Gunshot injury to the head and spine

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Journal of Clinical Neuroscience (2002) 9(1), 9–16 © 2002 Harcourt Publishers Ltd DOI: 10.1054/jocn.2001.0949, available online at http: //www.idealibrary.com on

Review

Gunshot injury to the head and spine Jeffrey V. Rosenfeld MS, FRACS, FRCS(ED), FACS Departments of Neurosurgery and Surgery, the Alfred Hospital and Monash University; Department of Surgery, University of Papua New Guinea

Summary The principles of management of civilian gunshot wounds (GSWs) to the head and spine have evolved directly from the experience gained in war by military neurosurgeons. The type of craniocerebral wounds being produced in urban gang warfare and suicide attempts using handguns or rifles at close range vary considerably from the lower velocity fragment injuries which are common in modern warfare. Civilian craniocerebral GSWs are often devastating. The in-hospital mortality for civilians with penetrating craniocerebral injury is 52–95% depending on the proportion of suicide victims in the series. The most important predictive factor is the post-resuscitation Glasgow Coma Score (GCS). Many civilian victims (47%) present with GCS 3–5 and only approximately 8.1% survive. Of these survivors, 1.4% will have nil, mild or moderate disability without surgery and 4.8% with surgery. Higher post-resuscitation GCS is associated with a significantly improved survival: GCS 6–8, 35.6% and GCS 9–15, 90.5%. A selective treatment policy is recommended for the patients with GCS 3–5. There are many clinical and radiological correlates with poor outcome that help the neurosurgeon decide on operative versus supportive treatment. Early aggressive resuscitation, surgery and vigorous control of intracranial pressure offers the best chance of achieving a satisfactory outcome. Spinal GSWs are uncommon and the neurosurgeon should be aware of the principles of management and prognosis. The indication for acute spinal cord decompression is deteriorating neurological status. Steroids are not indicated for these injuries. Neurosurgeons should take an active role in formulating and supporting public policy which aims to reduce possession and usage of firearms and therefore the prevalence of gunshot injuries. © 2002 Harcourt Publishers Ltd Keywords: Gunshot wounds, head injury, intracranial pressure, outcome, penetrating craniocerebral injury, spine injury, prevention

There is every reason to believe that by earlier operations, and by further improvement in technique along the lines of painstaking aseptic surgery, the accepted high mortality of cases with dural penetration can be very largely cut down … Harvey Cushing, 19181 The means of destruction are approaching perfection with frightful rapidity. Lieutenant General Antoine-Henri Baron de Jomini, Summary of the Art of War, 18382 INTRODUCTION Gunshot wounds (GSWs) to the head are the most lethal of all GSWs, and most patients do not survive to see a neurosurgeon.3 Assaults, suicides and accidents are the three causes of GSWs to the head and spine and vary in proportion depending on the geographical location. Australasia is relatively free of deliberate criminal gunshot trauma. Many of the GSWs to the head in Australia are self-inflicted in suicide attempts. Youth suicide is a serious public health problem in Australia and preventive strategies have been developed.4 Self-inflicted GSW is a common method used. However, in the USA, GSWs reached epidemic proportions in the 1980s and 90s due to urban gang and drug-related violence and far exceed, proportionately, any firearm-related civilian violence in Australasia.5,6 There is a considerable variability amongst neurosurgeons in the approach to the management of GSWs to the head.7 It is therefore timely to review best current management practice for an Received 7 December 2000 Accepted 15 May 2001 Correspondence to: Jeffrey V. Rosenfeld, Professor and Director, Department of Neurosurgery, The Alfred Hospital, PO Box 315, Prahran, 3181, Australia. Tel.: ;61 3 9 2762683; Fax: ;61 3 9 2762681

Australasian and European audience because gunshot wounds are so infrequently encountered by the individual civilian neurosurgeon in Australasia and Europe, and a vast experience in their management has been accrued in the last two decades, particularly in the USA. It was during the military conflicts of this century that the basic principles of the management of GSWs to the head and neurotrauma in general were developed.8 The Korean, Vietnam and Israeli experiences have demonstrated the advantage of rapid aeromedical evacuation, which has flowed on to civilian trauma systems. However, it has been the recent epidemic of urban violence in the USA which has resulted in more precise predictive tools being developed and a more selective management approach to emerge from the detailed analysis of large series of GSWs to the head in civilians. There are many lessons to be learnt. This review will consider whether recommendations or guidelines can be formulated on the basis of this experience. THE HISTORY OF PENETRATING CRANIOCEREBRAL AND SPINAL TRAUMA The instruments and techniques for treating penetrating wounds of the brain over the centuries are well described.9,10 Many ancients survived trepanation.10 The mortality of head wounds in the Crimean war was 73.9%, and 71.7% in the American Civil War.9 Harvey Cushing was a pioneer in the management of penetrating head injuries in World War I. He insisted that ‘a large number of the recorded fatalities were avoidable’. The mortality of these injuries in the pre-antibiotic and pre-diathermy era fell from 78% to 28.8% under his influence. Cushing brought neurosurgery as near to the front as feasible, classified head injuries according to severity, developed particular surgical techniques and instructed the surgeons responsible for the management of head injury. The craniectomy, debridement and closure he popularized for penetrating head wounds in WWI was replaced by osteoplastic craniotomy in WWII as practised by Cairns.11,12 Mobile Neurosurgical 9

