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Civilian Gunshot Wounds to the Head: a Case Report, Clinical Management, and Literature Review Haoyi Qi1 and Kunzheng Li2*

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Civilian Gunshot Wounds to the Head: a Case Report, Clinical Management, and Literature Review Haoyi Qi1 and Kunzheng Li2* Qi and Li Chinese Neurosurgical Journal (2021) 7:12 https://doi.org/10.1186/s41016-020-00227-9 中华医学会神经外科学分会 CHINESE MEDICAL ASSOCIATION CHINESE NEUROSURGICAL SOCIETY CASE REPORT Open Access Civilian gunshot wounds to the head: a case report, clinical management, and literature review Haoyi Qi1 and Kunzheng Li2* Abstract Background: Civilian gunshot wounds to the head refer to brain injury caused by projectiles such as gun projectiles and various fragments generated by explosives in a power launch or explosion. Gunshot wounds to the head are the deadliest of all gun injuries. According to literature statistics, the survival rate of patients with gunshot wounds to the head is only 9%. Due to the strict management of various types of firearms, they rarely occur, so the injury mechanism, injury and trauma analysis, clinical management, and surgical standards are almost entirely based on military experience, and there are few related reports, especially of the head, in which an individual suffered a fatal blow more than once in a short time. We report a case with a return to almost complete recovery despite the patient suffering two gunshot injuries to the head in a short period of time. Case presentations: We present a case of a 53-year-old man who suffered two gunshot injuries to the head under unknown circumstances. On initial presentation, the patient had a Glasgow Coma Scale score of 6, was unable to communicate, and had loss of consciousness. The first bullet penetrated the right frontal area and finally reached the right occipital lobe. When the patient reflexively shielded his head with his hand, the second bullet passed through the patient’s right palm bone, entered the right frontotemporal area, and came to rest deep in the lateral sulcus. The patient had a cerebral hernia when he was admitted to the hospital and immediately entered the operating room for rescue after a computed tomography scan. After two foreign body removals and skull repair, the patient recovered completely. Conclusions: Gunshot wounds to the head have a high mortality rate and usually require aggressive management. Evaluation of most gunshot injuries requires extremely fast imaging examination upon arrival at the hospital, followed by proactive treatment against infection, seizure, and increased intracranial pressure. Surgical intervention is usually necessary, and its key points include the timing, method, and scope of the operation. Keywords: Gunshot wound, Head trauma, Penetrating brain injury, Traumatic brain injury * Correspondence: [email protected] 2The Affiliated Hospital of Qinghai University, No. 29 Tongren Road, Xining 810000, Qinghai Province, China Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Qi and Li Chinese Neurosurgical Journal (2021) 7:12 Page 2 of 9 Background repetitive farming activities by himself without the The surgical management of gunshot wounds to the care of his family. head (GWH) is still a challenging issue in neurosurgery [1]. Even after experience acquired during the two Case presentation World Wars and multiple local wars, the surgical man- A 53-year-old male with two GWH to his right cerebral agement of such patients still needs further discussion hemisphere presented with a GCS score of 6 to the hos- because mortality and morbidity remain high despite pital. According to the emergency physician’s report, the technological improvements in the last decades [1, 2]. patient was taken to the hospital about 3 h after the in- Neurosurgeons vary considerably in their approaches to jury. The patient was on the way to the hospital with a GWH. Studies have shown that the age of the patient, a fixed right pupil, so he was given mannitol timely in the high preoperative Glasgow Coma Scale (GCS) score, lack ambulance. We speculated that the duration of brain of pupil abnormalities, and absence of intracerebral herniation was at least 1 h. He was hemodynamically hematoma are predictors of a good prognosis [1]. stable and intubated, there were two adjacent bullet The largest retrospective studies to date have shown holes in the patient’s right frontal area, and no ballistic that penetrating GWH are very often fatal even with exit was seen. Neurological examination revealed that appropriate medical and surgical treatment, with 71% his right pupil was fixed and dilated, and his left pupil of patients dying at the scene, 66-90% of those dying was 2.5-mm wide and reactive. He was responsive to before reaching a hospital, and up to a 51% survival pain stimuli but not to verbal stimuli. A computed tom- rate among those reaching the hospital alive [3–5]. ography (CT) scan of the head revealed a bullet trajec- We highlight the current management guidelines, tory with a right frontal comminuted fracture and bony prognostic factors, and survival outcomes in patients and metallic fragments in the right frontal and right oc- with penetrating GWH. We report a case that is cipital lobes. There was also some brain tissue swelling unique due to the successful outcome and return to with a midline shift to the left and subarachnoid almost complete recovery despite two gunshots to the hemorrhage (Fig. 1). Since the patient had a brain her- head and a low GCS score. We defined the almost niation at admission, he was immediately transferred to complete recovery as the ability to complete simple, the operating room for debridement and decompressive Fig. 1 Computed tomography (CT) upon admission. a Soft tissue windows and b bone windows, showing the metal artifacts from the bullet case. Postoperative CT on the same day in soft tissue windows c, and bone windows d after decompressive craniectomy Qi and Li Chinese Neurosurgical Journal (2021) 7:12 Page 3 of 9 Fig. 2 Computed tomography (CT) upon admission. a Soft tissue windows and b bone windows, showing the bullet fragment in the occipital lobe. Postoperative CT scan in soft tissue windows c and bone windows d after the second operation, clearly showing the skull window accommodating some swelling craniectomy after the first CT scan. Considering the spe- alone. There was no obvious cognitive impairment, but cificity of the patient’s intracranial hematoma location his personality had slightly changed. The main manifest- and foreign body location, we performed an extended ation was that he did not like to communicate with pterional approach and decompressive craniectomy in others. He did not experience seizures or other neuro- time. We did not temporarily remove the foreign body logical symptoms. The Wisconsin card sorting test was in the occipital lobe but waited for the patient’s vital used to assess the patient’s performance during the signs to stabilize after the first operation and then evalu- follow-up. The result was good. A series of non- ated whether it was suitable for removal or maintenance. cognitive function evaluations, such as the Functional The analysis of why this decision was taken is presented Activity Questionnaire and Hamilton Depression Scale, in detail in the surgical management section. The patient were also carried out. The results were satisfactory, and recovered well after the first operation with no infection the patient showed no signs of anxiety or depression. or brain abscess development and underwent a second operation 2 weeks later to remove the foreign body in Discussion the occipital lobe (Fig. 2). He was discharged 7 days later. Prehospital treatment The patient visited the hospital for a re-examination 2 Based on the outcomes of a prospective study, all GWH months after the injury, and hydrocephalus was found to patients should initially receive aggressive resuscitation have occurred. We performed skull repair 3 months after [6]. Patients with stable vital signs should be examined injury. The patient came in for a 6-month follow-up. by CT. If the patient’s GCS score after resuscitation is 3 During the subsequent follow-up, hydrocephalus did not to 5 and no operable hematomas are present, then no continue to develop, and head CT yielded no new or further therapy should be offered [2, 6]. All patients with concerning findings, so we did not perform additional a GCS score greater than 5 should receive aggressive clinical management (Fig. 3). The last telephone follow- surgical therapy [2, 6]. However, some recent retrospect- up was performed a year after his injury. According to ive studies have shown that GCS score at admission and the patient’s family members, the self-care ability of the the status of pupils and hemodynamics seem to be the patient was fair, and he could complete housework most significant predictors of outcome in penetrating Qi and Li Chinese Neurosurgical Journal (2021) 7:12 Page 4 of 9 Fig. 3 Two months after discharge, a head computed tomography (CT) scan a and b revealed hydrocephalus.
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