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Cranio-Cerebral Gunshot Wounds 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 were assessed on admission by the Glasgow Cranio-cerebral gunshots wounds Coma Scale (GCS). After investigations: X- (CCGW) are the most devastating injuries ray skull, brain CT, Angio-CT, cerebral to the central nervous system, especially MRI, SPECT; baseline investigations, made by high velocity bullets, the most neurological, haemodynamic and devastating, severe and usually fatal type of coagulability status all patients underwent missile injury to the head. surgical treatment following emergency Objective: To investigate and compare, intervention. The survival, mortality and using a retrospective study on five cases the functional outcome were evaluated by clinical outcomes of CCGW. Predictors of Glasgow Outcome Scale (GOS) score. poor outcome were: older age, delayed Results: Referring on five cases we mode of transportation, low admission evaluate on a retrospective study the clinical CGS score with haemodynamic instability, outcome, imagistics, microscopic studies on CT visualization of diffuse brain damage, neuronal and axonal damage generated by bihemispheric, multilobar injuries with temporary cavitation along the cerebral lateral and midline sagittal planes bullet’s track, therapeutics, as the review of trajectories made by penetrating high the literature. Two patients with an velocity bullets fired from a very close admission CGS 9 and 10 survived and three range, brain stem and ventricular injury patients with admission CGS score of 3, with intraventricular and/or subarachnoid with severe ventricular, brain stem injuries hemorrhage, mass effect and midline shift, and lateral plane of high velocity bullets evidence of herniation and/or hematomas, trajectories died despite treatment. high ICP and/or hypotension, abnormal Conclusion: CCGW is the most coagulation states on admission or devastating type of missile injury to the disseminated intravascular coagulation. Less head. Aggressive intensive care harmful effects were generated by retained management in combination with early missiles, bone fragments with CNS management with less aggressive infection, DAI lesions and neuronal meticulous neurosurgical technique, has damages associated to cavitation, seizures. significantly reduced the mortality and Material and methods: 5 patients (4 male morbidity associated with these injuries, and 1 female), age ranged 22-65 years, with but they still remain unacceptably high. CCGW, during the period 2004-2009, Primary prevention of these injuries caused by military conflict and accidental remains important, the patient must be firing. After initial resuscitation all patients monitored closely for possible Romanian Neurosurgery (2010) XVII 4: 438 – 444 439 complications. occipital; less aggressive in frontal, parietal Keywords: cranio-cerebral gunshot wounds without dural venous sinus tears. wounds (CCGW), high velocity bullets, In two cases were the missile trajectory neuronal damage, cavitation, DAI lesions traverses through the middle cerebral artery, cerebral angiography was performed, Cranio-cerebral gunshot wounds to exclude developement of a possible (CCGW) produce devastating injuries to pseudoaneurysm or dural sinus tear. Also the central nervous system structures, such cerebral MRI, SPECT (Figure 1) was as tangential, perforating and penetrating performed three weeks after shooting in (1) (2) (3), especially by high velocity two survived cases with neuronal damages bullets crossing in the lateral, midline, associated to cavitation, seizures, ischemia, sagittal (2-6), which are the most severe and DAI lesions. Baseline investigations, usually fatal type of missile injury to the neurological, haemodynamic and head. coagulability status were performed in all cases. Compatible blood transfusion, Material and methods treatment of coagulopathy and shock, Five patients (4 male and 1 female), age antibiotics and anticonvulsivant were used; ranged 22-65 years, with CCGW, during intracranial pressure monitoring was the period 2004-2009, caused by military performed in 4 patients placed conflict and accidental firing, underwent intraparenchymal cavities created after emergency intervention in Dubai – 4 cases blood clots evacuation. and Romania – 1 case. Transportation was initial made by ambulances with low Results equipment; after resuscitation, assessed by All patients underwent surgical the Glasgow Coma Scale (GCS) all patients treatment including primary closure of the were evacuated by plane. Assessed on wounds, debridement of skin, hairs, admission by the Glasgow Coma Scale necrotic tissues, removal of hematomas, (GCS) two patients has a CGS of 9, accessible and visible missiles and bone respectively 10 and three patients has a fragments, haemostasis, duraplasty. No CGS score of 3. attempts were made to chase any indriven X-ray skull and CT in bone window inaccessible bone and missile fragments, in demonstrated in all patients bone defects, order to avoid additional insult to injured different fractures types, intact or brain. In two cases bullets were intact (20 fragmented missiles, pneumocephalus (fig. and 30 mm lenghth, 10 and 14 mm in 1). Cerebral CT scan revealed multilobar diameter, 10 and 16 g in weight), but three injuries made by penetrating high velocity others deformed, mushroomed and bullets, mass effect and midline shift, fragmented. Therapy with broad spectrum evidence of herniation and/or hematomas. antibiotics, anticonvulsivants, mannitol was Brain stem and ventricular injury with started to all patients. Three patients with intraventricular and subarachnoid bitemporal, temporo-occipital injury died hemorrhage were described in two cases, in the first 48 hours postoperatively despite also retained missiles, bone fragments. The emergency intervention and surgical lethal wounds were bitemporal, temporo- treatment by early respiratory arrest. In this 440 C. Majer, G. Iacob Cranio-cerebral gunshot wounds cases brain swelling with midline shift were extravasations surrounding the permanent seen resistent to therapy. For two patients track, extended about 24-28 mm radially, with moderate hemiparesis a rehabilitation nerve cells and astrocyte destructions, program was started. One year after, their broken axons into fragments. medical condition improved, but unable to Illustrative case: P.C. aged 25 years old was gain initial activities; continuing cranio-cerebral gun shot with high velocity anticonvulsivant therapy with depakine for bullets fired by a sniper, in Afganistan, on seizures, without another postoperative 18.07.2007. The patient developped complications. immediate deep coma and dilated pupils, he A forensic neuropathologist was intubated and mechanical ventilated. reconstruction of brain injuries was made Transferred to Dubai on 19.07.2007 at for the three patients who died based on: admission he presented: GCS 3, bilateral macroscopic findings reffering on entrance mydriasis, no reflexes, intubated, and exit wounds, the missile track and mechanical ventilated, with Dopamine and secondary changes corelated to CT cephalosporines infusion. The patient was reconstruction. Microscopic evaluation of explored: cerebral CT, cerebral angio CT, the zones of cellular and axonal destruction SPECT.; an ICP monitoring and a radical around the permanent track corresponding debridement of entry point was performed. to the temporary cavity were performed on Despite all medical aids he died on three cases. We found that the most 19.07.2007. A postmortem detaliate dangerous trajectories of high velocity reconstruction of his brain injuries was bullets were bitemporal and temporo- performed. occipital; also areas of hemorrhagic 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 injured cases each year, in peaceful time, by Cranio-cerebral gunshot wounds firearm-related violence, 24000 deaths, (CCGW) are the most devastating injuries representing the fourth leading cause of in humans, afecting central nervous system death in the United States and the leading structures, representing a real concern to cause of death in persons aged 1-44 years. the community as a whole (1) (2) (6). This magnitude is similar with all American CCGW could be: penetrating - in which a losses during Vietnam conflict (4); a injury projectile breaches the cranium but does from firearms made the victim of a gunshot not exit it, made by low-velocity bullets as wound to the head 35 times more likely to air rifle, projectiles, nail guns used in die than is a patient with a comparable construction devices, stun guns used for nonpenetrating brain injury. animal slaughter, shrapnel produced during Cranio-cerebral head injuries (1) (4) (7) explosions, but also perforating - in which are known since 1700 BC in Egyptian the projectile passes
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