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Prognostic factors in civilian gunshot wounds to the head: a series of 110 surgical patients and brief literature review

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Abstract

This study was carried out to evaluate the early results and the prognostic factors affecting the outcome during the in-hospital stay of 110 patients with civilian gunshot wounds to the head admitted at the Hospital of Restauração, Recife, Brazil. Penetrating injury (66%) was the most prevalent type of wound encountered in the present series. Twelve of the 110 (10.9%) patients presented a unilateral dilated pupil at the admission. Motor impairment was present in 24/110 (21.8%) patients. Intracerebral hematoma was present in 36/110 (32.7%) and there were 15/110 (13%) patients with cerebrospinal fluid fistula. Eleven of 110 patients developed meningitis and in 9/110 intracranial abscesses occurred. Nine of 110 patients developed deep venous thrombosis, 11/110 had urinary infection, and coagulopathy was detected in 8/110. Following the surgical procedure, 27/110 (24.5%) patients died during their hospital stay. When the two groups, survivors and non-survivors, were compared, there were significant statistical differences and the univariate analysis identified five preoperative predictors of a poor outcome following surgery: age over 40 years (odds ratios (OR) 5.4, 95% CI 1.73–16.82); presence of unilateral pupil dilatation (OR 5.5, 95% CI 1.641–18.13); low (≤8) Glasgow coma score on admission (OR 6.50, 95% CI 2.27–18.60), presence of intracranial hematoma (OR 3.0, 95% CI 1.21–7.34), and respiratory infection (OR 4.8, 95% CI 1.75–13.47). Thus, (a) age of the patient (juvenile/young age), (b) high preoperative Glasgow coma score, (c) lack of pupil abnormalities, and (d) absence of intracerebral hematoma are predictors of a good prognosis.

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Authors and Affiliations

  1. Department of Neurological Surgery, Hospital of Restauração, University of Pernambuco, Rua Apipucos, 317/601, Recife, 52071-000, Brazil

    Patricia B. Ambrosi, Marcelo M. Valença & Hildo Azevedo-Filho

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  1. Patricia B. Ambrosi
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  2. Marcelo M. Valença
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  3. Hildo Azevedo-Filho
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Correspondence to Hildo Azevedo-Filho.

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Comments

Raimund Firsching, Magdeburg, Germany

We are grateful to Dr. Ambrosi and her collaborators who share their valuable experience. In Europe, with highly effective gun control, it is unusual to gain so much experience and the authors are to be congratulated on the good outcome they demonstrated in this current report.

Werner Dittmann, Aschaffenburg, Germany

The authors should be complimented for the compilation of this special type of open craniocerebral injuries that are a quantitative and qualitative neurosurgical challenge especially in Brazil.

Besides the main predictors of clinical outcome named by the authors, they suggest that: “the type of weapons used and the velocities of the bullets involved may play a significant role in the severity of the brain injuries… Therefore, we believe that the main used weapons by this population were some of the low cost handguns, which provoke ‘low velocity’ type of wounds.”

Referring to former studies (Dittmann W, 1988. “Wundballistische Untersuchungen zu Schädel-Hirn-Schussverletzungen”), it is known that the prognosis of these injuries can be correlated significantly to the caliber of the projectiles and their kinetic energy according to the formula \( {{E}_{\text{kin}}} = \frac{m}{2} \cdot {{v}^{{2}}} \). The higher the kinetic energy of the projectile, the more frequently the patients were comatose (unconscious) at the time of their clinical admittance and the more frequently they died within the first 2 days after the injury. This coherence results from the temporary wound cavity, which arises for fractions of a second within the viscoplastic/viscoelastic brain tissue. The size and expansion of this wound cavity, resulting from the kinetic energy, can only be partially correlated to the remaining shot channel visible for the neurosurgeon.

Especially in the case of civil gunshot wounds, the opportunity to verify this coherence in collaborative research with policemen and forensic scientists is given.

Whereas the assumption expressed by the authors that low-cost handguns possess comparatively poor kinetic energy and therefore only provoke low velocity type of wounds is not comprehensible from a weapon-technological point of view.

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Ambrosi, P.B., Valença, M.M. & Azevedo-Filho, H. Prognostic factors in civilian gunshot wounds to the head: a series of 110 surgical patients and brief literature review. Neurosurg Rev 35, 429–436 (2012). https://doi.org/10.1007/s10143-012-0377-2

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  • DOI: https://doi.org/10.1007/s10143-012-0377-2

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