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Units (‘Head Units’) were formed and trained in Oxford and provided small, well-trained and -equipped units which could deploy and supplement regular medical formations. Antibiotics were introduced in World War II and the mortality rate dropped to 14%,13 and in the Korean war to under 10%.9,14 In the Vietnam war, gunshot wounds to the brain resulted in a 22.7% mortality, and fragment wounds 7.64%.15 Matson reviewed the outcome of penetrating spinal cord injuries in WWI and WWII noting a mortality of 72% and 15% respectively, and 62% and 5 to 12% respectively if surgery was performed.16 The collective experience of UK and US neurosurgeons during WWII remains relevant today.17,18 MILITARY PENETRATING CRANIOCEREBRAL WOUNDS Small fragments and not bullets cause most of the wounds of modern combat.19 For instance, it is estimated that 90% of all brain wounds operated on by neurosurgeons in the Vietnam war were caused by fragments.19 Lower velocity shrapnel injury, 0.22 calibre rifle or occasionally high-velocity weapons from a distance result in survivable injuries in military conflict, whereas there has been an increasing use of high-velocity military weapons or pistols at close range in the civilian setting, often in execution style gang vendettas. These latter injuries are not often survivable, so that the military experience applies to an increasingly smaller group of civilians at least in the USA.8 Distance is a critical factor in survivability as the velocity of the missile decreases significantly over distance from the point of firing. Head wounds have accounted for almost half of all the deaths of ground combat soldiers since World War II.20 In war, the military medical system has required efficient and standardized protocol-based treatment of large numbers of casualties often over long evacuation routes. Although there is little room for flexibility, new advances, once accepted, can be quickly introduced throughout the theatre. The principles which emerged from the battles of this century have been that the initial procedure should be the definitive procedure, there should be minimum time to resuscitation, that the early debridement of wounds prevents infection and cerebritis and that rapid evacuation of haematomas saves lives.8 The Korean and Vietnam wars, for the first time, provided rapid aeromedical evacuation to definitive resuscitation and surgical care, and definitive specialty neurosurgical care in the field hospitals became routine. This significantly improved the early management of penetrating head injury.8 The concepts of careful dural closure to eliminate cerebritis, skin closure, antibiotics and anticonvulsants developed during this time but the decision to re-explore for deep bone fragments remained controversial.8 The Vietnam Head Injury Study (VHIS) prospectively followed a large number of victims of penetrating head injury into the 1980s.21–24 Of 58 000 US combat fatalities, 40% were due to head and neck wounds.25 Of the penetrating head injuries in Vietnam, 20% had very severe wounds and died without surgery soon after admission. The other 80% had surgery with a mortality of about 10% and most returned to productive lives.25 In the Israel–Lebanon conflict, less aggressive debridement was carried out by the Israelis with bone fragments left in situ compared with the more extensive debridement of the Vietnam war, and ICP monitoring was also used. The outcome was at least as good and the risk of epilepsy was lower.26 The less aggressive debridement approach was also used successfully on the Lebanese side.27 Aarabi reported experience with 1306 patients with missile head wounds in the Iran–Iraq war (1980–1988) treated at one institution.28 There were 964 patients with dural penetration. Shell fragments were the offending projectile in 69.8% cases and Journal of Clinical Neuroscience (2002) 9(1), 9–16

