Surg Neurol 1991;35:455-60
455
Penetrating Craniocerebral Missile Injuries in Civilians: A Retrospective Analysis of 314 Cases D. Siccardi, M.D., R. Cavaliere, M.D., A. Pau, M.D., F. Lubinu, M.D., S. Turtas, M.D., and G. L. Viale, M.D. Departments of Neurosurgery and Forensic Medicine, University of Genoa, Genoa, and University of Sassari, Sassari, Italy
Siccardi D, Cavaliere R, Pau A, Lubinu F, Turtas S, Viale GL. Penetrating craniocerebral missile injuries in civilians: a retrospective analysis of 314 cases. Surg Neurol 1991;35:455-60. Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0 - 3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases. KEY WORDS: Brain injury; Gunshot wounds; Glasgow Coma Scale; Glasgow Outcome Scale
Penetrating craniocerebral injuries in civilians are usually inflicted by small-caliber, low-velocity bullets, with a lower destructive p o w e r compared with high-velocity missiles fired from military guns. Assuming that civilian wounds tend to be less severe [5,7,11,15,18,27,28,30], an aggressive approach to these lesions might result in saving m o r e lives and preserving m o r e neurological functions [18,26]. In this regard, a n u m b e r of reports d o c u m e n t e d relatively high survival rates among operated patients [ 17,18,2 8]. It has been reported, however, that most o f the victims of penetrating gunshot wounds to the brain die on the scene or soon after the injury [6,18]. T h e purpose of the present report is to analyze the o u t c o m e in two consecutive series o f cases referred, dead or alive, to two different university hospitals.
Address reprint requests to: D. Siccardi, M.D., Clinica Neurochirurgica dell'Universit~t, Ospedale S. Martino, Pad.2, V.le Benedetto XV/10, 1-16132 Genoa, Italy. Received January 10, 1990; accepted October 30, 1990.
© 1991 by ElsevierSciencePublishingCo., Inc.
Clinical Material Two consecutive series of victims of missile injuries of the brain, composed, respectively, of 258 and 56 cases, represent the material for this report. In all cases the wounds were directly inflicted to the brain by penetrating missiles fired from guns, and there was evidence of intracranial space-occupying lesions on c o m p u t e d tomography (CT) scans or at autopsy. Patients presenting with lesions produced by either tangential impacts or scatter loads not penetrating into the brain were excluded from the series. Most o f the patients came from outside of town, with evacuation from the scene having occurred via ambulance or helicopter. Patients admitted alive to the emergency wards underwent vigorous resuscitation treatment. T h e victims who died on the scene, or who were found dead on arrival, were admitted to the mortuary r o o m s of the Forensic Institutes of the universities o f G e n o a and Sassari. Surgical treatment was done as soon as possible in those patients who maintained a score o f at least 4 on the Glasgow C o m a Scale (GCS) at the m o m e n t of decisionmaking, after emergency m a n a g e m e n t and radiological evaluation. Surgery consisted of debridement of necrosed brain, removal of readily accessible in-driven bone fragments and foreign bodies, evacuation of hematomas, accurate hemostasis, and watertight closure of the dura mater. Epidural or intraventricular recording of the intracranial pressure was p e r f o r m e d in several of the operated cases and in a few of the conservatively treated cases, with the decision to p e r f o r m this procedure usually dependent upon the judgment of the neurosurgeon in attendance. Most o f the operations started within 6 hours following injury, with the delay of surgical treatment being generally related to the time spent in referral from peripheral hospitals. T h e outcome of the survivors was assessed 3 - 6 months after injury, according to the expanded Glasgow O u t c o m e Scale (GOS) [16]. For the purpose of the present report, patient history, clinical findings, x-ray films, CT scans, and autopsy records were reexamined. Circumstances surrounding the wound and information about weapons and cartridges 0090-3019/91/$3.50
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Siccardi et al
Table 1. Summary of the Series of 314 Cases Self-inflicted
Accidental or unknown
Assaults
Age (yr)
No. cases
M
F
M
F
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
2 13 61 52 51 52 30 38 15
--
314
l 2 17 14 14 9 3 2 -62
1 2 4 5
Totals
-~ 4 2 4 1 1 2 l 18
3 32 29 28 39 22 32 14 199 217
M
F
.
.
3 4 2 1 2 3 2
-1 --16
Survived Op .
---i 1 ---2
17
.
No-op
Op
No-op
----------
1 4 3 1 3 1 5 -18
ll 48 43 45 47 27 33 14 270
.
1 9 6 5 2 2 -1 26
19
78
Died
2
26
288
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
three to four lobes of the same hemisphere, carried a significantly worse outcome (Table 5) compared with single-lobe lesions (p < 0.001 and p < 0.02, respectively, Fisher's exact test). Most of the injuries caused by small-caliber missiles, including those fired from the unloaded, primer-activated Flobert* cartridges, crossed the midline when shot point-blank, as in the cases of attempted suicides (Table 6). Wounds inflicted by smooth bore shotguns, often fired at very close range, usually caused devastating effects and were immediately lethal (Table 2). In the presence of hemorrhagic ventricular injuries, the mortality rate was significantly higher
were usually obtained by law enforcement officers and reported, when available, on the medical records. Results Age and sex of the victims, circumstances surrounding the wound, and overall mortality are reported in Tables 1 and 2. Out of the 288 patients who succumbed to their injury, 228 died on the scene and a further 38 within 3 hours (Table 3). Although self-inflicted injuries carried a higher mortality compared with lesions resulting from assaults (95 % and 88%, respectively), the difference was not statistically significant (Fisher's exact test). Suicide attempts had a high degree of success in both sexes (Tables 1 and 3). The overall mortality rate was significantly higher (p < 0.01, Fisher's exact test) in patients older than 49 years. There was no statistically significant difference in the mortality rate when comparing bullets of a caliber of 7.65 mm or less with heavier missiles (Table 4). Bilateral lesions, resulting from trajectories crossing the midline, as well as sagittal lesions involving
* Flobert a m m u n i t i o n : the nearly r o u n d - n o s e d , l o w - v e l o c i t y bullet, usually c o m p o s e d o f straight lead, is p r o p e l l e d by the p r i m i n g mixture inserted into the p r i m e r rim at the b o t t o m o f the cartridge, which is not l o a d e d with p o w d e r . This rim-fire c a r t r i d g e (also k n o w n as " B B cap" or b u l l e t e d breech-cap) was originally d e v e l o p e d , as an i m p r o v e m e n t to the pin-fire cartridge, by the Parisian gunsmith Nicolas F l o b e r t ( 1 8 1 9 - 1 8 9 4 ) in the 1850s for i n d o o r target service, and is p r o d u c e d in several calibers ranging up to 9 mm. The cartridge issued today in Europe, as 5 . 6 - m m (.22 in) or 6 . 3 5 - m m (.25 in) g a l l e r y a m m u n i t i o n , has a soft copper case, and the fulminate of the primer is still the only propellant, p r o v i d i n g all the p o w e r n e c e s s a r y to d r i v e the b u l l e t out.
