Gunshot Wounds To The Head Research Articles

The role of computed tomography angiography and digital subtraction angiography in the diagnosis and management of gunshot wounds to the head

Introduction: Traumatic intracranial pseudoaneurysms (TICAs) and penetrating cerebrovascular injuries (PCVI) complicate gunshot wounds to the head (GSWH) and other forms of penetrating traumatic brain injury (pTBI). Recent developments in neuroimaging have allowed early detection of these lesions in the minutes and hours following the initial injury. CT angiography (CTA) and digitally subtracted angiography (DSA) have different sensitivity, periprocedural risks, and logistical limitations. Growing evidence is defining their role in clinical practice. Methods: A systematic review of the literature was performed for published articles treating the use of CTA and DSA to diagnose PCVI and TICAs after pTBI and GSWH. Four series, three retrospective and one prospective, were selected for this review. Results: In three retrospective and one prospective series (with a sensitivity of ~70% in the former studies vs 36% in the latter), DSA emerges as the modality of choice to study the intracranial vasculature of patients that suffered pTBI. Nonetheless, the use of CTA in the first hours after the injury can provide a wealth of information in emergent scenarios where TICAs and PCVIs can significantly affect surgical management and risk. Further, a significantly higher incidence of TICAs was reported in the first hours after civilian GSWH via CTA. Conclusions: DSA and CTA emerged as two complementary techniques in the study and management of PCVI and TICA related to pTBI and GSWH. Their integration can provide a safe approach to the emergent surgical management of vascular lesions via CTA, allowing for delayed DSA characterization after neurological and hemodynamical stabilization.

Bilateral decompressive craniectomy as a damage control strategy for a preschooler multilobar bihemispheric firearm injury: a case report and systematic review.

The absence of guidelines for managing gunshot wounds to the head (GSWH) with bihemispheric lesions in pediatric patients highlights the need for prompt and diverse damage control strategies. This article aims to systematically evaluate the evidence surrounding the management of GSWH in preschoolers and to report a novel approach. We present a case of a 4-year-old girl who sustained a gunshot wound to the left parietal region. She was admitted to a level 1 trauma center 90min post-injury with stable vital signs, a Glasgow coma scale (GCS) of 12 (E3, V3, M6), and grade III hemiparesis in her right upper limb. Initial surgical management included left hematoma decompression and right frontotemporoparietal decompressive hemicraniectomy in two stages under the same anesthesia. Due to massive brain swelling during the left-sided procedure, it was converted to a left frontotemporoparietal decompressive hemicraniectomy. Both procedures included autologous pericranium augmentation duraplasty and watertight suturing. A right-side decompressive hemicraniectomy followed without exploring bullet lodging, using bilateral Kempe incisions. Bone flaps were stored under cryopreservation. During a 30-day hospital stay, neurological assessments showed a gradual recovery of right upper limb strength to grade IV + , with no other deficits or operative complications. Postoperative CT scans at 7, 14, and 28days showed minor pseudomeningoceles and a reduction of intraparenchymal edema. Multidisciplinary care continued throughout the stay. The patient showed no signs of endocrinological, infectious, or residual neurological issues and underwent bilateral autologous cranioplasty on day 35. She was discharged on day 38 with a GCS extended of 8 (full recovery/minor deficits not affecting daily activities) and minor right upper limb apraxia. A systematic review identified nine patients under 6years old with GSWH, with only one previously reported case of a 3-year-old patient with bihemispheric lesions undergoing bilateral craniectomies and achieving positive outcomes. Our case and the review suggest that bilateral decompressive hemicraniectomy is a feasible strategy for managing multilobar bihemispheric GSWH in preschoolers. However, the evidence of management for this population remains of low quality, highlighting the need for further research, and justifying this case report.

