Letter to the Editor: Air-gun pellet injuries to the head and neck: what are the mechanisms of injury and optimal steps in management?

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TO THE EDITOR: We read with interest the article by Kumar et al.3 (Kumar R, Kumar R, Mallory GW, et al: Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr 17:215–221, February 2016). The authors retrospectively collected the data of 14 victims of what they called air-gun pellet injuries who were referred to 3 different centers. They highlighted their findings in Table 2 of their manuscript. Their review of the muzzle velocity performance is very informative for readers of the neurosurgical literature who are interested in the field of penetrating head injuries.

Interestingly enough, our group published a collection of 16 pediatric cases injured by 0.177-caliber lead pellets with a diabolo-style shape in 1997.1 The summary of our findings is reproduced from that communication and added as a table in this letter to show that our results were rather similar to those of Kumar et al., although with some important differences. We would like to highlight some of them and also comment on some other issues as well.

1) The entrance points of the pellets into the skull are mentioned by the authors, but the weak roof of the orbit as the main avenue of entrance to the cranium for these low-velocity pellets should be better emphasized. The point is that the rifles or guns shooting these kinds of missiles are not engineered in standard industries and do not hold for example International Organization for Standardization numbers in every aspect. These guns and projectiles are produced by home-made manufacturers, lack advanced compressed gas technology (which means that the pellets are shot at different velocities), and are distributed by local sellers among the youngsters. So, the speed of pellets is nearly always less than the amount mentioned in Kumar et al.3 The skull entry site in the Kumar et al. series was frontal in 8 patients (57%), temporal in 2 (14%), orbital in only 3 (21%), and parietal in 1 (7%). The injury types overlapped among many patients, and some of them were not driven into the skull. Injuries included subarachnoid hemorrhage in 7 patients (50%), depressed skull fracture in 4 (29%), parenchymal contusion in 4 (29%), cerebral edema in 3 (21%), intraparenchymal hemorrhage in 2 (21%), subdural hematoma in 1 (7%), intraventricular hemorrhage in 1 (7%), and pseudoaneurysm formation in 1 (7%). Among them, 10 of the 14 patients required an operative intervention. This is quite different from our findings (Table 1), with the entrance through the orbit in 11/16 (69% orbital entrances). It shows that such missiles cannot easily penetrate through the skull bone, and need special circumstances to happen accidentally between the offender and the victim.

TABLE 1.

Characteristics, treatment, and outcome in 16 patients with pellet gun wounds

Case No.Age (yrs)SexPellet EntranceLodged*Imaging StudiesComplications & TreatmentResults
19MFront of neckVAAngioRemovedGood
26MOcciputSplitCTRemovedGood
35MRt temporalLt temporalAngioTA removedGood
48MLt orbitCone, orbit, & CSCT & angioCCF embolized iatrogenicallyGood
511MLt orbitMedial temporalCT & angioAgP w/in the CSGood
69MRt orbitRt parietalCT & angioBrain abscess & AgP removedGood
78MLt orbitFloor, anterior fossaCT & angioRemovedGood
815MRt orbitRt temporalCT & angioRemovedGood
98MRt orbitRt occipitalCT & angioRemovedGood
1010MRt orbitRt parietalCT & angioRemovedGood
118MRt orbit3rd ventricleCT & angioRefused surgeryGood
1211MLt orbitFloor, anterior fossaCT & angioRemovedGood
1314MRt orbitBeside carotid arteryAngioRemovedGood
1410MLt orbitFrontal deepCT & angioRemovedUnknown
158MLt temporalMedial temporalCT & angioRemovedUnknown
169MRt occipitalC-1, C-2 lamina juxta-VAX-rayRemovedUnknown

AgP = air-gun pellet; angio = angiography; CCF = carotid–cavernous sinus fistula; CS = cavernous sinus; TA = traumatic aneurysm; VA = vertebral artery.

Last location of air-gun pellet.

2) Considering passage of the missile through the skull base region in most of the cases, the shell often can be stopped in and around the sella. Damage to the cavernous sinus and its neurovascular structures was predictable, and we insist on some kind of vascular study in nearly all similar cases. We encountered both traumatic aneurysm and carotid cavernous fistula in our series (Table 1).

3) Even though it might not seem necessary to remove the BB pellets in all cases, because of the higher chance of development of late infection in these penetrating injuries (Table 1) in contrast to high-velocity war injuries,2 we deem early and complete debridement a mandatory procedure.

