Image guided surgery in the management of craniocerebral gunshot injuries

Tarek Elserry,Ignatiusngene Esene,Hesham Anwer

doi:10.4103/2152-7806.121642

Abstract

Background:A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option?Methods:We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge.Results:Five of the eight “stereotactic cases” had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine “neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery.Conclusion:Conventional craniotomy isn’t indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these treatment modalities for CCGSI.

Highlights

A craniocerebral trauma caused by gunshot is a complex injury with a broad spectrum of symptoms and high rates of morbidity and mortality.[2,34] Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in the United States and carry a fatality rate of more than 90%, with at least two-thirds of the victims dying before reaching a hospital.[21]A gunshot injury may result in a perforating or penetrating head injury
In considering the management of intracerebral bullets in salvageable patients, the first question that arises is that of the site of the bullet and the second is the whether the presence of the bullet is symptomatic, rendering its removal desirable
To answer the question of how to remove the missile with minimal injury to the brain, we examined stereotactic surgery in localizing and extraction of these missiles

Summary

Introduction

A craniocerebral trauma caused by gunshot is a complex injury with a broad spectrum of symptoms and high rates of morbidity and mortality.[2,34] Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in the United States and carry a fatality rate of more than 90%, with at least two-thirds of the victims dying before reaching a hospital.[21]A gunshot injury may result in a perforating (from high velocity) or penetrating (from low velocity) head injury. A craniocerebral trauma caused by gunshot is a complex injury with a broad spectrum of symptoms and high rates of morbidity and mortality.[2,34] Gunshot wounds to the head, the most lethal of all firearm injuries, rank among the leading causes of head injury in the United States and carry a fatality rate of more than 90%, with at least two-thirds of the victims dying before reaching a hospital.[21]. Primary and secondary brain insults are usual accompaniments and their management is often demanding.[22] The most intriguing part in the management of craniocerebral gunshot injuries (CCGSI) is the decision to remove the bullet/pellet: When, why, and how?.[11]. A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed.

Results

Discussion

Conclusion