missiles in 9.4%, the others were uncertain. 55.7% of wounds were penetrating, 22.4% were tangential, and 7.47% were perforating.28 Computed tomographic (CT) scanning of battle casualties was first used by the Israelis in their conflict with Lebanon 1982–85.29 The CT scan has proven very useful in the triage of patients and in determining the nature and extent of surgery required. CT scanning is now an integral part of USA military neurosurgical management.8 Portable CT scanners were by used the USA military on the ground as well as being available on hospital ships in the Gulf War.8 The lessons learned in military conflict are directly applicable to the civilian setting. EPIDEMIOLOGY OF CIVILIAN GUNSHOT WOUNDS The statistics of the gunshot injuries in the USA are sobering.3,30 In Los Angeles, 0.2% of the population is shot each year.31 From 1979 to 1986, firearms caused 14% of trauma deaths in the USA32,33 and accounted for 34% of all head injury deaths in the USA,33 and firearms are among the leading 12 causes of death in the USA and in the top 10 causes of accidental death.3 For every death, there are 7 non-fatal injuries from GSWs.3 Most of the victims are male.6 By 1992, the total cost of GSW was estimated at $16.2 billion per year, with most affected people having no insurance.30 These problems are significantly greater in the urban areas.34 The trends in GSW epidemiology in the USA over the last two decades have been an increase in younger victims and children probably because of their involvement in the drug trade, a decrease in suicide relative to homicide and assault, a predominance of black and Hispanic male victims, and an increased tendency to multiple woundings with the use of military style weapons.35 Kaufman concluded that GSWs to the head are the most lethal of all sites of gunshot injury and estimated that 990% of people shot in the head in civilian settings eventually died, two-thirds of these at the scene.3 Only 4% of the 105 children with GSW to the head at the University of Southern California were suicides. Most were victims of assault related to gang warfare.5 Unfortunately, occipital and assassination type wounds were the commonest seen in the children. In 1991, 925% of all GSW homicides in Los Angeles were 19 years or younger and the percentage of fatal shooting of juveniles mostly in gang-related violence increased from 12% in 1970 to 27% in 1992.5 By contrast, homicide rates are 3 to 40 times less in Europe and Japan, accidental fatalities in children are five times less in Europe, and most cases in European series result from suicide.3 Several large series have been reported from the USA. Seven hundred and eighty patients presented to the University of Southern California, Los Angles County Medical Center with a diagnosis of GSWs to the brain during an 8-year period.5 Frighteningly, one of the victims in Levy et al.’s series of 190 GSWs to the head patients had a zero transit time because the injury occurred in the hospital.36 Kaufman et al. presented a series of 143 civilians shot in the head and treated in the one centre in Houston over a two-and-a-half-year period.37 Stone et al. reported a series of 480 victims of GSW to the head at the Cook County Hospital, Chicago over 10 years. Ninety-four per cent resulted from assault, 35% had a tangential passage without dural penetration, the overall mortality was 34%, a mortality of 52% for penetrating cranial wounds, and 150 had a craniotomy with an operative mortality rate of 21%. Thirty-five per cent of victims had multiple GSWs.38 Of those patients with GSWs to the head who die, 71–79% die at the scene and 13–14% die within 3–5 hours post injury.37,39 The proportion of self-inflicted GSWs varies between countries from 27/480 (5.6%),38 to 61/143 (42.7%)37 in the USA, to 70% in © 2002 Harcourt Publishers Ltd

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Italy,40 to 83.3% in Finland,41 and was 94% of a series in rural USA.35 Self-inflicted GSW to the head carry a 95% mortality with assaults causing GSWs to the head resulting in an 88% mortality.39 Suicide victims have a higher mortality than assault victims.37–39 Only 2 of 65 patients survived suicide GSW to the head and both were severely disabled.41 Of Stone et al.’s self-inflicted GSW to the head there was a 63% mortality and only a 13% satisfactory outcome, significantly worse than those caused by assaults.38 Series with a large proportion of self-inflicted GSW will have a higher mortality.

EXPERIMENTAL STUDIES OF GSWs The pathophysiology of missile injuries to the brain has been elucidated using experimental animal models.42 Fatal apnoea often occurs immediately after injury, which is a direct function of the energy deposited by the missile. This may be due to a propagated pressure wave effect on respiratory neurons of the medullary respiratory centres. There is also evidence that cardiac output and therefore cerebral perfusion decreases soon after missile injury but that less energy is required to produce this change than the apnoea.19 The mechanism of death after GSWs to the head may also be due to acute brainstem pressure due to cerebral swelling.43 Carey’s unilateral hemispheral missile injury model also demonstrated that vasogenic oedema develops along the missile track.19 Carey’s research was prematurely stopped by protests from the animal rights movement. The changes that occur in intracranial pressure (ICP), and cerebral blood flow following GSW to the brain are complex. There is an initial steep rise in ICP which falls to an elevated level, and there is also an initial increase in mean arterial blood pressure (MABP), cerebral perfusion pressure (CPP), and a peri-wound hyperperfusion for 90 min then hypoperfusion in survivors. In contrast, there is an initial fall in cerebral blood flow (CBF) and CPP in non-survivors.42 Intracranial haemorrhage, vasospasm and clotting abnormalities are further contributing factors to the pathophysiology.

