Predictors of outcome in civilians with gunshot wounds to the head upon presentation

Abstract

Object Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome. Methods The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model. Results Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome. Conclusions Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.

Pediatric intracranial gunshot wounds: the Memphis experience

“…The mean score on the St. Louis Scale for Pediatric Gunshot Wounds to the Head in children who survived and those who died was 2.8 (range 0-12) and 10 (range [3][4][5][6][7][8][9][10][11][12][13][14], respectively. Table 5 shows the average scores and range for the survivors by GOS score.…”

“…8,9,18,28,30 The St. Louis scale is the only one that we know of that is specific for children and marks a significant contribution to the literature. 2 In Bandt and colleagues' series, a St. Louis scale score ≤ 4 was associated with a positive predictive value of 88.9% for survival; a score ≥ 5 was associated with a negative predictive value of 96.7% for death.…”

Outcomes and Demostration of Cranial Firearm Injuries: A Multicenter Retrospective Study

“…[5] Çırak et al [19] have reported that a patient's prognosis can be predicted on the basis of CT findings and GCS. Aarabi et al [22] and Hoppe et al [39] have reported mean admission GCSs of 7.8 and 13.5, respectively. They noted that GCS was inversely proportional to prognosis.…”

One Step at a Time, Stem Cell Therapy for Traumatic Brain Injury Needs Two More Breakthroughs

“…[4][5][6] Thus, among the estimated 5.3 million people living in the US with traumatic brain injury (TBI)-related disability, the proportion of gun-shot wound survivors has been rising steadily. 3,[7][8][9][10][11] Among head injuries, penetrating injuries (PTBI) are associated with the worst outcomes. 12,13 and no effective restorative treatment beyond physical therapy is currently available to mitigate post-TBI disability.…”