Table 2. Summary of the Penetrating Craniocerebral Wounds Caused by Missiles Fired by Handguns or Smooth Bore Shotguns Self-inflicted Weapon Handguns Single-bullet ammunition Shotguns Scatterqoaded cartridges Totals
Accidental or u n k n o w n
Assaults
Survived
Died
No. cases
M
F
M
F
M
F
Op
No-op
Op
No-op
234
144
17
44
16
11
2
18
--
15
201
80 314
55 199
I 18
18 62
-16
6 17
-2
8 26
---
3 18
69 270
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
Craniocerebral Missile Injuries
Surg Neurol 1991;35:455-60
Table 5. Involvement of Cerebral Lobes
Table 3. Time of Death After Injury Selfinflicted Died
No. cases
On the scene Within 3 h Within 24 h After 24 h Totals
228 38 7 15 288
457
Accidental or unknown
Assaults
No. Selfcases inflicted
Lesions M
F
M
F
M
F
156 22 3 8
12 4 -1
43 8 1 2
11 3 -1
5 1 3 3
1 ----
206
69
Survived Died Accidental or NoNoAssaults u n k n o w n O p op O p op
Bilateral Unilateral 1 lobe 2 lobes 3-4 lobes
166
125
38
3
6
--
8
152
52 29 67
29 14 49
14 12 14
9 3 4
12 6 2
----
8 1 1
32 22 64
13 Abbreviations: No-op, no operation; Op, operation.
Abbreviations: F, female; M, male.
Fisher's exact test). There was no significant difference in the outcome between patients who were and who were not submitted to postoperative measurement of intracranial pressure.
(p < 0.004, Fisher's exact test) than that in the remaining patients. On the contrary, there was no statistically significant difference as to lethality between patients with or without intracranial extraparenchymal hematomas (Table 7). There were 26 survivors among 44 operated patients (Tables 1 and 8). Of those, 12 had presented with a lesion involving a single cerebral lobe, six with bilateral lesions, and eight with unilateral lesions affecting two or more lobes (Table 9). None of the patients who were operated on with a score of 4-5 on the GCS survived their injuries (Table 10). Of the 10 good recoveries (score of 0-1 on the GOS), eight occurred in patients with a preoperative score of 13-15 on the GCS and six in patients with a single-lobe lesion (Tables 9 and 10). Moderate to severe disabilities were present in surviving patients who had been operated upon with a GCS score of 6-8. None of the survivors was vegetative. Comparing the subgroup with a preoperative GCS score of 9-15 with those ranging from 4 to 8, there was a statistically significant difference in the survival-death ratio (p 0.0001, Fisher's exact test). This difference still existed when the subgroup with a GCS score of 9-15 was compared with the subgroup with a GCS score of 6-8, excluding the patients with the score of 4-5 (p < 0.002,
Discussion The series reported herein can be regarded as highly representative of events occurring in definite geographical areas, with the University Medical Centers of Genoa and Sassari being the only academic, and also the largest, hospitals, respectively, in the northwestern region of Liguria, on the Italian peninsula, as well as in the northern provinces of the mediterranean island Sardinia. Despite their different demographic, socioeconomic, and cultural backgrounds, Liguria and Sardinia share a high rate of attempted suicides and crime. The present results unequivocally document an early lethality of penetrating missile injuries of the brain, heightening the already sinister reputation of these lesions [5,8,11,13, 20-22,25]. Of all the patients who died, 79% were dead on the scene and a further 13% died within 3 hours after injury. These figures are consistent with the findings of a previous series in which 71% of fatally injured civilians with craniocerebral gunshot wounds were dead at the
Table 4. Summary of the Series of 107 Patients with Wounds Inflicted by a Single Bullet of a Known Caliber Self-inflicted Caliber
No. cases
M
Flobert .22 l.r. 6.35 (.25ACP) 7.65 (.32ACP) .32 S & W 9 short (.380ACP) 9ultra(9 × 18) 9 para (Luger) .38 special
5 14 19 46 1 8 1 5 8
5 7 12 27 1 6 1 -4
F .
M .
M .
4 1 8 .
2 . -1
F .
1 3 3 .
Accidental or u n k n o w n
Assaults
. . .
. . 4 2
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
. .
.
.
Op
No-op
Op
No-op
4 3 6
----
2 -1 6
--
--
3 10 15 34 1 7 1 5 8
.
. 1
. . .
. . .
Died
. ---.
. .
1 1
F
. -2 5
2 1 3
Survived
. . .
. . .
. .
458
Surg Neurol 1991;35:455-60
Siccardi et al
Table 6. Involvement of Cerebral Lobes in 107 Patients with Wounds Inflicted by a Single Bullet of a Known Caliber Self-inflicted
Assaults
Unilateral
I lobe
Bilateral
Caliber
2 lobes
Unilateral
~ - 4 lobes
5 4
4
--
--
4
2
.