INDICATIONS FOR SURGERY – IS A SELECTIVE TREATMENT POLICY JUSTIFIED? All patients should receive initial vigorous resuscitation. Patients with stable vital signs undergo CT. CT scanning alone is not a reliable predictor and must be used in concert with the clinical assessment.44 But what is the place of surgery and how aggressive should it be? Civilian studies of the 1970s and 80s have often recommended conservative treatment because of the high mortality,41,45–47 but more aggressive and rapid resuscitation and a predominance of assaults over suicides in the USA have changed this balance. Grahm et al. recommended patients with a GCS of 3–5 after resuscitation should not be treated unless there was an operable haematoma and patients with a GCS of 98 should be treated aggressively.48 Nagib et al. proposed non-operative treatment for comatose patients with uni- or bilateral injuries, and scatter of bone and metal fragments on CT, and particularly when the patients were suicide victims.45 In Suddaby et al.’s series of 43 civilians with .22 calibre gunshot wounds, there were no deaths in patients with a GCS 912 but there was an 85% mortality for those with a GCS :7 and all those with fixed pupils at admission died. They recommended no treatment in patients with an admission GCS of 3 and/or fixed pupils.49 Cavaliere only operated on those patients with a GCS 9 6.40 Following an extensive review of the literature, Carey has recommended no surgery for the patients with GSW 3–5 and a selective policy on patients with GCS 6–8 even though these patients have a 50% mortality.50 © 2002 Harcourt Publishers Ltd

Other authors recommend a selective policy for performing surgery on civilians with GSW to the brain and GCS 3–5.36,38 Levy et al. evaluated 190 patients with craniocerebral GSW and GCS 3–5 which represented 39% of the total population and postulated that there is a subset of patients with a GCS 3–5 on admission who may benefit from aggressive management.36 Of the 60 patients who had surgery with a GCS on admission of 3, 4 or 5, only 2 patients had a good outcome (admission GCS 4 and 5). Despite the low GCS, neither patient had any other bad prognostic features.36 Levy et al. concluded that patients with a GCS 3–5 on admission may have a better survival with surgery but outcomes are generally poor. There may be a small subgroup of patients with GCS 3–5 who have reactive pupils, no fragmentation, no bihemispheric injury with ventricular involvement and no SAH who would have a reasonable chance of a good outcome with aggressive management and surgery. The patients with a GCS of 3–5 who are not in this group should receive supportive care only. Even though physicians are advocates for their patients, the poor outcomes resulting from maximal therapy encourage a rationing of treatment and this remains the most humane approach. Family considerations may also be important deciding factors. However, Stone et al. recommend that if the pupils are reactive and the patient is haemodynamically stable, surgery should proceed, even if the GCS is 3.38 A patient with clinical or radiological evidence of a mass effect from a haematoma on CT should have immediate surgery. Stone et al. also recommend patients with GCS 4–7 without hypotension receive surgery even if the pupils are fixed if there is a motor response, and patients with a GCS 8–15 were treated surgically unless there were no abnormalities on the CT.38 If aggressive therapy results in a high chance of severe disability or persistent vegetative state in survivors with only a very small chance of a good outcome most neurosurgeons would be discouraged from aggressively treating the GCS 3–5 group. The economic and psychosocial burden of caring for these disabled survivors is immense. The proportion of survivors in the GCS 3–5 group with a GOS 4 (moderate disability) is 1.4% for all patients and 3.6% for those receiving surgery, and for those with a GOS of 5 (nil or mild disability), the proportions are 0.0% for all patients and 1.2% for those receiving surgery. These statistics are based on pooled data from several studies.51 In making a management decision, the neurosurgeon must take into account the type of weapon used and the distance from which it was fired, the patient’s age and clinical condition and the CT findings. It is reasonable for the neurosurgeon to decide against active therapy for the patients in poor condition with multiple poor prognostic variables. Based on the evidence presented above, patients with a GCS 3–5 following resuscitation who have responsive pupils and are not hypotensive should have a CT scan. If the CT scan is not consistent with poor survival or high mortality risk (e.g. SAH, fragmentation, ventricular involvement, etc.), the patient should have surgery. They have a better chance of survival with surgery. Most neurosurgeons would agree that patients who have suffered a high-velocity GSW or a lower velocity injury at close range, and who are deeply comatose with bilaterally fixed dilated pupils with gross bilateral brain, brainstem or posterior fossa trauma on CT have sustained lethal injuries and should receive supportive care only. A large prospective multicentre study (preferably randomized) will be required to determine the benefits of aggressive medical and surgical management and particularly to refine the indications for surgery in the GCS 3 to 5 group. The decision not to undertake active treatment is ethically contentious and the economic (health rationing), family, societal, legal, moral, religious and ethical elements all need to be considered. What if the treatment is believed to be futile? Our society must Journal of Clinical Neuroscience (2002) 9(1), 9–16

