Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm

Clinical article

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  • 1 Department of Neurological Surgery, and
  • 2 Division of Biostatistics,
  • 3 Washington University School of Medicine; and
  • 4 Department of Pediatric Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri
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Object

There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population.

Methods

The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated.

Results

Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries.

Conclusions

The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.

Abbreviations used in this paper:GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure.

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Contributor Notes

Address correspondence to: S. Kathleen Bandt, M.D., Department of Neurological Surgery, Washington University School of Medicine, Campus Box 8057, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: bandtk@wudosis.wustl.edu.

Please include this information when citing this paper: published online September 28, 2012; DOI: 10.3171/2012.8.PEDS123.

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