6.35
13
2
--
--
1
I
--
7.65
22
7
1 --
9 para
.
.38 s p e c i a l
.
.
.
.
.
.
1
--
7.
m
2
--
2
1
. .
.
.
.
2
--
--
3
--
--
--
~
--
--
2
--
--
--
--
Associated F i n d i n g s Survived Died Accidental - No. Selfor NoNocases i n f l i c t e d A s s a u l t s u n k n o w n O p o p O p op
among patients submitted to surgery with a preoperative score of 4 - 5 . Death has been reported as the invariable outcome in the presence of a GCS score of 3, whether or not surgery was performed [7], and rejection of any type of treatment has been recommended in cases with fixed pupils on admission [29]. The management of patients with a GCS score of 4 - 5 is controversial, ranging from simple scalp wound debridement to extensive intracranial surgery. The present results did not provide evidence of the effectiveness of surgery in these situations. However, taking into account the occurrence of occasional survivals following either surgical or conservative treatment [18], the question as to the optimal management of deeply comatose patients remains unsettled. The survival rate of patients submitted to surgery with a preoperative GCS score ranging from 6 to 15 was 70%, with adequate recoveries (score o f 0 - 3 on the GOS) occurring in 73% of the survivors. These figures are consistent with the assumption that vigorous resuscitation and early surgery often result in useful survivals and occasionally in spectacular recoveries. Though advanced age, extensive involvement of the brain, ventricular injury, and severe impairment of consciousness represented negative prognostic factors, their occurrence alone did not necessarily prevent a favorable outcome. Even in the concomitant presence of all these negative factors, possibilities of survival still existed. One of the
Table 8. Time of Operation After Injury and Outcome
Intraventricular hemorrhage
2 .
.
3 - 4 lobes
.
--
.
.
2 lobes
. .
. .
.
scene and a further 14% died within 5 hours [18]. As shown by others [3,7,13,18,19,23,24,29J self-inflicted wounds in the present series carried a high degree of fatality (95%), even when the lesions were caused by small-caliber missiles traveling at very low speed, as in the case of the Flobert cartridges. A lower, though statistically not significant, fatality rate (88%) occurred in patients with injuries resulting from assaults. Most of them were the result of premeditated homicidal attempts and did not substantially differ, in severity of the lesions and in outcome, from self-inflicted wounds. In this regard, one can assume that both firing at close range and taking careful aim represent major factors as to the immediate effects of the shot. It is known that the energy imparted to the head by penetrating missiles is primarily dependent on their velocity and mass, with the missile track within the brain being also related both to design and configuration of the projectile, as well as to distance of firing and orientation of the weapon [2,9,10,12, 14,19]. It is, therefore, not surprising that in the present series, although several devastating lesions were produced by heavy bullets, there was no constant relationship between caliber and degree of involvement of cerebral structures. There were no survivors among patients treated conservatively with a GCS score of 3, as well as
Table
. .
2
.
1 lobe
Bilateral
--
.
.
. .
2 .
.
.
~ - 4 lobes
.
2 .
.
.
.
5
. 1
1
.
--
. 1
2
.
1
.
6
9 ultra
.
Unilateral
2 lobes
.221.r.
9 short
.
l lobe
Bilateral
Flobert
.32 S & W
.
Accidental/unknown
No. cases
Selfinflicted
135
93
36
6
3
--
9
123
Operation
53
30
17
6
6
--
6
41
Within 3 h
2
1
1
Within 6 h
33
13
11
9
4
--
44
18
12
Assaults
Accidental or unknown
Survived
Died
Sub/epidural hematomas Other body areas
28
3
24
1
28
After 6 h Totals
Abbreviations: No-op, no operation; op, operation.
-9
1
1
19
14
5
6
3
14
26
18
Craniocerebral Missile Injuries
Surg Neurol 1991;35:455-60
Extension of the Cerebral Lesion and Outcome in the Operated Patients
T a b l e 9.
Survived Glasgow Outcome Scale Lesions Bilateral Unilateral 1 lobe 2 lobes 3 - 4 lobes
No. cases
O- I
2 -3
4-5
Died
14
2
2
2
8
20 7 3
6 2 --
5 2 --
1 2 2
8 1 1
patients of this series, an 81-year-old man who attempted suicide, was admitted with a score of 6 on the GCS and presented with a lesion crossing the midline and producing massive intraventricular hemorrhage. He survived his injury, though he is severely disabled. The current series was exclusively composed of patients with cerebral injuries directly inflicted by penetrating missiles that had created permanent tracks sustaining mass displacements of various degrees. There is evidence that these lesions fare much worse than do shrapnel or tangential wounds [4]. It is our firm belief, in this regard, that a realistic evaluation of the effects of gunshot wounds in civilians should be focused on direct injuries in order to avoid conclusions resulting from a combination of heterogeneous and even trivial lesions. Management limited to local wound care was regarded as unsuitable in the cases reported here, with intracranial debridement having been excluded only in patients admitted moribund. Limited surgery has been advocated in a number of penetrating injuries of the brain, with emphasis on both preservation of viable cerebral tissue and lack of correlation between retained fragments and abscess formation [1,4,29]. In the present series, while no attempt was made to search for retained fragments, unless readily accessible, removal of necrosed tissue and clot was as extensive as needed in order to obtain a significant volumetric reduction of the space-occupying lesions. To the best of our knowledge, no elements
State of Consciousness Before Surgery and Outcome of the Operated Patients
T a b l e 10.
Survived
GCS 13-15 9-12 6-8 4-5
GOS No. SelfAccidental cases inflicted Assaults or unknown 0-1 2-3 4-5 Died 16 9 12 7
7 2 6 3
5 4 2 1
4 3 4 3
8 2 --
4 3 2
3 2 2
1 2 8 7
Abbreviations: GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale.