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openly debate what it expects its physicians to do where the prognosis is deemed hopeless. Neurosurgeons are already making these decisions.7,52,53 THE PRINCIPLES OF SURGERY FOR GSW TO THE HEAD AND SPINE The principles of surgery of GSW to the head are to debride devitalized tissue, evacuate haematomas causing mass effect, remove accessible missile or bone fragments, i.e. minimal local debridement, meticulous haemostasis, watertight dural closure (patch grafting if necessary), and postoperative control of intracranial pressure. Broad-spectrum antibiotic, anticonvulsant and tetanus prophylaxis are also administered.37 Standard means of treating intracranial hypertension are used including ventriculostomy. Siccardi et al. did not find any significant difference in outcome with ICP monitoring.39 Persistently high ICP despite all medical therapy may require frontal or temporal lobectomy of damaged brain. Clotting should be monitored and corrected if active treatment is proceeding. There is controversy as to whether prophylactic antibiotics should be used, which ones and their duration. Most authors recommend a course for 10–14 days. There is also controversy as to whether and how long prophylactic anticonvulsants are used but most use phenytoin or phenobarbitone and continue it for 6–12 months.53 The degree of debridement required is controversial. It is difficult to define the effect of the aggressiveness of the surgery on the mortality, which depends to a large extent on the preoperative neurological state of the patient, but there may be more of an effect on the complications. Stone et al. advise a more aggressive approach with debridement of devitalized tissue to reduce oedema and irrigation of the track to wash out fragments and debris.38 Debridement is particularly important for the temporal lobes and cerebellum. Ultrasound has been found useful by some to locate bone fragments and haematomas.53 Contrary opinion states that there is no need for extensive irrigation or debridement of the missile track and only debridment of the entry and exit sites and the removal of superficial bone fragments is necessary and it is unnecessary to reoperate for retained bone fragments.26,27,54,55 There is no correlation between presence of retained fragments and subsequent development of sepsis or epilepsy.26,56 The bone fragments have a much greater chance of causing late infection than metallic fragments (probably because of indrawn scalp, hair and dirt), and scalp wound dehiscence greatly increases the chance of intracranial infection.57 Scalp wound debridement and closure without intracranial exploration has been advocated in a series of 32 military patients with one case of brain abscess and all surviving.27 The spinal cord and the spinal roots and cauda equina may be injured by direct penetration of the missile, by cavitational effects of the missile passing close to the spine, and indirectly as a result of fractures and dislocations. The patients can be further divided into those having immediate and complete sensorimotor loss of function and into a second group with incomplete and nonprogressive neurological deficit. The first group has a poor prognosis for neurological recovery whereas there is a good prognosis for the second group.58 Hammoud et al. concluded in a series of 64 patients injured by bullets and shell fragments in the Lebanese civil war that there was no significant advantage in performing laminectomy for the complete and partial (fixed or stable) deficit groups.58 Decompressive laminectomy is indicated for the small group who have progressive neurological deficit. Laminectomy is also required to repair CSF fistulas. The missile wound(s) will require adequate debridement, but more urgent attention may be required for contiguous injury to the Journal of Clinical Neuroscience (2002) 9(1), 9–16

