Microsoft Word - 8.MajerC_CranioCerebral
438 C. Majer, G. Iacob Cranio-cerebral gunshot wounds
Cranio-cerebral gunshot wounds
C. Majer1, G. Iacob2
1Neurospinal Hospital Dubai, EAU
2Neurosurgery Clinic, Universitary Hospital Bucharest, Romania
Abstract
Cranio-cerebral gunshots wounds
(CCGW) are the most devastating injuries
to the central nervous system, especially
made by high velocity bullets, the most
devastating, severe and usually fatal type of
missile injury to the head.
Objective: To investigate and compare,
using a retrospective study on five cases the
clinical outcomes of CCGW. Predictors of
poor outcome were: older age, delayed
mode of transportation, low admission
CGS score with haemodynamic instability,
CT visualization of diffuse brain damage,
bihemispheric, multilobar injuries with
lateral and midline sagittal planes
trajectories made by penetrating high
velocity bullets fired from a very close
range, brain stem and ventricular injury
with intraventricular and/or subarachnoid
hemorrhage, mass effect and midline shift,
evidence of herniation and/or hematomas,
high ICP and/or hypotension, abnormal
coagulation states on admission or
disseminated intravascular coagulation. Less
harmful effects were generated by retained
missiles, bone fragments with CNS
infection, DAI lesions and neuronal
damages associated to cavitation, seizures.
Material and methods: 5 patients (4 male
and 1 female), age ranged 22-65 years, with
CCGW, during the period 2004-2009,
caused by military conflict and accidental
firing. After initial resuscitation all patients
were assessed on admission by the Glasgow
Coma Scale (GCS). After investigations: X-
ray skull, brain CT, Angio-CT, cerebral
MRI, SPECT; baseline investigations,
neurological, haemodynamic and
coagulability status all patients underwent
surgical treatment following emergency
intervention. The survival, mortality and
functional outcome were evaluated by
Glasgow Outcome Scale (GOS) score.
Results: Referring on five cases we
evaluate on a retrospective study the clinical
outcome, imagistics, microscopic studies on
neuronal and axonal damage generated by
temporary cavitation along the cerebral
bullet’s track, therapeutics, as the review of
the literature. Two patients with an
admission CGS 9 and 10 survived and three
patients with admission CGS score of 3,
with severe ventricular, brain stem injuries
and lateral plane of high velocity bullets
trajectories died despite treatment.
Conclusion: CCGW is the most
devastating type of missile injury to the
head. Aggressive intensive care
management in combination with early
management with less aggressive
meticulous neurosurgical technique, has
significantly reduced the mortality and
morbidity associated with these injuries,
but they still remain unacceptably high.
Primary prevention of these injuries
remains important, the patient must be
monitored closely for possible
Romanian Neurosurgery (2010) XVII 4: 438 – 444 439
complications.
Keywords: cranio-cerebral gunshot
wounds (CCGW), high velocity bullets,
neuronal damage, cavitation, DAI lesions
Cranio-cerebral gunshot wounds
(CCGW) produce devastating injuries to
the central nervous system structures, such
as tangential, perforating and penetrating
(1) (2) (3), especially by high velocity
bullets crossing in the lateral, midline,
sagittal (2-6), which are the most severe and
usually fatal type of missile injury to the
head.
Material and methods
Five patients (4 male and 1 female), age
ranged 22-65 years, with CCGW, during
the period 2004-2009, caused by military
conflict and accidental firing, underwent
emergency intervention in Dubai – 4 cases
and Romania – 1 case. Transportation was
initial made by ambulances with low
equipment; after resuscitation, assessed by
the Glasgow Coma Scale (GCS) all patients
were evacuated by plane. Assessed on
admission by the Glasgow Coma Scale
(GCS) two patients has a CGS of 9,
respectively 10 and three patients has a
CGS score of 3.
X-ray skull and CT in bone window
demonstrated in all patients bone defects,
different fractures types, intact or
fragmented missiles, pneumocephalus (fig.
1). Cerebral CT scan revealed multilobar
injuries made by penetrating high velocity
bullets, mass effect and midline shift,
evidence of herniation and/or hematomas.