459
emerge from the literature, suggesting that a more conservative attitude might have improved the outcome. Most of our patients were referred from peripheral hospitals and were often transferred by ground transportation. Their neurological condition at arrival may have also been dependent on effectiveness of first aid at the place of injury and adequacy of the conditions of referral. Whether improvement of these factors might result in a reduction of the number of patients in hopeless conditions on arrival remains a matter of speculation. The high mortality rate on the scene or soon after the injury drastically reduces the possibilities of effective management of brain injuries inflicted by penetrating missiles in civilians. Reports of series entirely or mainly composed of operated patients can be misleading because they document relatively high survival rates, not too far from those resulting from surgery of closed brain injuries. These figures, however, actually refer to a scant fraction of the victims. The authors thank Sergio Deseri for his excellent technical assistance.
References 1. Aarabi B. Causes of infections in penetrating head wounds in the Iran-Iraq war. Neurosurgery 1989;25:923-6. 2. Bakay L. Missile injuries of the brain. NY State J Med 1982;3:313-9. 3. Brandt F, Roosen K, Weiler G, Grote W. Die neurochirurgische Behandlung von Kopfschussverletzungen. Neurochirurgia 1983;26:164-71. 4. Brandvold B, Levi L, Feinsod M, George ED. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985. J Neurosurg 1990;72:15-21. 5. Byrnes DP, Crockard HA, Gordon PS, Gleadhill CA. Civilian penetrating craniocerebral missile injury in the civil disturbance in Northern Ireland. Br J Surg 1974;61:169-76. 6. Cavaliere R, Cavenago L, Siccardi D, Viale GL. Gunshot wounds of the brain in civilians. Acta Neurochir (Wien) 1988;94:133-6. 7. Clark WC, Muhlbauer MS, Watridge CB, Ray MW. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986;65:9-14. 8. Cooper PR. Gunshot wounds of the brain. Contemp Neurosurg 1983;6:1-6. 9. Crockard HA. Bullet injuries of the brain. Ann R Coil Surg Engl 1974;55:111-23. 10. George ED, Dagi TF. Penetrating injuries of the head. In: Schmidek HH, Sweet W H (eds). Operative neurosurgical techniques. Volume 1, ed 2. Philadelphia: WB Saunders, 1988:49-55. 11. HammonWM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971;34:127-31. 12. Harsh GR III, Harsh GR IV. Penetrating wounds of the head. In: Wilkins RH, Rengachary SS (eds). Neurosurgery. Volume 3. N e w York: McGraw-Hill, 1985:1670-8. 13. Hernesniemi J. Penetrating craniocerebral wounds in civilians. Acta Neurochir (Wien) 1979;49:199-205. 14. Hopkinson DAW, Marshall TK. Firearm injuries. Br J Surg 1967;54:344-53.
460
Surg N e u r o l 1991;35:455-60
15. Hubschmann O, Shapiro K, Baden M, Shulman K. Craniocerebral gunshot injuries in civilian practice. Prognostic criteria and surgical management: experience with 82 cases. J Trauma 1979;19:6-12. 16. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiatry 1981;44:285-93. 17. Kaufman HH, Loyola WP, Makela ME, Frankowsky RF, Wagner KA, Bustein DP, Gildenberg PC. Civilian gunshot wounds: the limit of salvageability. Acta Neurochir (Wien) 198:~;67: 115-25. 18. Kaufman HH, Makela ME, Lee KF, Haid RWJr. Gunshot wounds to the head: a perspective. Neurosurgery 1986;18:689-95. 19. KirkpatrickJB, Di Maio V. Civilian gunshot wounds of the brain. J Neurosurg 1978;49:185-98. 20. Lausberg G. Schadelschussverletzungen in Friedenszeit. Acta Neurochir (Wien) 1965;13:317-43. 21. Lillard PL. Five years' experience with penetrating craniocerebral gunshot wounds. Surg Neurol 1978;9:78-83. 22. Meirowski AM. Penetrating craniocerebral trauma. JAMA 1954;154:666-9. 23. Miner ME, CabreraJA, Ford E, Ewing-Cobbs L, AmlingJ. lntra-
Siccardi et al
cranial penetration due to BB air rifle iniuries. Neurosurgery 1986;19:952-4. 24. Nagib MG, Rockswold GL, Sherman RS, Lagaard MW. Civilian gunshot wounds to the brain: prognosis and management. Neurosurgery 1986;18:533-7. 25. Raimondi AJ, Samuelson GH. Craniocerebral gunshot wounds in civilian practice. J Neurosurg 1970;32:647-53. 26. Saba MI. Surgical management of gunshot wounds of the head. In: Schmidek HH, Sweet WH {eds). Operative neurosurgical techniques. Volume 1, ed 2. Philadelphia: WB Saunders, 1988: 37-48. 27. Seidel BU, Volgelsang H, Galanski M. Computertomographische Befunde und Verlaufskontrollen bei Schadel-Hirn-Schussverletzungen. Neurochirurgia 1983;26:172-6. 28. Shoung HM, SichezJP, Pertuiset B. The early prognosis ofcraniocerebral gunshot wounds in civilian practice as an aid to the choice of treatment. A series of 56 cases studied by the computerized tomography. Acta Neurochir (Wien) 1983;74:27-30. 29. Suddaby L, Weir B, Forsyth C. The management of .22 caliber gunshot wounds of the brain. A review of 49 cases. Can J Neurol Sci 1987;14:268-72. 30. Yashon D, Jane JA, Martonfly D, White RJ. Management of civilian craniocerebral bullet injuries. Ann Surg 1972;38:346-51.
