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438 C. Majer, G. Iacob Cranio-cerebral gunshot

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 ray , brain CT, Angio-CT, cerebral to the central nervous system, especially MRI, SPECT; baseline investigations, made by high velocity , the most neurological, haemodynamic and devastating, severe and usually fatal type of coagulability status all patients underwent missile 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 , neuronal and axonal damage generated by bihemispheric, multilobar injuries with temporary cavitation along the cerebral lateral and midline sagittal planes ’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 , trajectories died despite treatment. high ICP and/or , 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, fragments with CNS management with less aggressive , 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 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 , cerebral 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, , 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 (GCS) all patients treatment including primary closure of the were evacuated by plane. Assessed on wounds, 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 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 -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 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 made the victim of a gunshot not exit it, made by low-velocity bullets as to the head 35 times more likely to air , 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 entirely though the papyrus reffering to 4 cases of depressed head, leaving both entrance and exit skull fractures treated by anointing the scalp wounds, by high-mass and velocity metal- wound with grease, leaving the wound jacket bullets fired from military weapons, unbandaged, providing free drainage of the or guns fired from a very close range as in intracranial cavity. Hippocrates (460-357 agression or attempts (2) (3) (6-12) BC) performed trephination for (14). contusions, fissure fractures, and skull Approximately 2 million traumatic brain indentations. Galen's experience in 130-210 injuries occur each year and an approximate AD treating wounded gladiators led to 50% of all trauma deaths are secondary to recognition of a correlation between the and gunshot wounds side of injury and the side of motor loss. to the head caused 35% of these mortalities Thought for the centuries incurable, (1) (4). The magnitude of this problem in cranio-cerebral head injuries had a high the United States (4) (6-8): 230 milion fire mortality rate: about 76% in Homer’s era arms in circulation, generating > 700000 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 26% Iraq-Iran war and Lebanon war – the 17th century, Richard Wiseman asses despite CT scanning, respectively 32% with that deep wounds had a much worse bullets and 10,6% with shrapnells in the last prognosis than superficial ones, Yugoslav Civil war, generated by recommended the evacuation of subdural improvements in weapons technology, hematomas and the extraction of bone especially by the use of snipers (2) (8). fragments – cited by (4). Important After the bullet penetrates the outer and advances in the management of cranio- inner tables of the skull, it crosses whole cerebral injuries in the mid-19th century brain structures crushing tissues and a who dramatically reduced the incidence of percussion wave is transmitted throughout local and systemic , as well as the brain, causing temporary cavitation, mortality were related to the work of: Louis radial tissue displacement, shearing, Pasteur (1867), Robert Koch (1876) in compression and stretching of cerebral bacteriology and (1867) in tissue (15). The intracranial effect varies (3) (4) (6). Using Harvey Cushing’s from isolated to an "explosive" measures (1-3) (9-13) since the first world type of injury with comminuted fractures war as: aggressive and meticulously initial of the skull or bullet fragments generating debridement all devitalized tissue, laceration of the brain (1) (3) (11), also removing metal and bone fragments of widespread destruction of neuronal cell missile track, exploring the intradural space, membranes, which depends on the physical watertight closure of dural lacerations was properties of the projectile, but also by its advocated to reduced the rate of infections, (12) (15-18). The enhanced effects abscess formation and the mortality rate of temporary cavitation is generating an dropped from 56% to 28% (9) (13). During enlarged zone of disintegrated tissue, high World War II despite CCGW made by high intracranial pressures expressed muzzle velocity missiles with very high morphological by cortical contusion zones, mass, low-velocity shrapnel wounds, indirect skull fractures and perivascular extensive destruction of tissues, the haemorrhages remote from the tract. mortality rate was lower: 14% with the Varying degrees of cavitation in the brain advent of antibiotics and 9,7% in Vietnam occur along the bullet’s path, usually several War (1-3) (7-10). CCGW has been changed times larger than the diameter of the bullet from one uniquely military to broadly (1) (3) (5) (17) (18). In addition to the civilian concern in several countries primary destruction of brain tissue readily firearms (see Irak, Yemen a.s.o) considered visible at autopsy (permanent track), part of the personality of men, present in gunshot wounding to the brain creates a hands of most of population and used for pulsating temporary cavity due to radial many purposes as parties, social conflicts, expansion along the bullet's track. protecting farms and for entertainments (9). Surrounding the permanent track, extended However a higher mortality rate are in about 20 mm radially, a mantle-like zone of military CCGW(1-3) (8) (11) (12) justified astrocyte destruction was found within an especially by differences in wound area of hemorrhagic extravasation. (18); ballistics. The new military medecine nerve cells are shrunken; axons had been history has noticed a higher mortality rate: broken into tiny fragments (19), exhibiting