Brain stem and ventricular injury with
intraventricular and subarachnoid
hemorrhage were described in two cases,
also retained missiles, bone fragments. The
lethal wounds were bitemporal, temporo-
occipital; less aggressive in frontal, parietal
wounds without dural venous sinus tears.
In two cases were the missile trajectory
traverses through the middle cerebral
artery, cerebral angiography was performed,
to exclude developement of a possible
pseudoaneurysm or dural sinus tear. Also
cerebral MRI, SPECT (Figure 1) was
performed three weeks after shooting in
two survived cases with neuronal damages
associated to cavitation, seizures, ischemia,
DAI lesions. Baseline investigations,
neurological, haemodynamic and
coagulability status were performed in all
cases. Compatible blood transfusion,
treatment of coagulopathy and shock,
antibiotics and anticonvulsivant were used;
intracranial pressure monitoring was
performed in 4 patients placed
intraparenchymal cavities created after
blood clots evacuation.
Results
All patients underwent surgical
treatment including primary closure of the
wounds, debridement of skin, hairs,
necrotic tissues, removal of hematomas,
accessible and visible missiles and bone
fragments, haemostasis, duraplasty. No
attempts were made to chase any indriven
inaccessible bone and missile fragments, in
order to avoid additional insult to injured
brain. In two cases bullets were intact (20
and 30 mm lenghth, 10 and 14 mm in
diameter, 10 and 16 g in weight), but three
others deformed, mushroomed and
fragmented. Therapy with broad spectrum
antibiotics, anticonvulsivants, mannitol was
started to all patients. Three patients with
bitemporal, temporo-occipital injury died
in the first 48 hours postoperatively despite
emergency intervention and surgical
treatment by early respiratory arrest. In this
440 C. Majer, G. Iacob Cranio-cerebral gunshot wounds
cases brain swelling with midline shift were
seen resistent to therapy. For two patients
with moderate hemiparesis a rehabilitation
program was started. One year after, their
medical condition improved, but unable to
gain initial activities; continuing
anticonvulsivant therapy with depakine for
seizures, without another postoperative
complications.
A forensic neuropathologist
reconstruction of brain injuries was made
for the three patients who died based on:
macroscopic findings reffering on entrance
and exit wounds, the missile track and
secondary changes corelated to CT
reconstruction. Microscopic evaluation of
the zones of cellular and axonal destruction
around the permanent track corresponding
to the temporary cavity were performed on
three cases. We found that the most
dangerous trajectories of high velocity
bullets were bitemporal and temporo-
occipital; also areas of hemorrhagic
extravasations surrounding the permanent
track, extended about 24-28 mm radially,
nerve cells and astrocyte destructions,
broken axons into fragments.
Illustrative case: P.C. aged 25 years old was
cranio-cerebral gun shot with high velocity
bullets fired by a sniper, in Afganistan, on
18.07.2007. The patient developped
immediate deep coma and dilated pupils, he
was intubated and mechanical ventilated.
Transferred to Dubai on 19.07.2007 at
admission he presented: GCS 3, bilateral
mydriasis, no reflexes, intubated,
mechanical ventilated, with Dopamine and
cephalosporines infusion. The patient was
explored: cerebral CT, cerebral angio CT,
SPECT.; an ICP monitoring and a radical
debridement of entry point was performed.
Despite all medical aids he died on
19.07.2007. A postmortem detaliate
reconstruction of his brain injuries was
performed.
A B C D E
F G H I
Romanian Neurosurgery (2010) XVII 4: 438 – 444 441
K L M
Figure 1 A-B cerebral CT scan showing missile in right temporal area; C cerebral CT scan with missile in
parieto-occipital area; D CT scan shows the skull fracture underlying cerebral contusion and an intrusive
parietal bone fragment, E-G axial cerebral CT scan showing haemorrhagic missile tracks with adiacent small
cerebral contusions; H-I temporo-parietal peritentorial bullet on axial and coronal reconstruction cerebral CT
scan K-L angio-CT scan 3D shows metallic bullets in both hemispheres, no pseudoaneurysm or dural sinus
tear, M SPECT with severe cerebral ischemia
Discussions
Cranio-cerebral gunshot wounds
(CCGW) are the most devastating injuries
in humans, afecting central nervous system
structures, representing a real concern to
the community as a whole (1) (2) (6).
