Craniocerebral Gunshot Wounds Research Articles

Experience and successful treatment of craniocerebral gunshot injury at a regional trauma center in Korea: a case report and literature review

Craniocerebral gunshot injuries is gradually increasing in the civilian population with a worse prognosis than closed head trauma. We experienced a case of craniocerebral gunshot injury which a bullet penetrating from the submandibular area into the clivus of a patient. The patient did not show any symptom. However, serial laboratory findings showed an increase in blood lead level. We removed foreign bodies without any problems using an endoscopic transnasal transclival approach. Due to the extremely low frequency, guidelines for definitive management of gunshot injuries have not been presented in Korea yet. We introduce our surgical experience of a craniocerebral gunshot injury with an unusual approach for removing intracranial foreign bodies.

Wound vacuum-assisted closure as a bridge therapy in the treatment of infected cranial gunshot wound in a pediatric patient: illustrative case.

BACKGROUNDThe authors reported the first pediatric case of a craniocerebral gunshot injury successfully treated with a wound vacuum-assisted closure (VAC) device after dehiscence and infection of the initial cranial wound.OBSERVATIONSA 17-year-old boy suffered several gunshots to the left hemisphere, resulting in significant damage to the scalp, calvaria, and brain. Emergency hemicraniectomy was performed, with reconstruction of a complicated scalp wound performed at the initial surgery. The scalp was devitalized and ultimately dehisced, resulting in a cranial infection. It was treated first with a repeated attempt at primary closure, which failed because of persistent devitalized tissue, and was then treated with aggressive debridement followed by placement of a wound VAC device over the exposed brain as a bridge therapy to reconstruction. This procedure was deemed necessary given the active infection.LESSONSThe patient received delayed reconstruction with a free split-thickness skin graft and made a remarkable recovery, with cranioplasty performed 6 months later. The authors reviewed the literature on wound VAC use in cranial wound treatment and proposed it as a legitimate bridge therapy to definitive reconstruction in the setting of dirty wounds, active infection, or even hemodynamically unstable patients.

Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic

Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic

Non-powder lateral penetrating craniocerebral gunshot wound in a 10-year-old girl: A case report

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Clinic and diagnostics of the non-penetrating gun-shoot craniocerebral injuries in the local war

Objective ‒ to evaluate the features of the clinical manifestations and effectiveness of multi-slice computed tomography (MSCT) of the head for the diagnosis of non-penetrating gun-shoot head injuries in the local war.Materials and methods. The medical data of 155 patients who received a non-penetrating gun-shoot head injuries during the war in the Eastern Ukraine between 2014‒2020 were analyzed. All patients were males between 18 and 60 years (average age ‒ 35.1 years). The peculiarities of clinical manifestations and results of diagnostic evaluation of non-penetrating gun-shoot head injuries during specialized neurosurgical care in medical institutions on the third and fourth levels of medical aid have been studied.Results. Wide diagnostic capabilities of MSCT were revealed for determination of the wounds localization, type of the projectile, the nature of the wound channel, gunshot skull fractures, and associated intracranial injuries. It was found that with non-penetrating bullet and shrapnel tangential cranio-cerebral wounds, incomplete and depressed fractures usually occurred, and with single and multiple shrapnel blind wounds, incomplete ‒ perforated and depressed fractures with the presence of bone fragments. The pathomorphological features of the nature of the wound channels and intracranial injuries were determined. They are always associated by traumatic subarachnoid hemorrhages and brain contusions, in most cases – focal. Intracranial hematomas were observed in 3.1 % of the patients.Conclusions. Clinical manifestations of the non-penetrating craniocerebral gunshot wounds depend not only on the type of cranial soft tissue injury, but also on the nature of the skull fracture and are mainly occurred because of the severity of the traumatic brain injury. MSCT of the head makes it possible to determine the localization of the wound, the type of the wounding projectile, the nature of the cranial soft tissues damage, wound channel, gunshot skull fractures and associated intracranial injuries.