Intracranial Pressure and Brain Tissue Oxygen Multimodality Neuromonitoring in Gunshot Wounds to the Head in Children

Gunshot wounds to the head (GSWH) are a cause of severe penetrating traumatic brain injury (TBI). Although multimodal neuromonitoring has been increasingly used in blunt pediatric TBI, its role in the pediatric population with GSWH is not known. We report on 3 patients who received multimodal neuromonitoring as part of clinical management at our institution and review the existing literature on pediatric GSWH. We identified 3 patients ≤18 years of age who were admitted to a quaternary children's hospital from 2005 to 2021 with GSWH and received invasive intracranial pressure (ICP) and Pbto2 (brain tissue oxygenation) monitoring with or without noninvasive near-infrared spectroscopy (NIRS). We analyzed clinical and demographic characteristics, imaging findings, and ICP, Pbto2, cerebral perfusion pressure, and rSo2 (regional cerebral oxygen saturation) NIRS trends. All patients were male with an average admission Glasgow Coma Scale score of 4. One patient received additional NIRS monitoring. Episodes of intracranial hypertension (ICP ≥20 mm Hg) and brain tissue hypoxia (Pbto2 <15 mm Hg) or hyperemia (Pbto2 >35 mm Hg) frequently occurred independently of each other, requiring unique targeted treatments. rSo2 did not consistently mirror Pbto2. All children survived, with favorable Glasgow Outcome Scale-Extended score at 6 months after injury. Use of ICP and Pbto2 multimodality neuromonitoring enabled specific management for intracranial hypertension or brain tissue hypoxia episodes that occurred independently of one another. Multimodality neuromonitoring has not been studied extensively in pediatric GSWH; however, its use may provide a more complete picture of patient injury and prognosis without significant added procedural risk.

The Cost of Gunshot Wounds to the Head: An Unevenly Distributed Burden.

Despite the significant clinical consequences and socioeconomic costs of gunshot wounds to the head (GSWH), studies examining prehospital risk factors, geospatial patterns, and economic cost are lacking. A retrospective analysis was performed for patients with GSWH (single or multiple injuries) presenting to the level one Ryder Trauma Center (hospital patients) as well as the Miami-Dade County Medical Examiner (ME) Department, from October 2013 to October 2015. In addition, ME data were queried from the previous decade (2008-2017) to analyze longitudinal trends. A total of 402 consecutive patients met the inclusion criteria: 297 (74%) presented to the ME and 105 (26%) presented to the hospital. GSWH in our cohort had a case fatality rate of 89%, predominantly affecting males, whites, and individuals who committed suicide, with a mean age of 41.9 ± 20.6 years. Hospital patients were more likely to be black males from low socioeconomic status (SES) regions involved in assault. Older white males were overrepresented in patients attempting and completing suicide and thus comprised a higher percentage of ME cases. Geospatial analysis of hospital patient injury zip codes shows that GSWH are significantly clustered in low-income urban centers with greater poverty rates. In Miami-Dade County, the economic burden of GSWH, as measured by total health care costs and lifetime productivity losses, was estimated to be $11,867,415 and $246,179,498, respectively. In the first analysis of GSWH with the inclusion of both hospital and ME data in a representative urban setting, our findings show prehospital risk factors and the unequal distribution of the significant economic costs of GSWH.

774 Prognostication of Civilian Gunshot Wounds to the Head: Internal Validation of the Baylor Score

INTRODUCTION: Early prognostication of patients with gunshot wounds to the head (GSWH) can identify patients who may benefit from aggressive management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale, and bullet trajectory at initial presentation to predict mortality and functional status at six months and performed well when recently assessed at a separate level 1 trauma center demonstrating external validation of the score. METHODS: Retrospective chart review of patients with GSWH treated at an academic level 1 trauma center between 2008 and 2022 was performed with Baylor score calculated for each patient. Accuracy of the Baylor score in predicting mortality and good functional outcome (Glasgow Outcome Scale score of 4 or 5) was assessed using receiver operating characteristic (ROC) curves and area under the curve (AUC) as measures of performance. RESULTS: A total of 405 patients with GSWH were identified over the 14-year study period (mean age 31.5 years, 88.9% male, 19.5% white). 225 (55.6%) patients died, while 145 (35.8%) had favorable functional outcomes. Mortality rates ranged from 8% for Baylor score 0 to 97% for Baylor score 5, and good functional outcomes ranged from 15% for Baylor score 3 to 87% for Baylor score 0. Baylor score demonstrated good accuracy in prognosticating both mortality (AUC = 0.85) and good functional outcome (AUC = 0.90), though scores 0-2 underestimated favorable outcomes and scores 3-5 underestimated mortality. CONCLUSIONS: The Baylor score is a valuable tool for prognosticating GSWH survival and functional outcome and may aid in guiding treatment and family-centered discussions regarding patient prognosis earlier in the hospital course.