455
Penetrating Craniocerebral Missile Injuries in Civilians: A Retrospective Analysis of 314 Cases D. Siccardi, M.D., R. Cavaliere, M.D., A. Pau, M.D., F. Lubinu, M.D., S. Turtas, M.D., and G. L. Viale, M.D. Departments of Neurosurgery and Forensic Medicine, University of Genoa, Genoa, and University of Sassari, Sassari, Italy
Siccardi D, Cavaliere R, Pau A, Lubinu F, Turtas S, Viale GL. Penetrating craniocerebral missile injuries in civilians: a retrospective analysis of 314 cases. Surg Neurol 1991;35:455-60. Analysis of 314 cases of penetrating craniocerebral missile injuries in civilians revealed a high rate of early mortality, with 228 victims having died at the scene and a further 38 dead within 3 hours. Surgery was performed in 44 patients who had a preoperative Glasgow Coma Score of at least 4. Out of the 26 survivors, all operated upon, 19 had an adequate recovery (score of 0 - 3 on the expanded Glasgow Outcome Scale). Vigorous resuscitation and early surgery often resulted in useful survivals and occasionally in spectacular recoveries. However, the high mortality rate on the scene or soon after the injury restricted the possibility of effective management to a minority of cases. KEY WORDS: Brain injury; Gunshot wounds; Glasgow Coma Scale; Glasgow Outcome Scale
Penetrating craniocerebral injuries in civilians are usually inflicted by small-caliber, low-velocity bullets, with a lower destructive p o w e r compared with high-velocity missiles fired from military guns. Assuming that civilian wounds tend to be less severe [5,7,11,15,18,27,28,30], an aggressive approach to these lesions might result in saving m o r e lives and preserving m o r e neurological functions [18,26]. In this regard, a n u m b e r of reports d o c u m e n t e d relatively high survival rates among operated patients [ 17,18,2 8]. It has been reported, however, that most o f the victims of penetrating gunshot wounds to the brain die on the scene or soon after the injury [6,18]. T h e purpose of the present report is to analyze the o u t c o m e in two consecutive series o f cases referred, dead or alive, to two different university hospitals.
Address reprint requests to: D. Siccardi, M.D., Clinica Neurochirurgica dell'Universit~t, Ospedale S. Martino, Pad.2, V.le Benedetto XV/10, 1-16132 Genoa, Italy. Received January 10, 1990; accepted October 30, 1990.
© 1991 by ElsevierSciencePublishingCo., Inc.
Clinical Material Two consecutive series of victims of missile injuries of the brain, composed, respectively, of 258 and 56 cases, represent the material for this report. In all cases the wounds were directly inflicted to the brain by penetrating missiles fired from guns, and there was evidence of intracranial space-occupying lesions on c o m p u t e d tomography (CT) scans or at autopsy. Patients presenting with lesions produced by either tangential impacts or scatter loads not penetrating into the brain were excluded from the series. Most o f the patients came from outside of town, with evacuation from the scene having occurred via ambulance or helicopter. Patients admitted alive to the emergency wards underwent vigorous resuscitation treatment. T h e victims who died on the scene, or who were found dead on arrival, were admitted to the mortuary r o o m s of the Forensic Institutes of the universities o f G e n o a and Sassari. Surgical treatment was done as soon as possible in those patients who maintained a score o f at least 4 on the Glasgow C o m a Scale (GCS) at the m o m e n t of decisionmaking, after emergency m a n a g e m e n t and radiological evaluation. Surgery consisted of debridement of necrosed brain, removal of readily accessible in-driven bone fragments and foreign bodies, evacuation of hematomas, accurate hemostasis, and watertight closure of the dura mater. Epidural or intraventricular recording of the intracranial pressure was p e r f o r m e d in several of the operated cases and in a few of the conservatively treated cases, with the decision to p e r f o r m this procedure usually dependent upon the judgment of the neurosurgeon in attendance. Most o f the operations started within 6 hours following injury, with the delay of surgical treatment being generally related to the time spent in referral from peripheral hospitals. T h e outcome of the survivors was assessed 3 - 6 months after injury, according to the expanded Glasgow O u t c o m e Scale (GOS) [16]. For the purpose of the present report, patient history, clinical findings, x-ray films, CT scans, and autopsy records were reexamined. Circumstances surrounding the wound and information about weapons and cartridges 0090-3019/91/$3.50
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Table 1. Summary of the Series of 314 Cases Self-inflicted
Accidental or unknown
Assaults
Age (yr)
No. cases
M
F
M
F
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
2 13 61 52 51 52 30 38 15
--
314
l 2 17 14 14 9 3 2 -62
1 2 4 5
Totals
-~ 4 2 4 1 1 2 l 18
3 32 29 28 39 22 32 14 199 217
M
F
.
.
3 4 2 1 2 3 2
-1 --16
Survived Op .
---i 1 ---2
17
.
No-op
Op
No-op
----------
1 4 3 1 3 1 5 -18
ll 48 43 45 47 27 33 14 270
.
1 9 6 5 2 2 -1 26
19
78
Died
2
26
288
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
three to four lobes of the same hemisphere, carried a significantly worse outcome (Table 5) compared with single-lobe lesions (p < 0.001 and p < 0.02, respectively, Fisher's exact test). Most of the injuries caused by small-caliber missiles, including those fired from the unloaded, primer-activated Flobert* cartridges, crossed the midline when shot point-blank, as in the cases of attempted suicides (Table 6). Wounds inflicted by smooth bore shotguns, often fired at very close range, usually caused devastating effects and were immediately lethal (Table 2). In the presence of hemorrhagic ventricular injuries, the mortality rate was significantly higher
were usually obtained by law enforcement officers and reported, when available, on the medical records. Results Age and sex of the victims, circumstances surrounding the wound, and overall mortality are reported in Tables 1 and 2. Out of the 288 patients who succumbed to their injury, 228 died on the scene and a further 38 within 3 hours (Table 3). Although self-inflicted injuries carried a higher mortality compared with lesions resulting from assaults (95 % and 88%, respectively), the difference was not statistically significant (Fisher's exact test). Suicide attempts had a high degree of success in both sexes (Tables 1 and 3). The overall mortality rate was significantly higher (p < 0.01, Fisher's exact test) in patients older than 49 years. There was no statistically significant difference in the mortality rate when comparing bullets of a caliber of 7.65 mm or less with heavier missiles (Table 4). Bilateral lesions, resulting from trajectories crossing the midline, as well as sagittal lesions involving
* Flobert a m m u n i t i o n : the nearly r o u n d - n o s e d , l o w - v e l o c i t y bullet, usually c o m p o s e d o f straight lead, is p r o p e l l e d by the p r i m i n g mixture inserted into the p r i m e r rim at the b o t t o m o f the cartridge, which is not l o a d e d with p o w d e r . This rim-fire c a r t r i d g e (also k n o w n as " B B cap" or b u l l e t e d breech-cap) was originally d e v e l o p e d , as an i m p r o v e m e n t to the pin-fire cartridge, by the Parisian gunsmith Nicolas F l o b e r t ( 1 8 1 9 - 1 8 9 4 ) in the 1850s for i n d o o r target service, and is p r o d u c e d in several calibers ranging up to 9 mm. The cartridge issued today in Europe, as 5 . 6 - m m (.22 in) or 6 . 3 5 - m m (.25 in) g a l l e r y a m m u n i t i o n , has a soft copper case, and the fulminate of the primer is still the only propellant, p r o v i d i n g all the p o w e r n e c e s s a r y to d r i v e the b u l l e t out.