Pediatric craniocerebral gunshot injuries: A National Trauma Database study.

We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series. We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years. In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232). This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician. Prognostic and epidemiological, level III.

Noninvasive 7\xa0tesla MRI of fatal craniocerebral gunshots \u2013 a glance into the future of radiologic wound ballistics

Compared to computed tomography (CT), magnetic resonance imaging (MRI) provides superior visualization of the soft tissue. Recently, the first 7 Tesla (7 T) MRI scanner was approved for clinical use, which will facilitate access to these ultra-high-field MRI scanners for noninvasive examinations and scientific studies on decedents. 7 T MRI has the potential to provide a higher signal-to-noise ratio (SNR), a characteristic that can be directly exploited to improve image quality and invest in attempts to increase resolution. Therefore, evaluating the diagnostic potential of 7 T MRI for forensic purposes, such as assessments of fatal gunshot wounds, was deemed essential. In this article, we present radiologic findings obtained for craniocerebral gunshot wounds in three decedents. The decedents were submitted to MRI examinations using a 7 T MRI scanner that has been approved for clinical use and a clinical 3 T MRI scanner for comparison. We focused on detecting tiny injuries beyond the wound tract caused by temporary cavitation, such as microbleeds. Additionally, 7 T T2-weighted MRI highlighted a dark (hypo intense) zone beyond the permanent wound tract, which was attributed to increased amounts of paramagnetic blood components in damaged tissue. Microbleeds were also detected adjacent to the wound tract in the white matter on 7 T MRI. Based on the findings of radiologic assessments, the advantages and disadvantages of postmortem 7 T MRI compared to 3 T MRI are discussed with regard to investigations of craniocerebral gunshot wounds as well as the potential role of 7 T MRI in the future of forensic science.

First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant.

BACKGROUNDDecompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown.OBJECTIVETo integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension.METHODSA 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed.RESULTSIntermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from −5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements.CONCLUSIONThis first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population. A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231). Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients. This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization. Systematic Review, level IV.

FRACTURE MRI: Optimized 3D multi-echo in-phase sequence for bone damage assessment in craniocerebral gunshot injuries

FRACTURE MRI: Optimized 3D multi-echo in-phase sequence for bone damage assessment in craniocerebral gunshot injuries

Craniocerebral gunshot injury with no neurological deficit: the trending neurosurgical challenge

Craniocerebral gunshot injury with no neurological deficit: the trending neurosurgical challenge

Prognostic factors in craniocerebral gunshot wounds: Analysis of 30 patients from the neurosurgical viewpoint.

Craniocerebral gunshot wounds (CGW) are the most lethal injuries of the cranium. CGW is mostly secondary to military conflicts but may also be seen in civilian life. These injuries also have severe consequences, such as epilepsy, hydrocephalus, infection and late-term cognitive dysfunctions. The present study aims to present our series of CGW and to discuss the prognostic factors and consequences of these injuries. The data of patients who were treated in our department for CGW between 2011 and 2019 were retrospectively reviewed in this study. The injury type, wounding site, surgical management and outcomes were analyzed. Radiological evaluation was also performed. Thirty patients were treated with the diagnosis of CGW. All of the patients were male and the mean age was 27.9 years. The frontal lobe was affected in 12 (40%) patients, while temporal lobe in eight, occipital lobe in six, parietal lobe in three, and posterior fossa in one patients. Twenty-three patients underwent surgical treatment, seven patients were treated conservatively. Thirteen (43.3%) patients died despite the treatment. Mortality in CGW is high. Ventricular injuries, bihemispheric or midline injuries, perforating injuries, brain stem injuries and low GCS score at admission are prognostic factors for CGW. Appropriate management is mandatory to obtain a better clinical outcome.