327 Prophylactic Antibiotics Do Not Prevent CNS Infection in Civilian Gunshot Wounds to the Head

INTRODUCTION: Civilian gunshot wounds to the head (GSWH) are an ongoing epidemic in the US, with incidence rising each year. They are frequently devastating, with case fatality rates approaching 91%, accounting for fatalities occurring in the hospital and at the scene of injury. Although military GSWH are robust, data and management guidelines for civilian GSWH is relatively lacking. Specifically, the administration of prophylactic antibiotics in GSWH patients remains controversial. Prior studies indicate the incidence of intracranial infection after civilian GSWH to be as high as 25%, with significant impact on morbidity and mortality. METHODS: We retrospectively reviewed survivable GSWH at our level 1 trauma center between 2012-2017. Patients were assessed for CNS infection, and categorized with regard to the use of prophylactic antibiotics, length of stay, GCS at presentation, bullet trajectory, and demographics. RESULTS: 236 patients sustained survivable GSWH. 12/236 (5.1%) patients developed CNS infection following GSWH, and 3/12 (25%) of those patients had not received prophylactic antibiotics. Of the 133 patients who received prophylactic antibiotics, 10 (7.5%) subsequently developed CNS infection. Infection was diagnosed more commonly in patients who received antibiotics, but this was not statistically significant (p = 0.138). Bullet trajectories through the paranasal sinuses or oropharynx were significantly more likely to result in CNS infection (OR 3.04, p = 0.0624). Patients who underwent decompressive surgery and patients who underwent invasive ICP monitoring had significantly higher odds of developing CNS infections (OR 17.7, p = 0.00616; OR = 0.24, p = 0.048). CONCLUSION: Decompressive surgery, invasive ICP monitoring, and bullet trajectory were statistically significant factors associated with development of CNS infection following GSWH. Prophylactic antibiotics did not reduce the incidence of CNS infection, and may have increased the risk of infection.

Incorporating conditional survival into prognostication for gunshot wounds to the head.

Several scores estimate the prognosis for gunshot wounds to the head (GSWH) at the point of hospital admission. However, prognosis may change over the course of the hospital stay. This study measures the accuracy of the Baylor score among patients who have already survived the acute phase of hospitalization and generates conditional outcome curves for the duration of hospital stay for patients with GSWH. Patients in whom GSWH with dural penetration occurred between January 2009 and June 2019 were identified from a trauma registry at a level I trauma center in the southeastern US. The Baylor score was calculated using component variables. Conditional overall survival and good functional outcome (Glasgow Outcome Scale score of 4 or 5) curves were generated. The accuracy of the Baylor score in predicting mortality and functional outcome among acute-phase survivors (survival > 48 hours) was assessed using receiver operating characteristic curves and the area under the curve (AUC). A total of 297 patients were included (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male), and 129 patients survived the initial 48 hours of admission. These acute-phase survivors had a decreased mortality rate of 32.6% (n = 42) compared to 68.4% (n = 203) for all patients, and an increased rate of good functional outcome (48.1%; n = 62) compared to the rate for all patients (23.2%; n = 69). Among acute-phase survivors, the Baylor score accurately predicted mortality (AUC = 0.807) and functional outcome (AUC = 0.837). However, the Baylor score generally overestimated true mortality rates and underestimated good functional outcome. Additionally, hospital day 18 represented an inflection point of decreasing probability of good functional outcome. During admission for GSWH, surviving beyond the acute phase of 48 hours doubles the rates of survival and good functional outcome. The Baylor score maintains reasonable accuracy in predicting these outcomes for acute-phase survivors, but generally overestimates mortality and underestimates good functional outcome. Future prognostic models should incorporate conditional survival to improve the accuracy of prognostication after the acute phase.

The value of simplicity: externally validating the Baylor cranial gunshot wound prognosis score.