Romanian Neurosurgery (2010) XVII 4: 438 – 444 443

varicose changes and clumping. The extent of various medical therapies, ICP of traumatic could be remarked monitoring, prevention of infection, along the track from entry point to exit preservation of the nervous tissue, point by the temporary cavitation - a restoration of anatomical structures, with destruction zone of ca. 3.6 cm around the radical debridement (4) (9). Duration of permanent track, loss of glial fibrillary acid antiepileptics and antibiotics remains protein expression by astrocytes in the controversial, as does the use of white matter. (17) (18) hyperventilation, hypothermia, and steroids After CCGW frequently seen effects are: (9) (12). Use of jugular bulb catheters and neurodeficits, brain swelling with ICP rise, transcranial Doppler is institution- CSF leaks with severe infections, carotico- dependent (9). cavernous fistulas, pseudoaneurysms There are several predictors of poor correlated with morbidity and mortality outcome in CCGW, correlating with (3)(9-12). Many CCGW are incompatible morbidity and mortality (1-6) (8-15): with life, but moderately injured patients advanced age, high velocity missiles or more frequently are resuscitated and benefit fired from a very close range as in from aggressive treatment of secondary suicide attempts, admission CGS score 3 mechanisms of injury. There is and 4 (with mortality rates near 90% and considerable variability among rare satisfactory outcome), bilateral fixed neurosurgeons currently as to what dilated pupils with opac cornea, delayed and constitutes appropriate treatment of poor mode of transportation, apnea at CCGW (3) (4) (10): Raimondi and admission, associated injuries to chest, Samuelson (1970) noted the difference in abdomen and great vessels generating wound ballistics and offered a classification massive bleeding, haemodynamic instability scheme based on initial neurologic (hypotension), postoperative rise in ICP, assessment. Arendall and Meirowsky 1983 abnormal coagulation states on admission found that high mortality associated with or even DIC, CT visualization of diffuse penetrating wound of air sinuses can be brain damage, bihemispheric, bitentorial, reduced by prompt and radical debridment, multilobar missile track with lateral > Kaufman (14) appreciate the surgical midline sagittal planes trajectories made by debridement performed, the use of ICP high velocity bullets fired from a very close monitoring and various medical therapies, range, brain stem and ventricular injury, Helling et all 1992 found that early surgical ventricular and subarahnoid haemorrhage, intervention seemed to result in better vasospasm, mass effect and midline shift, survival, Gonul 1997, Singh 2003 acute or evidence of herniation and/or hematomas delayed CSF leak highly correlated with greater than 15 ml. intracranial infection (9) (12) Antibiotics Less harmful effects are generated by are no substitute for early surgical retained missiles, bone and hair debridment, a lower mortality rate reflects intraparenchymal fragments with CNS early and survivability decisions as infection, DAI lesions, pneumocephalus, much as treatment effectiveness (3) (13) and neuronal damages associated to CCGW treatment comprised of four cavitation, seizures (3) (9) (10) (13). stages: immediate saving of life by the use