Prognostic factors and management of civilian craniocerebral gunshot injuries; an institutional experience

Introduction: Surgeons face unique challenge in the management & prognosis related issues with intracranial gunshot injuries. These injuries are more commonly seen in military conflict zone. With easy availaibility of weapon and increase in the conflict between civilian and paramilitiary forces, clinician are facing more numbers of civilian gunshot injuries. In India the presentation and prognosis of gunshot injuries is different as many of these gunshot injuries are by country made weapons. Country made weapons have low velocity and caliber; henceforth the outcome and the management issues are different. We present our experience with 23 patients who sustained intracranial gunshot injuries, and identify the factors determining the outcome and management Material and Methods: From March 2016 to September 2019 data was collected from 23 cases who were treated for intracranial gunshot injuries in Department of Neurosurgery at J. N. Medical College, Aligarh. History, type of weapon used, clinical condition and radiological findings were noted. Outcome was assessed by Glasgow’s Outcome scale. Results: Overall mortality was 26.08% (6/23). Of the 4 patients in GCS (3-7) group there was 100% mortality. Of the 5 patients in GCS group (8-12) mortality was 2 and one patient in persistent vegetative stage. All patients survived in GCS group (13-15). 5 patients underwent surgery; there was one mortality in the surgical group. Better outcome was noted in single lobe involvement and trajectory involving supratentorial noneloquent areas. Conclusion: Early aggressive resuscitative measures may help in better management. GCS at presentation is the most important factor affecting outcome. CT scan offers to be an important predictor of prognosis and also help in planning the management. Suicidal wound, hypotension and midline shift has poor prognosis. We don’t recommend aggressive exploration of the bullet tract & pellet removal for every patient. Keywords: Intrac

P.110 Systematic review of civilian pediatric intracranial gunshot wounds

Background: Pediatric craniocerebral gunshot wounds occur in the context of both accidental and intentional trauma. Unique physiologic factors merited research into prognostic factors and treatment priorities in the pediatric population. Methods: A systematic search of MEDLINE, EMBASE, Web of Science, LILACS, Cochrane Registered Trials and Systematic Reviews, ISRCTN, and ClinicalTrials.gov was conducted. Selection criteria included all studies published in any language since 2000 which described intracranial isolated gunshot wounds in a civilian individual or population of pediatric age. Post-mortem and epidemiological studies were excluded. Screening was conducted through Covidence. Results: Initial database search revealed 349 unique studies for abstract and title screening. Fifty studies were selected for full text screening. Nine studies were included in the final review. Study quality was assessed with the Newcastle-Ottawa Scale. Case series noted bullet migration, pituitary deficiency, neurovascular and neuropsychological concerns. Three single-center retrospective studies of 71, 30, and 48 pediatric patients suggested multiple negative prognostic signs on initial presentation. Early aggressive surgical treatment was recommended by some authors. Conclusions: This systematic review analyzed the best current understanding of evidence for prognostic factors and treatment considerations of intracranial gunshot wounds in the pediatric neurotrauma context. Areas for future research with larger multi-center studies were highlighted.

Outcome of Craniocerebral Penetrating Injuries: Experience from the Syrian War.

Gunshot wounds to the brain are the most fatal of all firearm injuries. The aim of this study was to evaluate mortality and morbidity in patients with penetrating craniocerebral gunshot injuries and to identify risk factors that affect the outcome. A retrospective review from June 2012 to November 2013 of 44 Syrian patients with gunshot wound to the head was performed. A thorough physical examination and computed tomography (CT) of the brain was obtained for all patients at the time of admission. Associated systemic injuries were found in 19 patients (43%). Surgical intervention was performed in 25 patients (57%); the remaining patients were managed conservatively. The patients were followed for a period of 1 to 15 months (range: 6 ± 2 months). Univariate analysis of patient age, sex, type of penetrating object, Glasgow Coma Scale (GCS) score and pupil size on admission, brain CT findings, presence of systemic injuries, and surgical intervention on the patient outcome was performed. Eleven patients (25%) had a bullet injury; the remaining 33 (75%) patients had blast injuries. Initial brain CT revealed different types of skull fractures, intracerebral hemorrhage, and brain edema in all patients. The mortality rate during the follow-up period was 25%. Of the survivors, 25 patients (76%) had a good recovery, eight patients (24%) had a mild disability, and none had a severe disability. The significant factors determining outcome in this series were GCS on admission (p < 0.005) and positive pupil reaction to light (p < 0.05). The patient age, sex, CT findings, systemic injuries, neurosurgical intervention, and hospital length of stay were not significant prognostic factors (p > 0.05). Among various variables, GCS and pupil reactivity were the outcome predictors in patients with penetrating craniocerebral injuries. Age, sex, type of penetrating object, CT findings, and surgical intervention did not have a significant effect on survival for these kinds of injuries.

