Cerebral Gunshot Wounds Research Articles

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.

Renal Allografts from Brain Dead Donors Following Cerebral Gunshot Wounds

Renal allografts from brain dead donors following cerebral gunshot wounds. Introduction Severe brain injury following cerebral gunshot wounds may expose large amounts of tissue factor to the circulation and develop disseminated intravascular coagulation (DIC). DIC can lead to renal dysfunction. Objectives Analyse the validity for transplantation of kidneys harvested from brain dead donors (BDD) following cerebral gunshot wounds and the outcome of the transplanted renal grafts. Methods Retrospective descriptive study of renal allografts harvested from BDD following cerebral gunshot wounds, at a single center, between June 1, 2007 and May 31, 2017. Data on donors (patients´ characteristics, blood tests, associated injuries) and recipients (graft survival, rejection) were collected. Results We analysed data from six BDD following cerebral gunshot wounds (age 40.3 ± 9.6 years) without any cardiovascular risk factors, except one patient who had hypertension. All patients presented brain death in the first 24 hours of hospital admission. None of them had any associated injuries. One patient suffered a cardiopulmonary arrest (during 20 minutes) prior to ICU admission. One of the patients had elevated creatinine levels in the blood tests when he was admitted to the hospital. But, during the ICU length of stay, up to 50% of the patients presented acute renal failure. Fifty percent of the patients presented compatible or suggestive criteria for DIC. Four kidney grafts were not valid for transplantation because: acute renal failure (two kidney grafts), poor graft perfusion (one case) and complex vascular anomalies (one case). Eight kidney grafts (66.67%) were transplanted. Seven kidney grafts were transplanted in our center. One of them was explanted, in the first 24 hours after transplantation, due to cortical necrosis (pathology report: glomerular and vascular thrombotic microangiopathy lesions). Figure 1. The donor's contralateral kidney was not implanted due to poor perfusion. The pathology report of this kidney was: multiple fibrin trombi in glomerular capillaries and small-vessels (Figure 2). The remaining 6 grafts presented adequate function one year after the transplantation, except in one case which suffered underlying disease recurrence.Conclusion An accurate evaluation of kidney grafts from BDD following cerebral gunshot wounds is required, because those patients are at risk for DIC and acute renal failure. Almost all transplanted renal allografts from BDD, following cerebral gunshot wounds, had good results in our study. Pre-transplant biopsy and, perhaps, the reduction of ischemia time may be indicated. Further studies with larger simple sizes are needed.

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds.

Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis.

Routine cervical spine immobilisation is unnecessary in patients with isolated cerebral gunshot wounds: A South African experience.

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). 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. 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. 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.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score

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.

Validation of the Baragwanath mortality prediction score for cerebral gunshot wounds: the Pietermaritzburg experience.

Cerebral gunshot wounds (GSW) are highly lethal injuries. To date, only one clinical scoring system to predict mortality in a developing world setting has been described. This is the Baragwanath mortality prediction score ("ABC": admission blood pressure, brain matter spillage and consciousness level). We performed a retrospective review of prospectively entered data for a cohort of patients with isolated cerebral GSWs over a 5-year period (January 2010-December 2014) in our institution. We aimed to validate the Baragwanath ABC mortality prediction score in our population. During the 5-year study period, 102 patients with isolated cerebral GSWs were reviewed, 22% (22/102) of which died. Based on the total ABC score (1-5), the mortality was 0% for 1, 21% for 2, 67% for 3, 92% for 4, and 100% for 5. The ABC score has a sensitivityof 82% (95% CI 60-95%), specificityof 96% (95% CI 89-99%), PPVof 86% (95% CI 66-96%) and NPVof 95% (95% CI 86-99%). The Baragwanath mortality predictionscore accurately predicts non survival of patients with a cerebral GSWin our patient cohort. Further validation studies in other populations are required before this system can be widely adopted.

Civilian cerebral gunshot wounds in rural South African patients are associated with significantly higher mortality rates than in urban patients.

