Outcome and rational management of civilian gunshot injuries to the brain\u2014retrospective analysis of patients treated at the Helsinki University Hospital from 2000 to 2012

Juhana Frösen,Rahul Raj,Erkki Tukiainen,Ian Barner-Rasmussen,Juha Hernesniemi,Oskari Frisk

doi:10.1007/s00701-019-03952-y

Juhana Frösen, Rahul Raj + Show 4 more

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https://doi.org/10.1007/s00701-019-03952-y

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Abstract

BackgroundTreatment of gunshot wounds of the brain (GSWB) remains controversial and there is high variation in reported survival rates (from < 10 to > 90%) depending on the etiology and country. We retrospectively analyzed the outcome of a series of consecutive GSWB patients admitted alive to a level 1 trauma center in a safe high-income welfare country with a low rate of homicidal gun violence.MethodsPatients admitted due to a GSWB to the HUS Helsinki University Hospital during 2000–2012 were identified from hospital discharge registry and log books of the emergency room and ICU. CT scans and medical records of these patients were reviewed. Univariate analysis and backward logistic regression were performed, and their results compared with that of a systematic literature review of factors related to the outcome of GSWB patients.ResultsSixty-four patients admitted alive after GSWB were identified. Eighty percent had self-inflicted GSWB, 81% were contact shots, and 70% were caused by handguns. In-hospital mortality was 72%. Factors associated with mortality in our series were low GCS (≤ 8) at admission, transventricular bullet trajectory, and associated damage to deep brain structures, as reported before in the literature. Of the 64 patients admitted alive, 42% (27/64) were admitted to ICU, 34% (22/64) underwent surgery, and in 25% (16/64), craniotomy and hematoma evacuation was performed. Mortality in the surgically treated group was 32% but near 100% without surgery and ICU treatment. Median GOS in the surgically treated patients was 3 (range 1–5).ConclusionsGSWB caused by contact shot from handguns has a high mortality rate, but can be survived with reasonable outcome if limited to lobar injury without significant damage to deep brain structures or brain stem. In such GSWB patients, initial aggressive resuscitation, ICU admission, and surgery seem indicated.

Highlights

Civilian brain injuries caused by gunshot wounds of the brain (GSWB) are rare (< 1/100,000 person years) in times of peace in most societies [9, 21,10]
It is worth noting that in a prior clinical series of GSWB patients treated at our hospital in the pre-computerized tomography (CT) era GSWBs are rare in stable high-income welfare states such as most European countries, emergency room physicians and on-call neurosurgeons will be faced with them
Both our series as well as many of the previously published series demonstrate that GSWB without damage to deep brain structures can be survived with reasonable outcome

Summary

Introduction

Civilian brain injuries caused by gunshot wounds of the brain (GSWB) are rare (< 1/100,000 person years) in times of peace in most societies [9, 21,10]. They do happen as the result of self-inflicted suicidal injuries, related to homicidal assaults, or as the result of accidents [21,10]. Comparison of the incidence and etiology (suicidal, homicidal, accidental) of firearm-related injury between different countries shows great variation [9, 21,10]. We retrospectively analyzed the outcome of a series of consecutive GSWB patients admitted alive to a level 1 trauma center in a safe high-income welfare country with a low rate of homicidal gun violence

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