336 Civilian Penetrating Craniocerebral Gunshot Injuries

Abstract INTRODUCTION Civillian cranial gunshot wounds (GSWs) remain a frequently lethal and highly morbid injury uncommon to many civilian trauma centers. The vast majority of these patients die prior to reaching medical care. Of those who do survive their initial injury, recent series have shown that over 50% will succumb to their injuries or in-the-hospital complications. Furthermore, experience from wartime theaters has taught us that these patients are vulnerable to a multitude of complications (i.e. CSF leak, wound breakdown, hydrocephalus, vascular injury). Thus, the need and potential for improvement in care and understanding of these patients is large. Here, we present our institution's series of cranial GSWs with an emphasis on detailing our complications. METHODS We retrospectively performed a chart review from 2015–2017. RESULTS &gt;We identified 9 patients that underwent operative intervention in the form of decompressive craniectomy following a craniocerebral gunshot injury at a level 1 trauma center in Washington, D.C. The average age of patients was 31 years (3 females, 6 males) and time to operative intervention from initial presentation was less than 4 hours in 7 out of 9 patients and less than 12 hours in all patients. All patients underwent further operation for a multitude of reasons of which wound breakdown and CSF leak were the most common. These complications extended the hospital initial hospitalization for the majority of patients beyond 2 weeks and were invariably the cause of readmission of these patients. CONCLUSION Not only is aggressive and early intervention critical in caring for patients with cranial GSWs, but also it is important to be vigilant in looking for and preventing further secondary injury from subsequent complications such as wound infections/breakdown, CSF leaks, hydrocephalus and vasospasm. These almost inevitable complications must be anticipated in the treatment planning from the principal operation.

196 Meta-Analysis of the Effect of Intracranial Infections on Morbidity and Mortality of Civilian Craniocerebral Gunshot Injuries

Abstract INTRODUCTION Civilian gunshot wounds to the head (GSWH) are a significant cause of traumatic brain injury-related mortality in the US. Intracranial infections are feared delayed complications in civilian GSWH and the benefit of prophylactic antibiotics has not been thoroughly studied. METHODS We conducted a meta-analysis of retrospective studies. A database search was conducted in PubMed, EMBASE, Scopus, Web of Science and Cochrane Library for articles after 2000 for intracranial infections (meningitis, cerebritis, ventriculitis and cerebral abscess) after civilian GSWH. We compared the intracranial infection rate in patients who received antibiotic prophylaxis with those who did not. We also compared the mortality of postoperative patients developing intracranial infections with the rest, and their morbidity, as evidenced by their Glasgow Outcome Scale (GOS), and grouped as favorable (GOS 4–5) or unfavorable (GOS 2–3). RESULTS &gt;We identified 64 relevant articles, 7 of which had extractable information. Two articles compared intracranial infection rates with and without antibiotic prophylaxis in 219 GSWH patients. Prophylactic antibiotics did not decrease the risk of developing intracranial infections (OR 1.84; 95% CI 0.93–3.62; P = 0.08). Five articles reported 509 patients admitted with GSWH, 91.9% male, mean age 26.6 years old. 224 patients survived resuscitation and surgery. Postoperative intracranial infections did not significantly increase mortality (OR 0.67; CI 0.19–2.43; P = 0.55), but led to more unfavorable outcomes (OR 4.86; CI 1.19–19.79; P = 0.03). Of note, 160 out of the 224 initial survivors (71.4%) were reported to have received prophylactic antibiotics. CONCLUSION Prophylactic antibiotics are routinely given to GSWH patients to prevent infections. This meta-analysis of retrospective studies suggests that 1. prophylactic antibiotics did not decrease the risk of intracranial infections; 2. the presence of intracranial infections in a GSWH setting did not affect mortality and 3. patients developing intracranial infections had worse neurological outcomes.

