Craniocerebral Gunshot Wounds in Civilian Practice

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N EUROSURGICAL understanding of missile injuries of the head is derived from information compiled during the four major wars of this century? ,4,s,l~,~s,2~ Consequently, the concepts guiding the care and treatment of civilian gunshot wounds have, for the most part, been extrapolated from military experiences. The fundamental difference between military and civilian craniocerebral injury is related to the high velocity of the military missile compared to the low velocity in civilian injuries. Thus the broad extent of tissue damage noted in military practice is the result of the disruptive force caused by these exceptionally high levels of kinetic energy. 7,2~ This is rarely encountered in civilian practice. Although the mechanism of tissue disruption by high velocity missiles is not completely understood, it has long been recognized that even small missiles at high velocity will cause extensive tissue damage. 7,1z,~ Kinetic energy varies with the square of the velocity and linearly with missile mass. If one considers power rather than kinetic energy, then another parameter is introduced and one may say that power, or the rate at which the energy is expended, varies with the cube of the missile velocity. 7,2~ Clinical evidence, compiled during wartime, corroborates these physical considerations. High velocity military wounds cause extensive tissue damage at great distances from the missile track. 4,~~ If left unattended, these wounds become devascularized, hemorrhagic, proteinaceous masses impregnated by foreign body fragments, all of which predispose to a suppurative process. 2,~,~8,33 If an infection does not develop, large gliotic areas often result, which may become the nidus of epileptiform discharges. The two may occur together. The wars of this century