CCGW could be: penetrating - in which a
projectile breaches the cranium but does
not exit it, made by low-velocity bullets as
air rifle, projectiles, nail guns used in
construction devices, stun guns used for
animal slaughter, shrapnel produced during
explosions, but also perforating - in which
the projectile passes entirely though the
head, leaving both entrance and exit
wounds, by high-mass and velocity metal-
jacket bullets fired from military weapons,
or guns fired from a very close range as in
agression or suicide attempts (2) (3) (6-12)
(14).
Approximately 2 million traumatic brain
injuries occur each year and an approximate
50% of all trauma deaths are secondary to
traumatic brain injury and gunshot wounds
to the head caused 35% of these mortalities
(1) (4). The magnitude of this problem in
the United States (4) (6-8): 230 milion fire
arms in circulation, generating > 700000
injured cases each year, in peaceful time, by
firearm-related violence, 24000 deaths,
representing the fourth leading cause of
death in the United States and the leading
cause of death in persons aged 1-44 years.
This magnitude is similar with all American
losses during Vietnam conflict (4); a injury
from firearms made the victim of a gunshot
wound to the head 35 times more likely to
die than is a patient with a comparable
nonpenetrating brain injury.
Cranio-cerebral head injuries (1) (4) (7)
are known since 1700 BC in Egyptian
papyrus reffering to 4 cases of depressed
skull fractures treated by anointing the scalp
wound with grease, leaving the wound
unbandaged, providing free drainage of the
intracranial cavity. Hippocrates (460-357
BC) performed trephination for
contusions, fissure fractures, and skull
indentations. Galen's experience in 130-210
AD treating wounded gladiators led to
recognition of a correlation between the
side of injury and the side of motor loss.
Thought for the centuries incurable,
cranio-cerebral head injuries had a high
mortality rate: about 76% in Homer’s era
around 700 BC, 73,9% in the Crimean war
442 C. Majer, G. Iacob Cranio-cerebral gunshot wounds
and 71,7% in the American Civil war (4). In
the 17th century, Richard Wiseman asses
that deep wounds had a much worse
prognosis than superficial ones,
recommended the evacuation of subdural
hematomas and the extraction of bone
fragments – cited by (4). Important
advances in the management of cranio-
cerebral injuries in the mid-19th century
who dramatically reduced the incidence of
local and systemic infections, as well as
mortality were related to the work of: Louis
Pasteur (1867), Robert Koch (1876) in
bacteriology and Joseph Lister (1867) in
asepsis (3) (4) (6). Using Harvey Cushing’s
measures (1-3) (9-13) since the first world
war as: aggressive and meticulously initial
debridement all devitalized tissue,
removing metal and bone fragments of
missile track, exploring the intradural space,
watertight closure of dural lacerations was
advocated to reduced the rate of infections,
abscess formation and the mortality rate
dropped from 56% to 28% (9) (13). During
World War II despite CCGW made by high
muzzle velocity missiles with very high
mass, low-velocity shrapnel wounds,
extensive destruction of tissues, the
mortality rate was lower: 14% with the
advent of antibiotics and 9,7% in Vietnam
War (1-3) (7-10). CCGW has been changed
from one uniquely military to broadly
civilian concern in several countries
firearms (see Irak, Yemen a.s.o) considered
part of the personality of men, present in
hands of most of population and used for
many purposes as parties, social conflicts,
protecting farms and for entertainments (9).
However a higher mortality rate are in
military CCGW(1-3) (8) (11) (12) justified
especially by differences in wound
ballistics. The new military medecine
history has noticed a higher mortality rate:
26% Iraq-Iran war and Lebanon war –
despite CT scanning, respectively 32% with
bullets and 10,6% with shrapnells in the last
Yugoslav Civil war, generated by
improvements in weapons technology,
especially by the use of snipers (2) (8).