Combination of dura turning-over and decompressive craniectomy: a new pattern of surgery for cerebral infarction caused by craniocerebral gunshot injury

BackgroundCraniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue, resulting in the loss of function of a certain area or other fatal damage to the human brain. Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare, accounting for the majority of battle casualties. Most of the patients suffer from acute cerebral infarction caused by vascular injury. Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded.Case presentationWe present a 24-year-old man who was shot with a shotgun from a distance of 15 m in an accidental injury. Forty-seven grapeshots were found on his body surface by physical examination. A computed tomography (CT) scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later. Afterwards, the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai. Cranial computed tomography angiography (CTA) showed a high-density shadow in the initial part of the right middle cerebral artery. The branches after the initial part were obliterated. Prompt medical attention and decompressive craniotomy (DC) surgery contributed to the final recovery from cerebral infarction of this patient.ConclusionBullets can penetrate or be lodged in the brain, causing intracranial hypertension. The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery, causing acute cerebral infarction. Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure, which can increase the blood supply for hypertension-induced vessel stenosis, but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex. However, this new pattern of surgery needs further support from evidence-based medicine.

An unusual lethal gunshot wound to the head.

Atypical gunshot wounds present a challenge for the forensic expert, and sometimes differentiating these from a blunt trauma can be difficult. A careful crime scene investigation can be helpful in finding additional evidence and clarifying the nature of the injuries. We describe a case of an unusual craniocerebral injury that was initially interpreted as a blow from a wooden object. The appearance of the wound lacked the classical characteristics of entrance and exit bullet wounds, but the investigation showed it was due to the ricocheting of a destabilized bullet. Potentially lethal, craniocerebral gunshot injuries are a common occurrence in developing countries even in non-conflict areas, with very bad outcomes even when treated aggressively in specialized neurosurgical facilities. The authors briefly discuss similar cases and opinions in the relevant literature, emphasizing the importance of a rational approach during the reconstruction of the crime scene.

Craniocerebral gunshot wounds in civilian population: Analysis of experience in a single centre in Monterrey, México

Abstract Background Gunshot wounds in civilian population of Mexico were quite rare. Currently, conflicts amongst organised crime groups are carried out with weapons, which are considered as exclusive use by the nation's army. Objectives Describe the experience of our institution and share results of clinical and radiological factors influencing the prognosis of the patients. Materials and methods Observational and retrospective study of patients with cranial gunshot wounds, which penetrated the duramater, treated from January 2009 to January 2013. We considered several demographic variables, Glasgow Coma Scale, upon admission, state of pupils, type of surgery and size of decompression, Glasgow Outcome Score upon discharge, and after 6 months. Results Of 68 patients, we excluded those whose duramater was not penetrated, leaving 52 patients. The average age was 28.7 years, and 80.8% were males. All were surgically intervened, with 8% of general mortality. Mortality in the 3–5 points group was 43%, from the 6 to 8 points it was 6%, and no deaths in the 9–15 points. In patients with both pupils fixed, anisocoric and isocoric, mortality was 67%, 7%, and 3%, respectively. Bihemispheric, multilobar and unihemispheric trajectory of the bullet plus ventricular compromise was related to a Glasgow Outcome Score ≤ 3 upon discharge in 90.9% of the cases. Conclusions Glasgow Coma Scale upon admission and state of the pupils are the most influential factors in the prognosis. Patients with a Glasgow Coma Scale > 8