4) Advising the use of helmets for children playing with BB guns can be a good suggestion on the part of pediatric neurosurgeons, although it is of benefit only for the shooter and helmet manufacturer (because children who were not shooting BB guns wouldn't be wearing a helmet). Considering that these events are accidental and not preplanned, the use of helmets cannot possibly prevent all injuries to the victim.

References

  • 1

    Amirjamshidi AAbbassioun KRoosbeh H: Air-gun pellet injuries to the head and neck. Surg Neurol 47:3313381997

  • 2

    Amirjamshidi AAbbassioun KRahmat H: Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries. Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran-Iraq conflict. Surg Neurol 60:1051102003

  • 3

    Kumar RKumar RMallory GWJacob JTDaniels DJWetjen NM: Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr 17:2152212016

Disclosures

The authors report no conflict of interest.

Response

We appreciate the comments on our article and thank the writers for their additional insights.

We agree; the most vulnerable area on the face for projectile entry is the orbit, given the nature of the tissue. We encountered a plethora of orbital injuries due to nonpowder guns when reviewing the records, and yet, interestingly, only 3 of many included penetration of the intracranial compartment. This, indeed, is different from what was published by Amirjamshidi et al. in 1997.1 Potentially, in addition to their suggestion regarding helmets, safety glasses should be recommended.

In our study, the most common site of injury was the frontal bone, which is a far more robust bone than those of the orbits. We theorized that the increased incidence of convexity bone penetration may be due to the increase in muzzle velocities of contemporary nonpowder guns. In the letter Drs. Amirjamshidi and Abbassioun mention the inaccuracy of estimates of muzzle velocities. Indeed, there is some truth to this comment. Our calculations (based on the muzzle velocities reported by the manufacturers of popular air-powered guns) represent the worst-case scenario regarding projectile velocity and energy density at the point of skull penetration. Regardless of the calculations, 14 children presented with BBs or pellets in their brains. Certainly these rough calculations help to explain how a BB could penetrate the frontal bone, but they do not explain the gun safety failures that led to it being aimed in that direction in the first place. The main purpose of highlighting these calculations in our paper is to bring attention to the increased power and potential dangers of nonpowder guns. Perhaps this information could be used to facilitate a discussion on gun safety, when before these would be considered merely toys.

We also appreciate the authors' experience with these injuries and appreciate their recommendations. Because BBs and pellets lack the temporary cavitation in the traversed brain produced by larger firearms, they are thus generally less damaging to the neural tissue. However, BBs and pellets are still very capable of producing vascular injuries. We agree with the writers' recommendations, that there should be a low threshold for performing vascular studies after BB or pellet gun brain injury. In our opinion, the neurosurgeon should use his or her best judgment on whether debridement, decompression, or skull repair are necessary, and deeply lodged BBs or pellets should only be retrieved if they threaten imminent or ongoing neurological injury to the patient.

In the US, we live in an era of heightened sensitivity to any kind of gun regulation. Our authorship group includes avid gun owners and those who have never fired a gun before. The regulation of nonpowder guns is done at the state level and is inconsistent. Although we take no stance on the regulation of nonpowder guns, we strongly recommend close parental or mature supervision of children using these weapons, which pose risks that are underappreciated.

References

1

Amirjamshidi AAbbassioun KRoosbeh H: Air-gun pellet injuries to the head and neck. Surg Neurol 47:3313381997

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Article Information

INCLUDE WHEN CITING Published online July 15, 2016; DOI: 10.3171/2016.3.PEDS16136.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Amirjamshidi AAbbassioun KRoosbeh H: Air-gun pellet injuries to the head and neck. Surg Neurol 47:3313381997

  • 2

    Amirjamshidi AAbbassioun KRahmat H: Minimal debridement or simple wound closure as the only surgical treatment in war victims with low-velocity penetrating head injuries. Indications and management protocol based upon more than 8 years follow-up of 99 cases from Iran-Iraq conflict. Surg Neurol 60:1051102003

  • 3

    Kumar RKumar RMallory GWJacob JTDaniels DJWetjen NM: Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr 17:2152212016

  • 1

    Amirjamshidi AAbbassioun KRoosbeh H: Air-gun pellet injuries to the head and neck. Surg Neurol 47:3313381997

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