neck, chest, abdomen or pelvis. If the spinal cord is exposed it should be handled as little as possible to avoid compounding the injury which in many cases will be concussional in nature. Fragments of missile and bone should be removed, as much as is practicable, the dura closed watertight and the wound packed for delayed primary closure. An unstable spinal injury will require operative stabilization to prevent further injury. Internal fixation of the spine is preferable to skull tong application and traction for a cervical spine fracture dislocation. The administration of methyl prednisolone to patients with penetrating spinal missile injuries does not significantly improve functional outcome.59,60 THE OUTCOME AND PROGNOSIS OF GSW TO THE HEAD The most important aspect of outcome is the patient’s functional level over time, not mortality figures. Any analysis of survivors should report on their level of function. The combination of good recovery and moderate disability groups range from 63% to 92%.41,45,48,61 The patient’s functional outcome tends to improve with time,38 although Ewing-Cobbs et al. found the GOS to be remarkably stable over time in a small series of GSW to the brain in children.61 Stone et al. found 48% of the patients showed improvement and only 6% showed decline. Eight out of sixteen disabled and dependent patients were improved to functional status (GOS 4 and 5).38 Active and often prolonged rehabilitation of victims is necessary if their potential is to be maximized. Survivors often have significant disability which may include hemiparesis, blindness and seizures.62,63 The VHIS has detailed information on a psychosocial and cognitive outcome in a large group of penetrating head injuries.25 The effect on global cognitive processes correlated with the amount of brain lost, whereas specific mood and cognitive disturbance were affected by lesion site. Surprisingly, 56% were gainfully employed 15 years after the injury, and 80% had worked at some time after their injury. The volume of brain loss correlated with the success of a return to work.25 These results relate to predominantly fragment injury and therefore are not comparable to those of civilian penetrating head injury with high velocity missiles often at close range. The intellectual function following GSW to the head is more affected in children younger than 5 years compared with older children and children sustaining GSW to the head develop multiple neuropsychological, cognitive and behavioural deficits similar to or worse than the severe closed head injury group.61 Neuropsychological deficits were particularly marked for intelligence, attention and adaptive behaviour. Cognitive deficits were most closely related to persistent deficit in young children, whereas disability in older children and adolescents was particularly associated with impaired attention, adaptive behaviour and behavioural disturbance.61 Levy et al., in a review of 105 children and adolescents with GSW injuries to the head, found that the younger aged victims had a significantly worse outcome.5

COMPLICATIONS OF GSW TO THE HEAD AND SPINE Postoperative infection Brain abscess develops around bone chips usually within 3–5 weeks in 90% of cases but may present after years. Most of the missile tracks may not be highly contaminated after wounding, but it is more likely as the interval rises between wounding and neurosurgical treatment.64,65 Therefore the timing of surgery is important to avoid postoperative infection. The risk of infection is much higher in the presence of retained bone fragment if there © 2002 Harcourt Publishers Ltd

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is scalp dehiscence, hence the importance of obtaining a complete scalp closure.57 Brain abscess is less frequent around a metallic fragment. However, metallic fragments can remain a source of infection for years.66 Metallic fragments can also wander causing further damage. Others report a lack of correlation between retained fragments and abscess formation, therefore advocate limited surgery with preservation of viable cerebral tissue.26,49,54,67 The incidence of septic complications following GSWs to the spine in a series of 153 patients was reported to be 9.8%.68 There is evidence that retained bullet fragments in the spine do not increase the likelihood of sepsis.68 Infectious and non-infectious complications of penetrating spinal trauma are increased in those receiving steroids.60 Epilepsy From a combined series, the risk of post GSW seizure disorder ranges from 1.3% to 24% depending on the nature of the missile injury and whether prophylactic anticonvulsants are used.35 Surprisingly, the incidence of post-traumatic epilepsy in the VHIS was 51%, 15 years after injury.25 The seizure frequency in the first year predicted the future severity of the seizures, and lifeexpectancy was also reduced in the seizure group.25 Retained metal fragments may have a higher risk of epilepsy because of the effects of iron on the brain.69

figures for survival of civilian GSW to the brain are GCS 3–5 8.1%, GCS 6–8 35.6% and GCS 9–15 90.5%.51 Other series have had no survivors with a GCS of 3 or 4.47,56 Siccardi et al. had no survivors following surgery (7/7) with a preoperative GCS of 4–5, 4 of 12 survived surgery with poor outcome with a preoperative GCS of 6–8, whereas 70% survived surgery if the preoperative GCS was 6–15, with adequate recovery in 73% of the survivors.39 Grahm et al. reported a series of 100 patients with GSW to the head in which no patient with a GCS 3–5 had a satisfactory outcome even with an aggressive management policy.48 Aldrich et al. with a series from Texas of 151 severely head injured (comatose) GSW to the head reported an overall mortality of 88%, a 94% mortality for GCS 3–5, and a 70% mortality for GCS 6–8. There were no good outcomes and only 3 moderate recoveries in those with GCS :8.70 Aldrich et al. also found that the initial GCS was the strongest predictor of mortality and was even better than post resuscitation scores.70 Hernesiemi et al. reported a 22% mortality of GSWs to the head if the patient was conscious on admission, and a 93% mortality if they were unconscious on admission.41 Stone et al. also reported that GCS after resuscitation was the most significant predictor of outcome. Surprisingly, 2 patients in this series with GCS 3 after resuscitation had surgery and made a good recovery. Fourteen per cent of patients with GCS 3 or 4 survived although there were significant numbers with poor outcome.38 ICP control as a predictor of recovery