Gunshot wounds to the head (GSWH) are devastating injuries with a grim prognosis. Several prognostic scores have been created to estimate mortality and functional outcome, including the so-called Baylor score, an uncomplicated scoring method based on bullet trajectory, patient age, and neurological status on admission. This study aimed to validate the Baylor score within a temporally, institutionally, and geographically distinct patient population. Data were obtained from the trauma registry at a level I trauma center in the southeastern US. Patients with a GSWH in which dural penetration occurred were identified from data collected between January 1, 2009, and June 30, 2019. Patient demographics, medical history, bullet trajectory, intent of GSWH (e.g., suicide), admission vital signs, Glasgow Coma Scale score, pupillary response, laboratory studies, and imaging reports were collected. The Baylor score was calculated directly by using its clinical components. The ability of the Baylor score to predict mortality and good functional outcome (Glasgow Outcome Scale score 4 or 5) was assessed using the receiver operating characteristic curve and the area under the curve (AUC) as a measure of performance. A total of 297 patients met inclusion criteria (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male). A total of 205 (69.0%) patients died, whereas 69 (23.2%) patients had good functional outcome. Overall, the Baylor score showed excellent discrimination of mortality (AUC = 0.88) and good functional outcome (AUC = 0.90). Baylor scores of 3-5 underestimated mortality. Baylor scores of 0, 1, and 2 underestimated good functional outcome. The Baylor score is an accurate and easy-to-use prognostic scoring tool that demonstrated relatively stable performance in a distinct cohort between 2009 and 2019. In the current era of trauma management, providers may continue to use the score at the point of admission to guide family counseling and to direct investment of healthcare resources.

Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience

Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns. Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up. Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P=0.001) and mortality (P= 0.034). Dissection injuries (P=0.013), injuries to the vertebrobasilar system (P= 0.036), or the presence of ≥2 concurrent CVIs (P= 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours. CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

49 Organ Donation Potential in Cases of Fatal Gunshot Wounds to the Head: Tools for Timely Screening in the Emergency Department

Gunshot wounds to the head (GSWH) have a high mortality rate and account for over a third of deaths due to head injury. Here we hypothesize that out-of-hospital vital signs may be useful tools in preliminary identification of organ donation potential when a patient presents to the ED with a fatal GSWH. Retrospective analysis was performed on data from an urban level 1 trauma center’s trauma database. All adult patients with out-of-hospital vital signs on-scene who presented to the ED before expiring due to a fatal GSWH between 1/1/2012 and 12/31/2018 were included. Characteristics of organ donors vs non-donors were analyzed, including injury severity score/abbreviated injury scale-head (ISS/AIS), on-scene Glasgow Coma Score (GCS), on-scene systolic blood pressure (SBP), on-scene respiratory rate (RR), and location of death. For non-normally distributed data, differences between groups were assessed with Wilcoxon Rank Sum Test. Differences for categorical variables were assessed using either Pearson's chi-squared test or Fisher's Exact Test. Significance noted when p < 0.05. Of 208 subjects meeting inclusion criteria, organ donation requests were made in 36 (17.3%) cases and 22 (10.6%) patients donated organs. Neither mean ISS nor AIS-head differed significantly between donors and non-donors (ISS: 4.5 vs 4.7 p=0.3761. AIS-head: 33.7 vs 27.3 p=0.0647) (Table 1). Donors had significantly higher mean on-scene GCS (5.1 vs 3.9 p=0.0016), SBP (129.3 vs 82.1 p=0.0028) and RR (20.5 vs 10.7 p=0.0001) than non-donors (Fig. 1A, B, C). While there was no significant difference in mean GCS at the ED (3.6 vs 3.5 p=0.4093), donors had a significantly larger decrease in mean GCS vs non-donors (-1.4 vs -0.6 p=0.0018) between on-scene and hospital assessment (Fig 1A). At the ED, donors had significantly higher mean SBP than non-donors (114.1 vs 82.7 p=0.0323) (Fig 1B). More donors than non-donors died in the ICU (90.9% vs 45.7%); 9.1% of donors and 45.7% of non-donors died in the OR; no donor died in the ED compared to 52.2% of non-donors; one non-donor (0.5%) died on the floor. Differences in location of death were significant (p < 0.0001) (Table 1). Out-of-hospital GCS, SBP, and RR values were all significantly higher in donors than non-donors. Donors also had significantly higher mean SBP at the ED and a larger decline in GCS between on-scene and the ED compared to non-donors. Nearly half of the study group, all non-donors, died in the ED. Out-of-hospital vitals and status changes en route to the ED may be of use in early identification of potential donors, allowing timely referral to organ procurement agencies, increasing donor opportunity and organ donation. No extra time or resources would be required to collect these metrics, as they are already assessed during emergent resuscitation and management of patients. Timely identification of donor potential may allow fatally wounded patients who expire in the ED the chance to become donors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Gunshot wounds to the head: racial disparities in inpatient management and outcomes.

