Surgical Management of Penetrating Intracranial Bullet Injuries

Abstract

Objectives:This study aimed to determine the outcome after gunshot wounds (GSWs) to the head and to evaluate the impact of prognostic factors mentioned in the literature on the outcome. Methods:This prospective study included 30 patients; 24 males and 6 females with a mean age of 31 years. All with penetrating GSWs to the head admitted to the emergency department of Cairo University Hospitals from January 2008 till June 2011. Shotgun was the most common injury in this study, whereas bullet injury was in only 3 patients (10%). Preoperatively, patients were categorized according to their Glasgow Coma Scale (GCS) into mild, moderate, and severe penetrating head injury. Upon admission, all patients underwent a complete physical and neurological examination together with a computed tomography of the brain without contrast. Initial management included a variety of the following according to indications; resuscitation, prophylactic antiepileptics, antibiotics, control active bleeding from wounds, and measures to decrease intracranial pressure. Surgical intervention ranged from simple debridement to hematoma evacuation and/or bullet extraction. Outcome was assessed after surgical interference using GCS and Glasgow Outcome Scale. Results:Fifteen (50%) patients had mild penetrating head injury (GCS 13 to 15), 12 patients (40%) were severely injured (GCS 3 to 8), and only 3 patients (10%) were moderately injured (GCS 9 to 12). Eighteen patients (60%) were found to have isolated intracranial injury, whereas 40% had other associated injuries. Twelve patients (40%) had an associated intracranial hematoma on their initial computed tomography scan. The average follow-up period was 16 months. The most common systemic complications were urinary tract infection (12 patients) and chest infection (12 patients), whereas the most common local complications were wound infection (10 patients), cerebrospinal fluid fistula (8 patients), and hydrocephalus (5 patients). At the follow up, The GCS of 10 patients (33.3%) was (13 to 15), 6 patients (20%) were (9 to 12), 5 patients (16.7%) showed persistent vegetative state (<3), and 9 patients (30%) died. Postoperative outcome was significantly correlated with the preoperative one (P<0.001). According to Glasgow Outcome Scale, 33.3% of patients had good recovery and 30% of the patients died. The others suffered from various degrees of disability. Conclusions:The prevalence of GSWs to the head is increasing dramatically as private ownership of weapons and gang-related urban violence increases. Most of the irreversible brain damage from a GSW is sustained at impact and can be understood in terms of a missile’s trajectory and the pattern of energy transfer to brain tissue. Treatment is aimed at preventing subsequent brain injury that might further limit recovery. One third of patients obtain a good recovery.