Table 2. Summary of the Penetrating Craniocerebral Wounds Caused by Missiles Fired by Handguns or Smooth Bore Shotguns Self-inflicted Weapon Handguns Single-bullet ammunition Shotguns Scatterqoaded cartridges Totals
Accidental or u n k n o w n
Assaults
Survived
Died
No. cases
M
F
M
F
M
F
Op
No-op
Op
No-op
234
144
17
44
16
11
2
18
--
15
201
80 314
55 199
I 18
18 62
-16
6 17
-2
8 26
---
3 18
69 270
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
Craniocerebral Missile Injuries
Surg Neurol 1991;35:455-60
Table 5. Involvement of Cerebral Lobes
Table 3. Time of Death After Injury Selfinflicted Died
No. cases
On the scene Within 3 h Within 24 h After 24 h Totals
228 38 7 15 288
457
Accidental or unknown
Assaults
No. Selfcases inflicted
Lesions M
F
M
F
M
F
156 22 3 8
12 4 -1
43 8 1 2
11 3 -1
5 1 3 3
1 ----
206
69
Survived Died Accidental or NoNoAssaults u n k n o w n O p op O p op
Bilateral Unilateral 1 lobe 2 lobes 3-4 lobes
166
125
38
3
6
--
8
152
52 29 67
29 14 49
14 12 14
9 3 4
12 6 2
----
8 1 1
32 22 64
13 Abbreviations: No-op, no operation; Op, operation.
Abbreviations: F, female; M, male.
Fisher's exact test). There was no significant difference in the outcome between patients who were and who were not submitted to postoperative measurement of intracranial pressure.
(p < 0.004, Fisher's exact test) than that in the remaining patients. On the contrary, there was no statistically significant difference as to lethality between patients with or without intracranial extraparenchymal hematomas (Table 7). There were 26 survivors among 44 operated patients (Tables 1 and 8). Of those, 12 had presented with a lesion involving a single cerebral lobe, six with bilateral lesions, and eight with unilateral lesions affecting two or more lobes (Table 9). None of the patients who were operated on with a score of 4-5 on the GCS survived their injuries (Table 10). Of the 10 good recoveries (score of 0-1 on the GOS), eight occurred in patients with a preoperative score of 13-15 on the GCS and six in patients with a single-lobe lesion (Tables 9 and 10). Moderate to severe disabilities were present in surviving patients who had been operated upon with a GCS score of 6-8. None of the survivors was vegetative. Comparing the subgroup with a preoperative GCS score of 9-15 with those ranging from 4 to 8, there was a statistically significant difference in the survival-death ratio (p 0.0001, Fisher's exact test). This difference still existed when the subgroup with a GCS score of 9-15 was compared with the subgroup with a GCS score of 6-8, excluding the patients with the score of 4-5 (p < 0.002,
Discussion The series reported herein can be regarded as highly representative of events occurring in definite geographical areas, with the University Medical Centers of Genoa and Sassari being the only academic, and also the largest, hospitals, respectively, in the northwestern region of Liguria, on the Italian peninsula, as well as in the northern provinces of the mediterranean island Sardinia. Despite their different demographic, socioeconomic, and cultural backgrounds, Liguria and Sardinia share a high rate of attempted suicides and crime. The present results unequivocally document an early lethality of penetrating missile injuries of the brain, heightening the already sinister reputation of these lesions [5,8,11,13, 20-22,25]. Of all the patients who died, 79% were dead on the scene and a further 13% died within 3 hours after injury. These figures are consistent with the findings of a previous series in which 71% of fatally injured civilians with craniocerebral gunshot wounds were dead at the
Table 4. Summary of the Series of 107 Patients with Wounds Inflicted by a Single Bullet of a Known Caliber Self-inflicted Caliber
No. cases
M
Flobert .22 l.r. 6.35 (.25ACP) 7.65 (.32ACP) .32 S & W 9 short (.380ACP) 9ultra(9 × 18) 9 para (Luger) .38 special
5 14 19 46 1 8 1 5 8
5 7 12 27 1 6 1 -4
F .
M .
M .
4 1 8 .
2 . -1
F .
1 3 3 .
Accidental or u n k n o w n
Assaults
. . .
. . 4 2
Abbreviations: F, female; M, male; No-op, no operation; Op, operation.
. .
.
.
Op
No-op
Op
No-op
4 3 6
----
2 -1 6
--
--
3 10 15 34 1 7 1 5 8
.
. 1
. . .
. . .
Died
. ---.
. .
1 1
F
. -2 5
2 1 3
Survived
. . .
. . .
. .