After the bullet penetrates the outer and
inner tables of the skull, it crosses whole
brain structures crushing tissues and a
percussion wave is transmitted throughout
the brain, causing temporary cavitation,
radial tissue displacement, shearing,
compression and stretching of cerebral
tissue (15). The intracranial effect varies
from isolated soft tissue to an "explosive"
type of injury with comminuted fractures
of the skull or bullet fragments generating
laceration of the brain (1) (3) (11), also
widespread destruction of neuronal cell
membranes, which depends on the physical
properties of the projectile, but also by its
ballistics (12) (15-18). The enhanced effects
of temporary cavitation is generating an
enlarged zone of disintegrated tissue, high
intracranial pressures expressed
morphological by cortical contusion zones,
indirect skull fractures and perivascular
haemorrhages remote from the tract.
Varying degrees of cavitation in the brain
occur along the bullet’s path, usually several
times larger than the diameter of the bullet
(1) (3) (5) (17) (18). In addition to the
primary destruction of brain tissue readily
visible at autopsy (permanent track),
gunshot wounding to the brain creates a
pulsating temporary cavity due to radial
expansion along the bullet's track.
Surrounding the permanent track, extended
about 20 mm radially, a mantle-like zone of
astrocyte destruction was found within an
area of hemorrhagic extravasation. (18);
nerve cells are shrunken; axons had been
broken into tiny fragments (19), exhibiting
Romanian Neurosurgery (2010) XVII 4: 438 – 444 443
varicose changes and clumping. The extent
of traumatic bleeding could be remarked
along the track from entry point to exit
point by the temporary cavitation - a
destruction zone of ca. 3.6 cm around the
permanent track, loss of glial fibrillary acid
protein expression by astrocytes in the
white matter. (17) (18)
After CCGW frequently seen effects are:
neurodeficits, brain swelling with ICP rise,
CSF leaks with severe infections, carotico-
cavernous fistulas, pseudoaneurysms
correlated with morbidity and mortality
(3)(9-12). Many CCGW are incompatible
with life, but moderately injured patients
more frequently are resuscitated and benefit
from aggressive treatment of secondary
mechanisms of injury. There is
considerable variability among
neurosurgeons currently as to what
constitutes appropriate treatment of
CCGW (3) (4) (10): Raimondi and
Samuelson (1970) noted the difference in
wound ballistics and offered a classification
scheme based on initial neurologic
assessment. Arendall and Meirowsky 1983
found that high mortality associated with
penetrating wound of air sinuses can be
reduced by prompt and radical debridment,
Kaufman (14) appreciate the surgical
debridement performed, the use of ICP
monitoring and various medical therapies,
Helling et all 1992 found that early surgical
intervention seemed to result in better
survival, Gonul 1997, Singh 2003 acute or
delayed CSF leak highly correlated with
intracranial infection (9) (12) Antibiotics
are no substitute for early surgical
debridment, a lower mortality rate reflects
early triage and survivability decisions as
much as treatment effectiveness (3) (13)
CCGW treatment comprised of four
stages: immediate saving of life by the use
of various medical therapies, ICP
monitoring, prevention of infection,
preservation of the nervous tissue,
restoration of anatomical structures, with
radical debridement (4) (9). Duration of
antiepileptics and antibiotics remains
controversial, as does the use of
hyperventilation, hypothermia, and steroids
(9) (12). Use of jugular bulb catheters and
transcranial Doppler is institution-
dependent (9).
There are several predictors of poor
outcome in CCGW, correlating with
morbidity and mortality (1-6) (8-15):
advanced age, high velocity missiles or
handguns fired from a very close range as in
suicide attempts, admission CGS score 3
and 4 (with mortality rates near 90% and
rare satisfactory outcome), bilateral fixed
dilated pupils with opac cornea, delayed and
poor mode of transportation, apnea at
admission, associated injuries to chest,
abdomen and great vessels generating
massive bleeding, haemodynamic instability
(hypotension), postoperative rise in ICP,
abnormal coagulation states on admission
or even DIC, CT visualization of diffuse
brain damage, bihemispheric, bitentorial,
multilobar missile track with lateral >
midline sagittal planes trajectories made by
high velocity bullets fired from a very close
range, brain stem and ventricular injury,
ventricular and subarahnoid haemorrhage,
vasospasm, mass effect and midline shift,
evidence of herniation and/or hematomas
greater than 15 ml.
Less harmful effects are generated by
retained missiles, bone and hair
intraparenchymal fragments with CNS
infection, DAI lesions, pneumocephalus,
and neuronal damages associated to
cavitation, seizures (3) (9) (10) (13).
