Civilian and military gunshot wounds to the head


Authors: N. Svoboda 1;  V. Beneš 1;  D. Netuka 1;  M. Sokol 1,2;  K. Langová 3;  M. Májovský 1
Authors‘ workplace: Neurochirurgická a neuroonkologická klinika 1. LF UK a ÚVN Praha 1;  Vojenský ú stav soudní ho lé kař ství , Ú VN – VFN Praha 2;  Ústav lékařské biofyziky a Ústav molekulární a translační medicíny, LF UP, Olomouc 3
Published in: Cesk Slov Neurol N 2019; 82(6): 670-676
Category: Original Paper
doi: 10.14735/amcsnn2019670

Overview

Aim: Gunshot wound to the head is one of the most severe injuries with high morbidity and mortality. Appropriately indicated extensive surgical treatment leads to improved patient prognosis. Thus, the evaluation of preoperative factors that would predict patients` prognosis is of high importance at the time of admission to the hospital.

Methods: A retrospective analysis of the results of patients with gunshot head wounds hospitalized in the Military University Hospital in Prague during the period 2000–2018 was performed. Epidemiological data; Injury cause, type, and motive; Glasgow Coma Scale (GCS) on admission; CT scan findings; therapeutic approach; and clinical outcome according to the Glasgow Outcome Score Extended (GOSE) were evaluated and statistically analyzed.

Results: 81 patients were enrolled in the study. Out of these 81 patients, 71 (88%) were injured in a civilian and 10 (12%) in a military setting. Mean GCS on admission was 5.8 (3–15). We operated on 18 patients. Mean GOSE after surgery was 2.8 (1–8). Patients with an overpenetration type of injury, with low GCS value on admission, with a higher number of injured brain lobes and with a bullet trajectory crossing the midsagittal and/or midcoronal plane had statistically significantly worse outcome (P ≤ 0.0001).

Conclusion: GCS on admission, injury cause and motive, and CT findings proved to be significantly important predictive factors. Chosen therapeutic approach should reflect these factors as they correlate with patient’s prognosis.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu­script met the ICMJE “uniform requirements” for biomedical papers.


平民和军人头部的枪伤

目的:头部枪伤是发病率和死亡率最高的严重伤害之一。恰当的研究指出,广泛的外科治疗可改善患者的预后。因此,在入院时评估能够预测患者预后的术前因素非常重要。

方法:对2000-2018年在布拉格军事大学医院住院的枪击性颅脑伤口患者的结果进行回顾性分析。流行病学数据;伤害原因,类型和动机;入院时的格拉斯哥昏迷量表(GCS); CT扫描结果;治疗方法;根据格拉斯哥成果评分扩展(GOSE)对临床结果进行评估并进行统计学分析。

结果:81名患者被纳入研究。在这81名患者中,71名(88%)平民受伤,10名(12%)军人受伤。入院时的平均GCS为5.8(3-15)。我们对18例患者进行了手术。术后平均GOSE为2.8(1–8)。具有穿透性损伤类型,入院时GCS值低,受伤的脑叶数量更多,子弹轨迹越过矢状中和/或冠状中平面的患者在统计学上有较差的预后,结果显著(P≤0.0001)。
结论:GCS在入院,损伤原因和动机以及CT表现方面被证明是重要的预测因素。选择的治疗方法应反映这些因素,因为它们与患者的预后相关。

关键词:颅脑外伤–自杀–伤口–枪击–军事医学

Keywords:

traumatic brain injury – suicide – wounds – gunshot – military medicine


Sources

1. Aarabi B. Surgical outcome in 435 patients who sustained mis­sile head wounds dur­­ing the Iran-Iraq War. Neurosurgery 1990; 27(5): 692– 695.

2. Aarabi B, Tofighi B, Kufera JA et al. Predictors of outcome in civilian gunshot wounds to the head. J Neurosurg 2014; 120(5): 1138– 1146. doi: 10.3171/ 2014.1.JNS131869.