458
Surg Neurol 1991;35:455-60
Siccardi et al
Table 6. Involvement of Cerebral Lobes in 107 Patients with Wounds Inflicted by a Single Bullet of a Known Caliber Self-inflicted
Assaults
Unilateral
I lobe
Bilateral
Caliber
2 lobes
Unilateral
~ - 4 lobes
5 4
4
--
--
4
2
.
6.35
13
2
--
--
1
I
--
7.65
22
7
1 --
9 para
.
.38 s p e c i a l
.
.
.
.
.
.
1
--
7.
m
2
--
2
1
. .
.
.
.
2
--
--
3
--
--
--
~
--
--
2
--
--
--
--
Associated F i n d i n g s Survived Died Accidental - No. Selfor NoNocases i n f l i c t e d A s s a u l t s u n k n o w n O p o p O p op
among patients submitted to surgery with a preoperative score of 4 - 5 . Death has been reported as the invariable outcome in the presence of a GCS score of 3, whether or not surgery was performed [7], and rejection of any type of treatment has been recommended in cases with fixed pupils on admission [29]. The management of patients with a GCS score of 4 - 5 is controversial, ranging from simple scalp wound debridement to extensive intracranial surgery. The present results did not provide evidence of the effectiveness of surgery in these situations. However, taking into account the occurrence of occasional survivals following either surgical or conservative treatment [18], the question as to the optimal management of deeply comatose patients remains unsettled. The survival rate of patients submitted to surgery with a preoperative GCS score ranging from 6 to 15 was 70%, with adequate recoveries (score o f 0 - 3 on the GOS) occurring in 73% of the survivors. These figures are consistent with the assumption that vigorous resuscitation and early surgery often result in useful survivals and occasionally in spectacular recoveries. Though advanced age, extensive involvement of the brain, ventricular injury, and severe impairment of consciousness represented negative prognostic factors, their occurrence alone did not necessarily prevent a favorable outcome. Even in the concomitant presence of all these negative factors, possibilities of survival still existed. One of the
Table 8. Time of Operation After Injury and Outcome
Intraventricular hemorrhage
2 .
.
3 - 4 lobes
.
--
.
.
2 lobes
. .
. .
.
scene and a further 14% died within 5 hours [18]. As shown by others [3,7,13,18,19,23,24,29J self-inflicted wounds in the present series carried a high degree of fatality (95%), even when the lesions were caused by small-caliber missiles traveling at very low speed, as in the case of the Flobert cartridges. A lower, though statistically not significant, fatality rate (88%) occurred in patients with injuries resulting from assaults. Most of them were the result of premeditated homicidal attempts and did not substantially differ, in severity of the lesions and in outcome, from self-inflicted wounds. In this regard, one can assume that both firing at close range and taking careful aim represent major factors as to the immediate effects of the shot. It is known that the energy imparted to the head by penetrating missiles is primarily dependent on their velocity and mass, with the missile track within the brain being also related both to design and configuration of the projectile, as well as to distance of firing and orientation of the weapon [2,9,10,12, 14,19]. It is, therefore, not surprising that in the present series, although several devastating lesions were produced by heavy bullets, there was no constant relationship between caliber and degree of involvement of cerebral structures. There were no survivors among patients treated conservatively with a GCS score of 3, as well as
Table
. .
2
.
1 lobe
Bilateral
--
.
.
. .
2 .
.
.
~ - 4 lobes
.
2 .
.
.
.
5
. 1
1
.
--
. 1
2
.
1
.
6
9 ultra
.
Unilateral
2 lobes
.221.r.
9 short
.
l lobe
Bilateral
Flobert
.32 S & W
.
Accidental/unknown
No. cases
Selfinflicted
135
93
36
6
3
--
9
123
Operation
53
30
17
6
6
--
6
41
Within 3 h
2
1
1
Within 6 h
33
13
11
9
4
--
44
18
12
Assaults
Accidental or unknown
Survived
Died
Sub/epidural hematomas Other body areas
28
3
24
1
28
After 6 h Totals
Abbreviations: No-op, no operation; op, operation.
-9
1
1
19
14
5
6
3
14
26
18
Craniocerebral Missile Injuries
Surg Neurol 1991;35:455-60
Extension of the Cerebral Lesion and Outcome in the Operated Patients
T a b l e 9.
Survived Glasgow Outcome Scale Lesions Bilateral Unilateral 1 lobe 2 lobes 3 - 4 lobes
No. cases
O- I
2 -3
4-5
Died
14
2
2
2
8
20 7 3
6 2 --
5 2 --
1 2 2
8 1 1
patients of this series, an 81-year-old man who attempted suicide, was admitted with a score of 6 on the GCS and presented with a lesion crossing the midline and producing massive intraventricular hemorrhage. He survived his injury, though he is severely disabled. The current series was exclusively composed of patients with cerebral injuries directly inflicted by penetrating missiles that had created permanent tracks sustaining mass displacements of various degrees. There is evidence that these lesions fare much worse than do shrapnel or tangential wounds [4]. It is our firm belief, in this regard, that a realistic evaluation of the effects of gunshot wounds in civilians should be focused on direct injuries in order to avoid conclusions resulting from a combination of heterogeneous and even trivial lesions. Management limited to local wound care was regarded as unsuitable in the cases reported here, with intracranial debridement having been excluded only in patients admitted moribund. Limited surgery has been advocated in a number of penetrating injuries of the brain, with emphasis on both preservation of viable cerebral tissue and lack of correlation between retained fragments and abscess formation [1,4,29]. In the present series, while no attempt was made to search for retained fragments, unless readily accessible, removal of necrosed tissue and clot was as extensive as needed in order to obtain a significant volumetric reduction of the space-occupying lesions. To the best of our knowledge, no elements
State of Consciousness Before Surgery and Outcome of the Operated Patients
T a b l e 10.
Survived
GCS 13-15 9-12 6-8 4-5
GOS No. SelfAccidental cases inflicted Assaults or unknown 0-1 2-3 4-5 Died 16 9 12 7
7 2 6 3
5 4 2 1
4 3 4 3
8 2 --
4 3 2
3 2 2
1 2 8 7
Abbreviations: GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale.