444 C. Majer, G. Iacob Cranio-cerebral gunshot wounds

Conclusions Youmans Neurological Surgery, Editor: Winn H.R., 5th Edition Saunders, 2004, 5019-5024 Aggressive intensive care management in 8. Spaic M., Branislav A. – The lost race, Indian Journal combination with early management with of Neurotrauma 2009, 6, 1, 1-4 9. Rashid B.A et al. – Analysis of 3794 civilian less aggressive, meticulous, neurosurgical craniocerebral missile injuries – Results from 20 years technique, when appropriate, already has of Kashmir conflict, Pan Arab Journal of Neurosurgery, significantly reduced the mortality and 2010, 14,1, 24-32. 10. Meirowsky A.M. – Secondary removal of retained morbidity associated with these injuries, bone fragments in missile wounds of the brain, but they still remain unacceptably high . J.Neurosurg. 1982, 57, 617-621 Primary prevention of cranio-cerebral 11. Bakir A. et al. – High Velocity Gunshot Wounds to the head: analysis of 135 patients, Neurol. Med. Chir gunshot wounds remains important, the (Tokyo) 2005, 45, 281-287 patient must be monitored closely for 12. Erdogan E., Gonul E., Seber N. – Craniocerebral possible complications. With the increasing gunshot wounds, Neurosurg Q. 2002, 12, 1-18 13. Gonul E., Baysefer A., Kahraman S. Et al. – Causes numbers of firearms and firearm-related of infections and management results in penetrating violence in our society, discussing the issues craniocerebral injuries, Neurosurg. Rev. 1997, 20, 177- of violence with patients and offering 181 14. Kaufman H.H. – Civilian gunshot wounds to the appropriate intervention becomes the duty head, Neurosurg. 1993, 32, 962-964 of all health care providers. 15. Karger B. – Penetrating gunshots to the head and lack of immediate incapacitation, Wound ballistics and mechanisms of incapacitation, Int. J. Legal Med. 1995, References 108,(2), 53-61 1. Federico C Vinas - Penetrating Head Trauma: 16. Kim K.A., Wang M.Y., McNatt S.A. et al. - Vector Multimedia, May 27, 2009 Analysis Correlating Bullet Trajectory to Outcome after 2. Antic B., Spaic M. – Penetrating Craniocerebral Civilian Through-and-Through to the Injuries from the former Yugoslavia Battlefields, Ind. J. Head: Using Imaging Cues to Predict Fatal Outcome, Neurotrauma (IJNT), 2006, 3, 27-30 Neurosurgery, 2005: 737-747 3. Iacob M., Iacob G. – Plagi craniocerebrale prin arma 17. Oehmichen M., Meissner C., Konig H.G., Gehl H. de foc, Simpozionul de Neurochirurgie Cluj Napoca R. – Gunshot injuries to the head and brain caused by 1987 low velocity handguns and ; A. review, Forensic 4. Shaffrey M.E. et al. - Classification of civilian science international, Congrès European Congress of craniocerebral gunshot wounds: a multivariate analysis Neuropathology No7, Helsinki, Finlande, 2004, vol. predictive of mortality, J Neurotrauma. 1992 Mar; 9, 146, nr.2-3, 111-120. Suppl 1:S279-85. 18. Oehmichen M., Meissner C., Konig H.G. – Brain 5. Izci Y., Kayali H.,Daneyemez M., Koksel T. – Injury after Gunshot Wounding: Morphometric Comparison of clinical outcomes between Analysis of Cell Destruction Caused by temporary anteroposterior and lateral penetrating craniocerebral Cavitation, Journal of Neurotrauma. 2000, 17(2): 155- gunshot wounds, Emerg. Med. J. 2005, 22, 409-410 162. 6. Rosenfeld J.V. – Gunshot injury to the head and 19. Francisc A., Majer C., Iacob G. – Diffuse axonal spine, J. Clin. Neurosci 2002, 9, 9-16 injuries: clinical, neuroimaging and microscopic 7. Marshall L.F., Marshall S.B., Sean G.M. – Modern features- literature review, Romanian Journal of Legal neurotraumatology: a brief historical review, in Medicine, 2008, XVI, 3, 172-180