Vascular injuries Venous sinus injury is probably the most common vascular injury in craniocerebral missile injuries but traumatic aneurysm, arterial dissection, arterial occlusion, and arteriovenous fistulae may also occur. The reported incidence of traumatic aneurysms following craniocerebral missile injuries is 2–8%.28 Seven out of nineteen aneurysms were discovered after rupture in Aarabi’s series.28 Undetected traumatic aneurysms are likely to bleed and this results in a high mortality. However, it may be the underlying penetrating brain injury which is responsible for this poor outcome.28 Some aneurysms heal spontaneously but most manifest within 2–3 weeks following the injury.28 Most aneurysms occur along the missile track. Angiography should be performed within a few days when the missile track passes through the Sylvian fissure or other vascular areas and is indicated if delayed intracerebral haemorrhage occurs. Some authors recommend early angiography and repeat angiography at 14 days.53 The factors which increase the risk of traumatic aneurysm in penetrating head injury are intracranial haematoma, especially if delayed, facio-orbito-pterional entry of the projectile, and penetration of more than one dural compartment.28 The treatment of these traumatic aneurysms is beyond the scope of this review and is adequately described in the literature.25 CSF leak The risk of CSF leak is very low with complete dural closure.27 CSF fistulas are a significant risk factor for post-debridement infection.67 OUTCOME PREDICTION GCS and conscious state as predictors of mortality Post-resuscitation GCS is one of the most significant predictors of outcome.37,38,51 Survival from GSWs to the head is directly related to the GCS and ranges from 3% for a GCS of 3–5, to 52% for a GCS 6–8, to 92% for a GCS 9–12, and to a 100% survival for a GCS of 13–15.37 When multiple series are pooled the overall © 2002 Harcourt Publishers Ltd

A good ICP response to aggressive therapy is associated with an improved outcome.38 Intracranial hypertension is a strong predictor of death in children with GSW to the head.71 THE FACTORS WHICH CONTRIBUTE TO POOR OUTCOME The factors which are associated with a poor outcome and an increased mortality have been identified more precisely using multivariate analysis.51,52 The factors associated with a poor outcome from GSW to the head are a GCS :5 at admission, subarachnoid haemorrhage (SAH) on CT, intracerebral haematoma, ventricular injury, multilobar or bihemispheric wounding associated with intraventricular hemorrhage and diffuse fragmentation, the missile passing through the geographic center of the brain, hypoxia, hypotension at admission, increased retrieval time, suicide, midline shift of .10 mm on CT scan, compressed or obliterated mesencephalic cisterns on CT scan, high-velocity injury, disseminated intravascular coagulation, and advanced age.36–40,47,51,70,72 Patients with large or unreacting pupils are likely to have a poor outcome.37,40 Levy et al. found admission GCS, and/or SAH or pupillary changes are significantly related to increased mortality.36 There is a close association between post-traumatic SAH on CT scan and vasospasm. The degree of vasospasm correlates with prognosis.42 Vasospasm in the penetrating head injury group has a similar onset and time course to blunt head injury and aneurysmal SAH.42 The volume of contused brain and the number of midline anatomical planes (axial, sagittal and coronal) the missile crossed also predict mortality.51,73 The bifrontal lobe injuries are an exception with a relatively good prognosis (50% had a satisfactory outcome) and a mortality of 12% probably because they miss the basal vessels and the brainstem.38 Posterior fossa GSW have a poor prognosis if there is brainstem involvement or delay in debriding the wound.38 Aldrich et al. found that intracranial hypertension on ICP monitoring was a bad prognostic sign and also noted that calibre of the gun, the distance of the gun from the head and that hypotension did not significantly affect the risk of death.70 Other adverse factors are Journal of Clinical Neuroscience (2002) 9(1), 9–16