3. Aldrich EF, Eisenberg HM, Saydjari C et al. Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank. Surg Neurol 1992; 38(6): 418– 423. doi: 10.1016/ 0090-3019(92)90109-z.

4. Fathal­la H, Ashry A, El-Fiki A. Manag­­ing military penetrat­­ing brain injuries in the war zone: les­sons learned. Neurosurg Focus 2018; 45(6): E6. doi: 10.3171/ 2018.8.FOCUS18371.

5. Gres­sot LV, Chamoun RB. Patel AJ et al. Predictors of outcome in civilians with gunshot wounds to the head upon presentation. J Neurosurg 2014; 121(3): 645– 652. doi: 10.3171/ 2014.5.JNS131872.

6. Clark WC, Muhlbauer MS, Watridge CB et al. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986; 65(1): 9– 14. doi: 10.3171/ jns.1986.65.1.0009.

7. Martins RS, Siqueira MG, Santos MT et al. Prognostic factors and treatment of penetrat­­ing gunshot wounds to the head. Surg Neurol 2003; 60(2): 98– 104. doi: 10.1016/ s0090-3019(03)00302-1.

8. Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg 2009; 111(4): 683– 687. doi: 10.3171/ 2009.2.JNS08817.

9. Kong VY, Odendaal J, Sartorius B et al. Develop­­ing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score. Ann R Coll Surg Engl 2018; 100(2): 97– 100. doi: 10.1308/ rcsan­n.2017.0141.

10. Levy ML. Outcome prediction fol­low­­ing penetrat­­ing craniocerebral injury in a civilian population: aggres­sive surgical management in patients with admis­sion Glasgow Coma Scale scores of 6 to 15. Neurosurg Focus 2000; 8(1): e2.

11. Joseph B, Aziz H, Pandit V et al. Improv­­ing survival rates after civilian gunshot wounds to the brain. J Am Coll Surg 2014; 218(1): 58– 65. doi: 10.1016/ j.jamcol­lsurg.2013.08.018.

12. Valadka AB, Gopinath SP, Mizutani Y et al. Similarities between civilian gunshot wounds to the head and non--gunshot head injuries. J Trauma 2000; 48(2): 296– 302. doi: 10.1097/ 00005373-200002000-00017.

13. DuBose JJ, Barmaparas G, Inaba K et al. Isolated severe traumatic brain injuries sustained dur­­ing combat operations: demographics, mortality outcomes, and les­sons to be learned from contrasts to civilian counterparts. J Trauma 2011; 70(1): 11– 18. doi: 10.1097/ TA.0b013e318207c563.

14. Naghavi M, Marczak LB, Kutz M et al. Global mortality from firearms 1990– 2016. JAMA 2018; 320(8): 792– 814. doi: 10.1001/ jama.2018.10060.

15. Häckel M. Střelná poranění mozku. Rozhl Chir 2013; 92(6): 353– 356.

16. Hirt M, Krajsa J. Krvácení v perivaskulárních prostorech mimo oblast střelného kanálu u poranění mozku. Cesk Slov Neurol N 2005; 68/ 101(1): 26– 28.

17. Klener J, Zvěřina E, Houšťava L et al. Střelná poranění hlavy a možnosti neurochirurgické léčby. Naše zkušenosti za 10 let. Vojen zdr listy 1993; 62(6): 197– 202.

18. Komenda J, Juříček L. Ranivá balistika. Brno: Vojenská akademie 2003.

19. Sova MD, Vybíhal V, Šprláková A et al. Střelná poranění hlavy a mozku. Cesk Slov Neurol N 2010; 73/ 106(5): 547– 551.

20. Fusek I, Vladyka V. Extrakce cizích těles z mozku stereotaktickou metodou: k 60. narozeninám genm. prof. MU Dr. Zdeňka Kunce, DrSc. Vojen zdr listy 1968; 37: 46– 51.

