Characteristics of civilian head gunshot injuries in a country with low firearm related violence

Abstract

Head gunshot injuries in civilian settings are severe traumas associated with high morbidity and mortality. Most studies focus on populations from regions with high firearm violence, limiting their applicability to low-violence settings. This study investigates the characteristics, management, and outcomes of head gunshot injuries in the Czech Republic, a country with low firearm-related violence and a unique injury profile dominated by suicides. We analyzed a prospectively collected cohort of 100 patients treated for head gunshot injuries at a single center between 2000 and 2024. Inclusion criteria included civilian head gunshot injuries in patients aged ≥ 18 years, admitted with signs of life. Data collected included demographic characteristics, context of injury (suicide, assault, accident, law enforcement), firearm types (conventional, less-lethal, captive bolt guns), Glasgow Coma Scale (GCS) scores, imaging findings, surgical interventions, and outcomes. Statistical analyses included Chi-square, Mann-Whitney tests, Kaplan-Meier survival analysis, and Cox regression modeling. Of 100 patients (94% male, mean age 50.0 years), 81% sustained injuries from suicide attempts. Conventional firearms caused 74% of injuries, while less-lethal guns (21%) and captive bolt guns (15%) contributed significantly. The mean GCS on admission was 6.35, with 65% of patients presenting with a GCS of 3. Penetrating injuries occurred in 58% of cases. Surgical intervention was performed in 27 patients (27%) and was associated with lower mortality (25.9% vs. 75.3%, p < 0.001). Overall survival varied significantly by firearm type, with less-lethal gun injuries showing improved outcomes (30-day mortality: 19.0%; mean survival: 2634 days). Suicidal injuries had worse outcomes compared to other contexts (30-day mortality: 70.4% vs. 26.3%, p < 0.001). In this low-violence setting, firearm-related suicides dominate head gunshot injuries, with a notable prevalence of less-lethal guns and captive bolt guns. The study highlights the importance of regional variations in injury patterns and outcomes, underscoring the need for tailored clinical guidelines and public health interventions to address specific demographic and cultural contexts.

Keywords: Ballistic trauma; Civilian gunshot wounds; Firearm-related violence; High-velocity injuries; Low-velocity injuries; Penetrating head injury; Traumatic brain injury.

Fig. 1

Kaplan-Meier survival analysis comparing survival between individuals with suicide as the context of injury (purple) and others (yellow).

Fig. 2

Kaplan-Meier survival analysis comparing survival between groups categorized by type of firearm: conventional firearms (red), captive bolt guns (blue), and less-lethal guns (green).

Fig. 3

A 3D CT reconstruction demonstrating a typical penetrating craniocerebral gunshot injury sustained during a suicide attempt. (a) Entrance wound characterized by a small, circular defect in the right temporal region, accompanied by a displaced skull fracture. (b) Exit wound in the left temporoparietal region, surrounded by comminuted fractures with radiating fracture lines. (c) Axial CT slice showing the wound track of a 9 mm projectile crossing the midline, with extensive hemorrhage involving critical deep structures and extending into the occipital horns of the lateral ventricles. (We express our gratitude to the Editor-in-Chief of Czech and Slovak Neurology and Neurosurgery for kindly granting permission to include Fig. 3 in this manuscript, which was previously published in their journal.