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occipital entry site and young children.5 A cerebral blood flow (CBF) pattern based on transcranial doppler (TCD) ultrasound measurement, which remains depressed or decreases further is associated with a poor prognosis.42 CAN THE MORTALITY BE IMPROVED? Rapid transport to a major trauma center is essential for the patient with a craniocerebral GSW, as there is an inverse relationship between the time to arrival at the emergency department and survival.37 Most patients have raised intracranial pressure; therefore early intubation, aggressive resuscitation and ICP monitoring are advised.37 These aspects of care can all be optimized. It is not known whether vigorous control of ICP and CPP improves outcome of craniocerebral GSW, but this and the intensive physiological monitoring of metabolic brain function requires further investigation, just as is being done with closed head injury. Pharmacological therapy and neural protective agents are likely to have an increasing role in improving outcome following craniocerebral GSW. Carey showed benefit from the mannitol, dimethyl sulfoxide and a suggestion of benefit from GM-1 Ganglioside used early after missile wounding of the brain in an experimental animal model.19 More attention should be directed to identifying cerebral vasospasm using TCD ultrasound and using standard haemodynamic and pharmacotherapy such as calcium channel blockers to counter it. PREVENTION OF GSW IN THE COMMUNITY An important focus of public health policy should be on the prevention of GSW and this means reducing the relatively free access to firearms in many countries. There were an estimated 212 million firearms available for sale to or possessed by civilians in the USA in 1992. This total includes roughly 72 million handguns, 76 million rifles, and 64 million shotguns.74 Handguns were estimated to be increasing by 2–3 million per year in the USA in 1993.3 The gun control debate is strongly polarized and touches on issues of federal versus state control, the effectiveness of the criminal justice system, and the extent of governmental control over the individual (particularly with respect to regulation of lawfully used and possessed firearms).74 Legislation restricting the possession of firearms in the USA has been limited particularly by the Second Amendment of the Constitution which states: ‘A well regulated militia, being necessary to the security of a free state, the right of the people to bear arms shall not be infringed’.74 The regulation of the types of firearms and ammunition, their storage and sale, the modification of firearm design to produce safer weapons, and the placement of bans on the possession of automatic and semi-automatic military style weapons should be encouraged. A firearm fatality reporting system is needed.75 In 1996, Port Arthur in Tasmania was the site of the worst mass murder by an individual in Australian history. Thirty-five men, women and children were shot dead. This resulted in more stringent firearm legislation and a government buyback of 640 000 weapons from 1996 to 1997. There was a Nationwide Agreement on Firearms which included the nationwide registration of all firearms and the licensing of firearm owners. Prior to this, the two states with more permissive legislation had consistently higher rates of firearmrelated deaths. From 1998 to 1999, there were 64 firearm homicides, which equates to 3 firearm homicides per million population in Australia, which compares to a rate 14 times this in the USA. Of the 2827 firearm-related deaths between 1993 and 1998 in Australia, 78% were suicides, 16% were homicides, and 4% were accidents. Since 1997, over 90% of firearms used to commit homicide in Australia were not registered and their owners not licensed.76 Journal of Clinical Neuroscience (2002) 9(1), 9–16

The reasons for the use of firearms are clearly complex and multifactorial. Some of the contributory factors are the influence of violence in the media, especially in television77 and film, the illicit drug industry, the alienation of the individual, domestic violence, alcohol abuse, poverty and unemployment. Guns kept in the home are associated with an increase in the risk of homicide by a family member or intimate acquaintance,78 and an increased risk of suicide.79 There is evidence that firearm control legislation, including a 28-day ‘cooling-off’ period before firearm purchase, reduces suicide rates, especially among younger adult men.80 Reduction in unemployment and the associated feelings of despondency may be an important preventive strategy.81 An education program in the schools is under way in California which is aimed at informing and recovering the children affected by gangs.5 Access to guns promotes homicide, suicide and accidents3 and therefore gun control is a legitimate preventive health strategy. The Royal Australasian College of Surgeons has developed a gun control policy.82 Neurosurgeons have been at the forefront of trauma prevention policy such as road safety campaigns, the Think First campaign to prevent spinal injury, and in taking a stance against boxing. Gun control should be added to this list. CONCLUSION Although poor outcome statistics encourage a nihilistic approach to the management of penetrating craniocerebral GSWs, all patients should initially be rapidly transported to a trauma center, receive aggressive resuscitation and a CT scan. Following this, patients with a GCS 95 should receive urgent surgery and ongoing intensive care treatment. A selective treatment policy is indicated for patients with a GCS 3–5. Adverse clinical and radiological prognostic features discourage active intervention. Future advances in cerebral protection therapy and neurointensive care management may improve the prognosis for the victim of penetrating craniocerebral GSWs. There is enough evidence to develop guidelines for management in the civilian and military setting. Prevention is clearly the best solution to GSW. Neurosurgeons should play an active role in education of the community as to the damage caused to the individual and to society by the use of guns and should promote gun control, gun safety and services to prevent youth suicide. Neurosurgeons should promote and contribute to the ethical debate about the treatment of the severely brain injured patients who have little hope of a satisfactory outcome. REFERENCES 1. 2. 3. 4. 5.

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