21. Haninec P, Houstava L, Klener J. Shotgun pel­let embolus of the middle cerebral artery treated by emergency embolectomy. Br J Neurosurg 1996; 10(3): 311– 314. doi: 10.1080/ 02688699650040214.

22. Kuchyňová Z, Zvěřina E, Pipková R. Úraz frontálních dutin způsobený zábavnou pyrotechnikou. Otorinolarynol 1999; 48(4): 241– 244.

23. Kim KA, Wang MY, McNatt SA et al. Vector analysis cor­relat­­ing bul­let trajectory to outcome after civilian through-and-through gunshot wound to the head: us­­ing imag­­ing cues to predict fatal outcome. Neurosurgery 2005; 57(4): 737– 747.

24. Skarupa DJ, Khan M, Hsu A et al. Trends in civilian penetrat­­ing brain injury: a review of 26,871 patients. Am J Surg 2018; 218(2): 255– 260. doi: 10.1016/ j.amjsurg.2018.11.034.

25. Rosenfeld JV, Bell RS, Armonda R. Cur­rent concepts in penetrat­­ing and blast injury to the central nervous system. World J Surg 2015; 39(6): 1352– 1362. doi: 10.1007/ s00268-014-2874-7.

26. Nikolic S, Zivkovic V, Babic D et al. Suicidal single gunshot injury to the head: dif­ferences in site of entrance wound and direction of the bul­let path between right- and left-handed –  an autopsy study. Am J Forensic Med Pathol 2012; 33(1): 43– 46. doi: 10.1097/ PAF.0b013e31823a8a32.

27. Oehmichen M, Meis­sner C, Konig HG, Brain injury after gunshot wounding: morphometric analysis of cell destruction caused by temporary cavitation. J Neurotrauma 2000; 17(2): 155– 162. doi: 10.1089/ neu.2000.17.155.

28. Schyma C. Wound­­ing capacity of muzzle-gas pres­sure. Int J Legal Med 2012; 126(3): 371– 376. doi: 10.1007/ s00414-011-0641-y.

29. Elnour AA, Har­rison J. Lethality of suicide methods. Inj Prev 2008; 14(1): 39– 45. doi: 10.1136/ ip.2007.016246.

30. Smrcka M. Poranění mozku: střelná poranění. Praha: Grada 2001: 72– 74.

31. Mancuso P, Chiaramonte I, Pas­sanisi M et al. Craniocerebral gunshot wounds in civilians. Report on 40 cases. J Neurosurg Sci 1988; 32(4): 189– 194.

32. Shaf­frey ME, Polin RS, Phil­lips CD et al. Clas­sification of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality. J Neurotrauma 1992; 9 (Suppl 1): S279– S285.

33. Bizhan A, Mos­sop C, Aarabi JA. Surgical management of civilian gunshot wounds to the head. Handb Clin Neurol 2015; 127: 181– 193. doi: 10.1016/ B978-0-444-52892-6.00012-X.

34. Aarabi B, Taghipour M, Alibali E et al. Central nervous system infections after military mis­sile head wounds. Neurosurgery 1998; 42(3): 500– 509. doi: 10.1097/ 00006123-199803000-00014.

35. Maragkos GA, Papavas­siliou E, Stippler M et al. Civilian gunshot wounds to the head: prognostic factors af­fect­­ing mortality: meta-analysis of 1774 patients. J Neurotrauma 2018; 35(22): 2605– 2614. doi: 10.1089/ neu.2018.5682.

36. Zverina E. Systems for clas­sify­­ing head and brain injuries, isolated or combined with general trauma, at dif­ferent stages of operation. IRAFMS 1990; 63 (No 7/ 8/ 9): 207.

37. Matson DD. The treatment of acute craniocerebral injuries due to mis­siles. Springfield: Charles C Thomas 1948.

38. Cush­­ing H. Notes on penetrat­­ing wounds of the brain. Br Med J 1918; 1(2982): 221– 226. doi: 10.1136/ bmj. 1.2982.221.

Labels
Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 6

2019 Issue 6

Most read in this issue

This topic is also in:


Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account