459
emerge from the literature, suggesting that a more conservative attitude might have improved the outcome. Most of our patients were referred from peripheral hospitals and were often transferred by ground transportation. Their neurological condition at arrival may have also been dependent on effectiveness of first aid at the place of injury and adequacy of the conditions of referral. Whether improvement of these factors might result in a reduction of the number of patients in hopeless conditions on arrival remains a matter of speculation. The high mortality rate on the scene or soon after the injury drastically reduces the possibilities of effective management of brain injuries inflicted by penetrating missiles in civilians. Reports of series entirely or mainly composed of operated patients can be misleading because they document relatively high survival rates, not too far from those resulting from surgery of closed brain injuries. These figures, however, actually refer to a scant fraction of the victims. The authors thank Sergio Deseri for his excellent technical assistance.
References 1. Aarabi B. Causes of infections in penetrating head wounds in the Iran-Iraq war. Neurosurgery 1989;25:923-6. 2. Bakay L. Missile injuries of the brain. NY State J Med 1982;3:313-9. 3. Brandt F, Roosen K, Weiler G, Grote W. Die neurochirurgische Behandlung von Kopfschussverletzungen. Neurochirurgia 1983;26:164-71. 4. Brandvold B, Levi L, Feinsod M, George ED. Penetrating craniocerebral injuries in the Israeli involvement in the Lebanese conflict, 1982-1985. J Neurosurg 1990;72:15-21. 5. Byrnes DP, Crockard HA, Gordon PS, Gleadhill CA. Civilian penetrating craniocerebral missile injury in the civil disturbance in Northern Ireland. Br J Surg 1974;61:169-76. 6. Cavaliere R, Cavenago L, Siccardi D, Viale GL. Gunshot wounds of the brain in civilians. Acta Neurochir (Wien) 1988;94:133-6. 7. Clark WC, Muhlbauer MS, Watridge CB, Ray MW. Analysis of 76 civilian craniocerebral gunshot wounds. J Neurosurg 1986;65:9-14. 8. Cooper PR. Gunshot wounds of the brain. Contemp Neurosurg 1983;6:1-6. 9. Crockard HA. Bullet injuries of the brain. Ann R Coil Surg Engl 1974;55:111-23. 10. George ED, Dagi TF. Penetrating injuries of the head. In: Schmidek HH, Sweet W H (eds). Operative neurosurgical techniques. Volume 1, ed 2. Philadelphia: WB Saunders, 1988:49-55. 11. HammonWM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971;34:127-31. 12. Harsh GR III, Harsh GR IV. Penetrating wounds of the head. In: Wilkins RH, Rengachary SS (eds). Neurosurgery. Volume 3. N e w York: McGraw-Hill, 1985:1670-8. 13. Hernesniemi J. Penetrating craniocerebral wounds in civilians. Acta Neurochir (Wien) 1979;49:199-205. 14. Hopkinson DAW, Marshall TK. Firearm injuries. Br J Surg 1967;54:344-53.
460
Surg N e u r o l 1991;35:455-60
15. Hubschmann O, Shapiro K, Baden M, Shulman K. Craniocerebral gunshot injuries in civilian practice. Prognostic criteria and surgical management: experience with 82 cases. J Trauma 1979;19:6-12. 16. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiatry 1981;44:285-93. 17. Kaufman HH, Loyola WP, Makela ME, Frankowsky RF, Wagner KA, Bustein DP, Gildenberg PC. Civilian gunshot wounds: the limit of salvageability. Acta Neurochir (Wien) 198:~;67: 115-25. 18. Kaufman HH, Makela ME, Lee KF, Haid RWJr. Gunshot wounds to the head: a perspective. Neurosurgery 1986;18:689-95. 19. KirkpatrickJB, Di Maio V. Civilian gunshot wounds of the brain. J Neurosurg 1978;49:185-98. 20. Lausberg G. Schadelschussverletzungen in Friedenszeit. Acta Neurochir (Wien) 1965;13:317-43. 21. Lillard PL. Five years' experience with penetrating craniocerebral gunshot wounds. Surg Neurol 1978;9:78-83. 22. Meirowski AM. Penetrating craniocerebral trauma. JAMA 1954;154:666-9. 23. Miner ME, CabreraJA, Ford E, Ewing-Cobbs L, AmlingJ. lntra-
Siccardi et al
cranial penetration due to BB air rifle iniuries. Neurosurgery 1986;19:952-4. 24. Nagib MG, Rockswold GL, Sherman RS, Lagaard MW. Civilian gunshot wounds to the brain: prognosis and management. Neurosurgery 1986;18:533-7. 25. Raimondi AJ, Samuelson GH. Craniocerebral gunshot wounds in civilian practice. J Neurosurg 1970;32:647-53. 26. Saba MI. Surgical management of gunshot wounds of the head. In: Schmidek HH, Sweet WH {eds). Operative neurosurgical techniques. Volume 1, ed 2. Philadelphia: WB Saunders, 1988: 37-48. 27. Seidel BU, Volgelsang H, Galanski M. Computertomographische Befunde und Verlaufskontrollen bei Schadel-Hirn-Schussverletzungen. Neurochirurgia 1983;26:172-6. 28. Shoung HM, SichezJP, Pertuiset B. The early prognosis ofcraniocerebral gunshot wounds in civilian practice as an aid to the choice of treatment. A series of 56 cases studied by the computerized tomography. Acta Neurochir (Wien) 1983;74:27-30. 29. Suddaby L, Weir B, Forsyth C. The management of .22 caliber gunshot wounds of the brain. A review of 49 cases. Can J Neurol Sci 1987;14:268-72. 30. Yashon D, Jane JA, Martonfly D, White RJ. Management of civilian craniocerebral bullet injuries. Ann Surg 1972;38:346-51.