Several studies have indicated that racial disparities may exist in the management and outcomes of acute trauma care. One segment of trauma care that has not been as extensively investigated, however, is that of cranial trauma care. The goal of this study was to determine whether significant differences exist among racial and ethnic groups in various measures of inpatient management and outcomes after gunshot wounds to the head (GWH). In this study, the authors used the Nationwide (National) Inpatient Sample (NIS) to investigate all-cause mortality, receipt of surgery, days from admission to initial intervention, discharge disposition, length of hospital stay, and total hospital charges of those with GWH from 2012 to 2016. A 1:1 propensity score-matched analysis was conducted to evaluate the effect of race on these endpoints, while controlling for baseline demographics and comorbidities. A total of 333 patients met the inclusion and exclusion criteria: 148 (44.44%) white/Caucasian, 123 (36.94%) black/African American, 54 (16.22%) Hispanic/Latinx, and 8 (2.40%) Asian. African American patients were sent to immediate care and rehabilitation significantly less often than Caucasian patients (RR 0.17 [95% CI 0.04-0.71]). There were no significant differences in mortality, length of stay, rates of surgical intervention, or total hospital charges among any of the racial groups. The authors' findings suggest that racial disparities in inpatient cranial trauma care and outcomes may not be as prevalent as previously thought. In fact, the disparities seen were only in disposition. More research is needed to further elucidate and address disparities within this population, particularly those that may exist prior to, and after, hospitalization.

Pediatric firearm-related traumatic brain injury in United States trauma centers.

Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death. All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003-2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at α < 0.001 accounting for multiple comparisons. In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 ± 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3-8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 ± 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3-8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7-3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2-5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2-0.5, p < 0.001). From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.

Meta-Analysis of Functional Outcomes in 5508 Patients Sustaining a Gunshot Wound to the Head

Abstract INTRODUCTION There is currently no consensus regarding prognosis and management for gunshot wounds to the head (GSWH). To the author’' knowledge, this is the first meta-analysis to study functional outcomes in GSWH. METHODS Five online databases and the reference lists of relevant articles were queried for cohort studies of GSWH reporting factors associated with functional outcome. PRISMA guidelines were followed. Study quality was assessed using the Newcastle–Ottawa scale. Glasgow Outcome Scale (GOS) outcomes were divided into unfavorable (GOS 1-3) and favorable (GOS 4-5). Pooled estimates of odds ratios and 95% confidence intervals were derived using random-effects models. Heterogeneity was assessed with I-square and meta-regression. Funnel-plots were utilized to assess publication bias. RESULTS We identified 35 retrospective cohort studies encompassing 5508 GSWH patients. Out of the factors assessed, the ones significantly associated with unfavorable functional outcome were: postresuscitation GCS 3 to 8 (Odds Ratio 33.2, 95% Confidence Interval [10.1-108.6]), suicide attempt (3.6 [1.7-7.8]), penetration of the dura (10.3 [1.8-60.5]), bullet trajectory through both hemispheres (8.3 [4.1-17.2]), through the ventricles (8.8 [1.6-48.8]), and through multiple lobes (8.6 [2.2-33.5]). No statistical significance was found for unfavorable functional outcome regarding patient age, sex, pupillary response, and the existence of an exit wound. CONCLUSION This is the first systematic review and meta-analysis regarding prognostic factors for neurologic outcomes in patients sustaining GSWH. Such factors can inform clinical decision-making and assist in setting patient and physician expectations in the acute setting. Further research is required to properly incorporate this information into management guidelines.

Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers.