444 C. Majer, G. Iacob Cranio-cerebral gunshot wounds
Conclusions
Aggressive intensive care management in
combination with early management with
less aggressive, meticulous, neurosurgical
technique, when appropriate, already has
significantly reduced the mortality and
morbidity associated with these injuries,
but they still remain unacceptably high .
Primary prevention of cranio-cerebral
gunshot wounds remains important, the
patient must be monitored closely for
possible complications. With the increasing
numbers of firearms and firearm-related
violence in our society, discussing the issues
of violence with patients and offering
appropriate intervention becomes the duty
of all health care providers.
References
1. Federico C Vinas - Penetrating Head Trauma:
Multimedia, May 27, 2009
2. Antic B., Spaic M. – Penetrating Craniocerebral
Injuries from the former Yugoslavia Battlefields, Ind. J.
Neurotrauma (IJNT), 2006, 3, 27-30
3. Iacob M., Iacob G. – Plagi craniocerebrale prin arma
de foc, Simpozionul de Neurochirurgie Cluj Napoca
1987
4. Shaffrey M.E. et al. - Classification of civilian
craniocerebral gunshot wounds: a multivariate analysis
predictive of mortality, J Neurotrauma. 1992 Mar; 9,
Suppl 1:S279-85.
5. Izci Y., Kayali H.,Daneyemez M., Koksel T. –
Comparison of clinical outcomes between
anteroposterior and lateral penetrating craniocerebral
gunshot wounds, Emerg. Med. J. 2005, 22, 409-410
6. Rosenfeld J.V. – Gunshot injury to the head and
spine, J. Clin. Neurosci 2002, 9, 9-16
7. Marshall L.F., Marshall S.B., Sean G.M. – Modern
neurotraumatology: a brief historical review, in
Youmans Neurological Surgery, Editor: Winn H.R., 5th
Edition Saunders, 2004, 5019-5024
8. Spaic M., Branislav A. – The lost race, Indian Journal
of Neurotrauma 2009, 6, 1, 1-4
9. Rashid B.A et al. – Analysis of 3794 civilian
craniocerebral missile injuries – Results from 20 years
of Kashmir conflict, Pan Arab Journal of Neurosurgery,
2010, 14,1, 24-32.
10. Meirowsky A.M. – Secondary removal of retained
bone fragments in missile wounds of the brain,
J.Neurosurg. 1982, 57, 617-621
11. Bakir A. et al. – High Velocity Gunshot Wounds to
the head: analysis of 135 patients, Neurol. Med. Chir
(Tokyo) 2005, 45, 281-287
12. Erdogan E., Gonul E., Seber N. – Craniocerebral
gunshot wounds, Neurosurg Q. 2002, 12, 1-18
13. Gonul E., Baysefer A., Kahraman S. Et al. – Causes
of infections and management results in penetrating
craniocerebral injuries, Neurosurg. Rev. 1997, 20, 177-
181
14. Kaufman H.H. – Civilian gunshot wounds to the
head, Neurosurg. 1993, 32, 962-964
15. Karger B. – Penetrating gunshots to the head and
lack of immediate incapacitation, Wound ballistics and
mechanisms of incapacitation, Int. J. Legal Med. 1995,
108,(2), 53-61
16. Kim K.A., Wang M.Y., McNatt S.A. 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: 737-747
17. Oehmichen M., Meissner C., Konig H.G., Gehl H.
R. – Gunshot injuries to the head and brain caused by
low velocity handguns and rifles; A. review, Forensic
science international, Congrès European Congress of
Neuropathology No7, Helsinki, Finlande, 2004, vol.
146, nr.2-3, 111-120.
18. Oehmichen M., Meissner C., Konig H.G. – Brain
Injury after Gunshot Wounding: Morphometric
Analysis of Cell Destruction Caused by temporary
Cavitation, Journal of Neurotrauma. 2000, 17(2): 155-
162.
19. Francisc A., Majer C., Iacob G. – Diffuse axonal
injuries: clinical, neuroimaging and microscopic
features- literature review, Romanian Journal of Legal
Medicine, 2008, XVI, 3, 172-180