Predictors of outcome in civilian gunshot wounds to the head

Clinical article

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  • 1 Department of Neurosurgery,
  • 2 University of Maryland School of Medicine;
  • 3 Office of Chief Medical Examiner of the State of Maryland;
  • 4 Division of Neurosurgery, Johns Hopkins University, Baltimore;
  • 5 Peninsula Neurosurgical Associates, Salisbury;
  • 6 Central Maryland Neurosurgical Associates, Baltimore;
  • 7 Division of Neurosurgery, Parkway Neuroscience and Spine Institute, Hagerstown;
  • 8 Western Maryland Health, Cumberland, Maryland; and
  • 9 Department of Neurosurgery, Georgetown University, Washington, DC
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Object

Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period.

Methods

The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data.

Results

Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up.

Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome.

Conclusions

Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.

Abbreviations used in this paper:APR = abnormal pupillary response; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; GSWH = gunshot wounds to the head; ISS = Injury Severity Score; STC = Shock Trauma Center; TBI = traumatic brain injury.

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Contributor Notes

Address correspondence to: Bizhan Aarabi, M.D., F.R.C.S.C., Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Ste. S-12-D, Baltimore, MD 21201. email: baarabi@smail.umaryland.edu.

Please include this information when citing this paper: published online February 7, 2014; DOI: 10.3171/2014.1.JNS131869.

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