Craniocerebral Gunshot Injuries; A Review of the Current Literature

Abstract

Craniocerebral gunshot injuries (CGI) are increasingly encountered by neurosurgeons in civilian and urban settings. Unfortunately, more prevalent condition in developing countries, with major armed conflicts which is still persisting, since the main trigger is violence at the national or state level. Management goals of CGI should focus on aggressive resuscitation and correction of coagulopathy; those with stable vital signs should undergo CT scan head at the earliest possible opportunity. Neuroimaging is vital for planning of surgical management, especially to determine the type of surgery, routes of the approach to the surgical target area and extraction of the impacted foreign bodies, however, surgical management is not always indicated. Although subset of such cases may be managed even with non-surgical management. The treatment comprises of immediate life salvaging resuscitative measures including control of the persistent bleeding, care of associated injury, management of raised intracranial pressure, prevention of cerebrospinal fistula formation by primary watertight dural repair and prevention of infection, through extensive debridement of contaminated, macerated or ischemic tissues; preservation of nervous tissue and restoration of anatomic structures through the hermetic sealing of dural and scalp defect. Recently, only few studies of craniocerebral penetrating injuries are published that too involving smaller patients sample sizes; although classic studies in the military and civil situation noticed associated relatively very high mortality and morbidity and psychological as well as economic impact on the affected individual, the family and the health system in providing ongoing care to the sufferers and society at large. Currently various measures are advocated with aim to reduce the incidence of CGI especially in civilian populations. It is highly necessary and immensely urgent to promote research in a neurocritical care of CGI to provide positive impact on improvement of the quality of life and further providing better care and reduction of overall health care cost.

Keywords: Craniocerebral gunshot injuries; Management; Neurotrauma; Outcome; Penetrating head injury; Prognosis.

Fig. 1

Simple brain CT scan in a case of CGI A. multiple shrapnel from the left region to the right parieto-occipital region, accompanied by subdural hematoma, cerebral edema and ventricular collapse. B. CT bone window, right frontal fracture, accompanied by multiple intracranial shrapnel

Fig. 2

Management guideline for craniocerebral gunshot injury (Adopted from Tsuei YS, Sun MH, Lee HD, Chiang MZ, Leu CH, Cheng WY, et al. Civilian gunshot wounds to the brain. J Chin Med Assoc. 2005 Mar;68(3):126-30).

Fig. 3

Adult male victim of CGI during assault; patient received prompt transfer to our emergency service, receiving vigorous resuscitation despite GCS of 5 (E1V2M2) and emergent damage control neurosurgery. A. Image showing the inlet hole of CGI in left parietal region with perilesional tissue devitalization. B. comminuted left skull associated to dural tear, brain laceration and output of macerated brain parenchyma. C. Postoperative image of subtotal left fronto-parietal lobectomy with drain of left intraparenchymal hemorrhage; also evidence a blunt and congestive hemisphere. D. Incisional raffia with Corachan points