Civilian firearm injury is an important public health concern in the United States. Gunshot wounds to the head (GSWH) remain in need of update and systematic characterization. We identify predictors of prolonged hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), medical complications, mortality, and discharge disposition from a population-based sample using the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), years 2003-2012. Statistical significance was assessed at α < 0.001 to correct for multiple comparisons. In total, 8148 adult GSWH patients were included extrapolating to 32,439 national incidents. Age was 36.6 ± 16.4 years and 64.4% were severe traumatic brain injury (TBI; Glasgow Coma Scale [GCS] score 3-8). Assault (49.2%), handgun (50.3%), and residential injury (43.2%) were of highest incidence. HLOS and ICU LOS were 7.7 ± 14.2 and 5.7 ± 13.4 days, respectively. Overall mortality was 54.6%; suicide/self-injury was associated with the highest mortality rate (71.6%). GCS, Injury Severity Score, and hypotension were significant predictors for outcomes overall. Medicare/Medicaid patients had longer HLOS compared to private/commercial insured (mean increase, 4.4 days; 95% confidence interval [2.6-6.3]). Compared to the Midwest, the South had longer HLOS (mean increase, 3.7 days; [2.0-5.4]) and higher odds of complications (odds ratio [OR], 1.7 [1.4-2.0]); the West had lower odds of complications (OR, 0.6; [0.5-0.7]). Versus handgun, shotgun (OR, 0.3; [0.2-0.4]) and hunting rifle (OR, 0.5; [0.4-0.8]) resulted in lower mortality. Patients with government/other insurance had higher odds of discharging home compared to private/commercially insured (OR, 1.7; [1.3-2.3]). In comparison to level I trauma centers, level II trauma centers had lower odds of discharge to home (OR, 0.7; [0.5-0.8]). Our results support hypotension, injury severity, injury intent, firearm type, and U.S. geographical location as important prognostic variables in firearm-related TBI. Improved understanding of civilian GSWH is critical to promoting increased awareness of firearm injuries as a public health concern and reducing its debilitating injury burden to patients, families, and healthcare systems.

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.

Chapter 12 - Surgical management of civilian gunshot wounds to the head

Each year close to 20000 Americans are involved in gunshot wounds to the head (GSWH). Over 90% of the victims of GSWH eventually fail to survive and only a meager 5% of the patients have a chance to continue with a useful life. One of the fundamental jobs of providers is to realize who the best candidate for the best possible management is. Recent evidence indicates that a good Glasgow Coma Scale (GCS) score at the time of admission puts such patients at high priority for management. Lack of abnormal pupillary response to light, trajectory of slug away for central gray, and visibility of basal cisterns upgrade the need for utmost care for such a victim. Surgical management is careful attention to involvement of air sinuses and repair of base dura. Patients with diffuse injury should have intraventricular intracranial pressure (ICP) monitoring and if needed a timely decompressive craniectomy. Since close to 2% of patients with penetrating brain injury may harbor a vascular injury, subjects with injuries close to the Sylvian fissure and those with the fragment crossing two dural compartments should have computed tomography angiography and if needed digital subtraction angiography to rule out traumatic intracranial aneurysms. In case of a positive study, these patients should have endovascular management of their vascular injuries in order to prevent catastrophic intracerebral hematomas and permanent deficit. Although supported by class III data, subjects of GSWH need to be on broad spectrum antibiotics for a period of 3-5 days. If cerebrospinal fluid (CSF) fistulas are observed at any time during the patient's hospital course, they should be taken very seriously and appropriate management is needed to prevent deep intracranial infections.

Bihemispheric gunshot wounds: survival and long-term neuropsychological follow-up of three siblings.

Penetrating gunshot wounds to the head (GSWH) have notoriously poor outcomes with extremely high mortality. Long-term follow-up data of affected children is scant in the medical literature. This report summarizes clinical presentation, management, and long-term outcomes from three children who survived "execution style" frontal, bihemispheric gunshot wounds with no or minimal surgical intervention. A retrospective chart review of available medical records and outcomes from standardized, validated psychological instruments was undertaken, summarized, and evaluated. Despite bihemispheric injuries in each patient, no patient required operative intervention. Each child survived without readily evident neurologic impairment; however, the extent of impaired executive function varied widely, and severe disinhibition remains profoundly disabling in one survivor. Bihemispheric penetrating gunshot injuries are not uniformly fatal and can occasionally be associated with long-term favorable survival; however, impaired executive function has significant potential to be profoundly disabling in these injuries.

Predictors of outcome in civilian gunshot wounds to the head

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period. The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data. Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome. Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Penetrating gunshot wound to the head: transotic approach to remove the bullet and masseteric-facial nerve anastomosis for early facial reanimation

Gunshot wounds to the head (GSWH) account for the majority of penetrating brain injuries, and are the most lethal. Since they are rare in Europe, the number of neurosurgeons who have experienced this type of traumatic injury is decreasing, and fewer cases are reported in the literature. We describe a case of gunshot to the temporal bone in which the bullet penetrated the skull resulting in the facial nerve paralysis. It was excised with the transotic approach. Microsurgical anastomosis among the masseteric nerve and the facial nerve was performed. GSWH are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is very high. Survivors often have high rate of complications. When facial paralysis is present, masseteric-facial direct neurorraphy represent a good treatment.