Linking basic mechanistic studies in translational TBI models with investigation of ICP monitoring that more faithfully replicates the clinical setting will provide clinical investigators with a more informed understanding of the pathophysiology of IC-HTN, thus facilitating development of improved therapies for sTBI patients.

The role of microglial inflammasome activation in pyroptotic cell death following penetrating traumatic brain injury

BACKGROUND

Traumatic brain injury remains a significant cause of death and disability in the USA. Currently, there are no effective therapies to mitigate disability except for surgical interventions necessitating a need for continued research into uncovering novel therapeutic targets. In a recent study, we used a rodent model of penetrating traumatic brain injury known as penetrating ballistic-like brain injury (PBBI) to examine the role of innate immunity in post-traumatic secondary injury mechanisms. We previously reported that the inflammasome, a multiprotein complex composed of apoptosis-associated speck-like protein containing card and caspase-1, plays a role in secondary cell death mechanisms after PBBI, including inflammatory cell death (pyroptosis).

METHODS

In the current study, we used flow cytometry analysis to evaluate activated microglia and CD11b-positive leukocytes after PBBI and assessed inflammasome activation and pyroptosis of specific cellular populations. Sprague-Dawley male rats underwent PBBI or sham-operated procedures and ipsilateral cortical regions processed for flow cytometry and cellular analysis. Flow cytometry results were compared using one-way ANOVA followed by Tukey's multiple comparisons.

RESULTS

At 48 h following PBBI, there was an increase in activated microglia and infiltrating leukocytes compared to sham controls that were associated with increased caspase-1 activity. Using a florescent probe to identify caspase-1 activity and a fluorescent assay to determine cell viability, evidence for pyroptosis in CD11b+ cells was also determined. Finally, while post-traumatic treatment with an anti-ASC antibody had no effect on the number of activated microglia and infiltrating leukocytes, antibody treatment decreased caspase-1 activity in both resident microglia and infiltrating leukocytes and reduced pyroptotic CD11b+ cell death.

CONCLUSIONS

These results provide evidence for inflammasome activation in microglia and infiltrating leukocytes after penetrating traumatic brain injury and a role for pyroptotic cell death in the pathophysiology. In addition to inhibiting neuronal cell death, therapeutic treatments targeting inflammasome activation may also provide beneficial effects by reducing the potentially detrimental consequences of activated microglia and infiltrating CD11b+ leukocytes following penetrating traumatic brain injury.

Managing military penetrating brain injuries in the war zone: lessons learned

OBJECTIVE

Managing penetrating military brain injuries in a war zone setting is different than managing common civilian penetrating brain injuries. Triage, i.e., deciding on which patients to treat or not treat, and which to be flown back home, is essential to avoid wasting valuable limited resources. In this study the authors aim to identify reliable predictors of mortality and poor outcome to help develop a protocol for treating their patients in the battlefield. They also demonstrate all the lessons learned from their collective experience regarding some of the controversial management issues.

METHODS

This study was a retrospective review of 102 patients with penetrating military missile head injuries treated by the authors in various facilities in northern Sinai between 2011 and 2018. Patient demographics, clinical characteristics, imaging characteristics, postoperative complications, and Glasgow Outcome Scale (GOS) scores were recorded for each patient. Several variables associated with mortality and poor outcome that were derived from the literature were analyzed, in addition to variables obtained by direct observation by the authors over time.

RESULTS

There were 50 patients (49%) with GOS score of 1 (death), 12 patients (11.8%) with GOS score of 2 (survivors in persistent vegetative state), and 40 survivors (39.2%) with varying degrees of disability on the last follow-up evaluation. The authors identified an anatomical danger zone that was found to predict mortality when traversed. Bilateral dilated fixed pupils and low Glasgow Coma Scale score on admission were also found to be independent predictors of mortality and poor outcome. Based on these findings, a protocol was developed for managing these patients in the war zone.

CONCLUSIONS

Managing military penetrating head injuries in the war zone is different than civilian gunshot head injuries encountered by most neurosurgeons in urban cities. The authors developed a simple protocol for managing military penetrating injuries in the war zone. They also describe important lessons learned from this experience.