This study focuses on a specific and often dramatic injury, namely gunshot wounds(GSW) of the head in order to determine whether there is a discrepancy in outcome between patients who sustain their injury in a rural setting and those who sustain it in an urban setting. This study involves aretrospective review of our prospectively maintained regional electronic trauma registry. All patients who sustained a cerebral GSW from January 2010 to December 2014 were reviewed. During the 5-year study period, a total of 102 patients sustained an isolated cerebral GSW. Ninety-two per cent (94/102) were male and the mean age was 29years. Ninety-four per cent (94/102) of injuries were related to interpersonal violence. Of the 102 patients in the study, 54% (55/102) were urban and were transported directly to our trauma centre. The remaining 46% (47/102) were rural and were transported to a rural district hospital prior to being referred to our trauma centre. The time of injury was available in 60% (61/102) of patients. The mean time from injury to arrival for all patients was 11h (SD 7). The mean time from injury to arrival was significantly shorter for urban versus rural, 6h (SD 5) and 15h (SD 5), respectively (p<0.001). The median admission GCS score was significantly lower in rural compared to urban patients (p=0.022). The need for neurosurgery, need for ICU admission or length of hospital stay was not significantly different between rural and urban patients. Rural patients have a fourfold higher mortality compared with urban patients (36 vs 9%, p=0.001). Amongst survivors, there was no significant difference in median length of hospital stay or mean discharge GCS. Cerebral GSWs are highly lethal injuries associated with significant mortality. Rural patients have a significantly longer transfer time, lower GCS on arrival and higher mortality than urban patients. Efforts should be directed at improving the pre-hospital EMS system in order to reduce delay to definitive care so that patient outcome can be optimised.

Civilian cerebral gunshot wounds: a South African experience.

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. 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. 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). 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.

Surgical Resection for Epilepsy Following Cerebral Gunshot Wounds

The surgical management of epilepsy after penetrating gunshot wounds (GSWs) to the head has not been described in the modern era. Given the extensive damage to the cranium and cortex from such injuries, the safety and efficacy of surgical intervention are unclear. We report surgical strategy and outcomes after resection for medically refractory epilepsy following GSWs in 4 patients. A prospectively compiled database of 325 patients with epilepsy was used to identify patients undergoing surgery for medically refractory epilepsy after a GSW to the brain. Seizure frequency, scalp and intracranial electroencephalography evaluation, type of resection, and seizure outcomes were compiled. All 4 patients underwent direct electrocorticography recordings either with implanted electrodes or intraoperatively that were used to drive surgical decision making. All patients had intracranial shrapnel fragments and large areas of encephalomalacia on imaging. Intracranial electrodes were placed in 2 patients to localize seizure onsets. Two patients underwent frontal lobe resections, and the other 2 patients underwent multilobar resections. Latency between injury and epilepsy surgery was 12 years, and mean age at surgery was 28 years. In all cases, epilepsy surgery led to a significant improvement in seizure control (Engel class I, 2 patients; II, 1 patient; and III, 1 patient). Epilepsy is common after penetrating head injury, and the incidence is likely to increase given the growing numbers of armed conflicts in urban centers worldwide. In selected cases, intracranial monitoring and surgical resections may be safely performed and can lead to favorable seizure outcomes.

Cerebral gunshot wounds: a score based on three clinical parameters to predict the risk of early mortality

To provide a score to predict the risk of early mortality after single craniocerebral gunshot wound (GSW) based on three clinical parameters. All patients admitted to Baragwanath Hospital, Johannesburg, South Africa, between October 2000 and May 2005 for an isolated single craniocerebral GSW were retrospectively evaluated for the documentation of (i) blood pressure (BP) on admission; (ii) inspection of the bullet entry and exit site; and (iii) initial consciousness (n= 214). Conscious GSW victims had an early mortality risk of 8.3%, unconscious patients a more than fourfold higher risk (39.2%). Patients with a systolic BP between 100 and 199 mm Hg had an 18.2% risk of mortality. Hypotension (<100 mm Hg) doubled this risk (37.7%) and severe hypertension (> or =200 mm Hg) was associated with an even higher mortality rate of 57.1%. Patients without brain spilling out of the wound ('non-oozer') exhibited a mortality of 19.7%, whereas it was twice as high (43.3%) in patients with brain spill ('oozer'). By logistic regression, a prognostic index for each variant of the evaluated parameters could be established: non-oozer:0, oozer:1, conscious:0, unconscious:2, 100 < or =RR(sys) < 200 mm Hg:0, RR(sys) < 100 mm Hg:1, RR(sys)>/= 200 mm Hg:2. This resulted in a score (0-5) by which the individual risk of early mortality after GSW can be anticipated. Three immediately obtainable clinical parameters were evaluated and a score for predicting the risk of early mortality after a single craniocerebral GSW was established.

Presentation and outcomes for organ donation in patients with cerebral gunshot wounds.

