Surviving the Scene in Civilian Penetrating Brain Injury: Injury Type, Cause and Outcome in a Consecutive Patient Series in Austria

Abstract

Background: Penetrating brain injury (PBI) is a heterogeneous condition with many variables. Few data exist on civilian PBI. In some publications, PBI differentiation between low-velocity injury (LVI) and high-velocity injury (HVI) is made, but exact definitions are not given yet. The incidence of PBI depends heavily on the country of origin. Furthermore, captive bolt pistol (CBP) injuries represent a rare type of LVI and almost no reports exist in the human medical literature. Treatment of PBI has been controversially discussed due to high morbidity and mortality with results varying considerably between series. Prognostic factors are of utmost importance to identify patients who presumably benefit from treatment.

Methods: A retrospective, single-center analysis of a consecutive patient series was performed from September 2005 to May 2018. We included all patients with PBI who reached our hospital alive and received any neurosurgical operative procedure.

Results: Of 24 patients, 38% died, 17% had an unfavourable outcome, and 46% had a favourable outcome. In total, 58% of patients with PBI were self-inflicted. Leading causes of injury were firearms, while captive bolt pistols were responsible for 21% of injuries. LVI represented 54%, and HVI represented 46%. The outcome in HVI was significantly worse than that in LVI. A favourable outcome was achieved in 69% of LVI and 18% of HVI. Low GCS and pathological pupillary status at admission correlated significantly with an unfavourable outcome and death.

Conclusions: PBI is a heterogeneous injury with many variables and major geographical and etiological differences. Differentiation between LVI and HVI is crucial for decision-making and predicting outcomes. In patients presenting with object trajectories crossing the midline, no favourable outcome could be achieved. Nevertheless, in total, a favourable outcome was possible in almost half of the patients who succeeded in surgery.

Keywords: firearm injury; high velocity; low velocity; penetrating brain injury; traumatic brain injury.

Figure 1

(A) Low-velocity injury (LVI). (B) Accidental nailgun injury; note that there are no signs of parenchymal damage surrounding the nail. (C,D) Captive bolt pistol injury. Note the pathognomic finding with a wide hemorrhagic wound canal and corresponding bone fragment at the end of the canal with the absence of metallic fragments or exit sites (–21).

Figure 2

High-velocity injury (HVI); self-inflicted gunshot wound; (left) bilateral trajectory on CCT, (right) muzzle stamp.