This study was undertaken to examine the presentation and outcomes relative to solid organ donation in patients with fatal cerebral gunshot wounds at a level I trauma center over a 7-year period. A retrospective chart review of patients with such wounds over the years 1993-99 was completed. Eighty (80) patients were considered potential solid organ donors. Of these, 28 (35%) became organ donors, yielding 97 transplantable organs. Ninety-six percent presented with a GCS of less than 6. Mean SBP on presentation was 130, ranging from 48 to 225. Median time from presentation to death was 18 hours. Intravenous fluids given over the first 6 hours averaged 4.3 liters. Pressors were required in 68% of cases, blood products in 34%. Consent rate for donation was 32% when requested by a physician and 59% when requested by an organ procurement organization (OPO) co-ordinator. No request was made in 15 cases. Patients with fatal cerebral gunshot wounds, but with solid organ donor potential, have a characteristic presentation. Those with hemodynamic stability and those whose hypotension responds promptly to treatment can be expected to have a donor potential despite their devastating brain injury. Minimal time and resources are required to support such patients. Additional organs may have been obtained if the request for donation was consistently separated from the families' notification of brain death, and if the request was initiated by an OPO coordinator rather than a physician. Further, all patients admitted with cerebral gunshot wounds and poor neurologic function should have local OPO referral, potential survival notwithstanding.

Surgical Management of Patients With Severe Head Injuries

ABSTRACT Minutes can make the difference between life and death when patients with severe head injuries require surgery. Subdural, epidural, and intracerebral hematomas and cerebral contusions and gunshot wounds are the pathologic entities encountered most frequently during emergency surgery in patients with severe head injuries. Neurosurgical team members frequently use hyperventilation, mannitol and barbiturates, and sophisticated monitoring modalities to manage patients with severe head injuries during and after surgery. Although monitoring a patient's intracranial pressure (ICP) through a ventriculostomy catheter remains the most widely used gauge of cerebral metabolism, neurosurgical teams also are using fiber-optic ICP monitoring catheters, cerebral blood flow measurement probes, microdialysls catheters, jugular venous oxygen saturation catheters, and brain oxygen content measurement electrodes. Coordinated teamwork by perioperative nurses, neurosurgeons, anesthesia care providers, and emergency department staff members helps ensure the best possible outcomes for patients who require surgery for management of severe head injuries. AORN J 63 (May 1996) 854–867.

Gunshot Wounds to the Brain in Children and Adolescents

Neurobehavioral outcome after craniocerebral gunshot wounds was evaluated in a prospective, 3-year, longitudinal follow-up of a consecutive case series of 13 children and adolescents. The younger group was composed of seven children, ages 1.5 to 4 years, and the older group contained six children, ages 5 to 14. Outcome measures included the Glasgow Outcome Scale and neuropsychological assessment of intelligence, language, motor, memory, attention, academic achievement, and adaptive behavior. Glasgow Outcome Scale scores at baseline indicated moderate and severe disabilities in 69 and 23%, respectively. At the 3-year follow-up, 85% had moderate disabilities but only 8% were severely disabled. Significant and persistent neurobehavioral deficits varied with developmental level at the time of cerebral insult. Intellectual functioning was clearly more impaired in children younger than 5 years of age at the time of injury than in older children. Cognitive and motor factors were most closely related to deficits in the younger group. Disability in older children and adolescents was associated with impaired attention, adaptive behavior, and behavioral disturbance. Disabilities appear to be at least as severe in our sample after cerebral gunshot wounds as in our studies of severe pediatric closed-head injury. At the time of follow-up, younger children sustaining gunshot wounds had slightly lower intelligence quotient scores and similar receptive language, expressive language, and gross motor scores compared with children with severe closed-head injury. The older gunshot wound patients were significantly more impaired than patients with severe closed-head injuries on measures of adaptive behavior and attention.(ABSTRACT TRUNCATED AT 250 WORDS)

Civilian gunshot wounds to the brain: prognosis and management.

The extent of treatment for the victims of gunshot wounds to the brain remains quite controversial, particularly when these patients present with extensive neurological dysfunction. We propose guidelines regarding the degree and aggressiveness of therapy. The factors that seem to have a significant impact on the patient's final outcome are the neurological examination at the time of admission, the radiological findings, and the motivation for the shooting. Thus, the authors propose a nonsurgical line of therapy for comatose patients with unilateral or bilateral cerebral gunshot wounds where bone or metal fragments are visualized away from the bullet path on computed tomography scan, particularly when these individuals are suicide victims.