Traumatic Cerebrovascular Injuries Associated with Gunshot Wounds to the Head: A Single-Institution Ten-Year Experience

Overview

Journal World Neurosurg

Publisher Elsevier

Date 2020 Nov 23

PMID 33227526

Citations 2

Authors

Fakhry M Dawoud

Michael J Feldman

Aaron M Yengo-Kahn

Steven G Roth

Daniel I Wolfson

Ranbir Ahluwalia

Patrick D Kelly

Rohan V Chitale

Affiliations

Soon will be listed here.

Abstract

Background: Cerebrovascular injury (CVI) is a potentially devastating complication of gunshot wounds to the head (GSWH), with yet unclear incidence and prognostic implications. Few studies have also attempted to define CVI risk factors and their role in patient outcomes. We aimed to describe 10 years of CVI from GSWH and characterize these injury patterns.

Methods: Single-institution data from 2009 to 2019 were queried to identify patients presenting with dural-penetrating GSWH. Patient records were reviewed for GSWH characteristics, CVI patterns, management, and follow-up.

Results: Overall, 63 of 297 patients with GSWH underwent computed tomography angiography (CTA) with 44.4% showing CVI. The middle cerebral artery (22.2%), dural venous sinuses (15.9%), and internal carotid artery (14.3%) were most frequently injured. Arterial occlusion was the most prominent injury type (22.2%) followed by sinus thrombosis (15.9%). One fifth of patients underwent delayed repeat CTA, with 20.1% showing new/previously unrecognized CVI. Bihemispheric bullet tracts were associated with CVI occurrence (P = 0.001) and mortality (P = 0.034). Dissection injuries (P = 0.013), injuries to the vertebrobasilar system (P = 0.036), or the presence of ≥2 concurrent CVIs (P = 0.024) were associated with increased risk of mortality. Of patients with CVI on initial CTA, 30% died within the first 24 hours.

Conclusions: CVI was found in 44.4% of patients who underwent CTA. Dissection and vertebrobasilar injuries are associated with the highest mortality. CTA should be considered in any potentially survivable GSWH. Longitudinal study with consistent CTA use is necessary to determine the true prevalence of CVI and optimize the use of imaging modalities.

Citing Articles

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Acute and Delayed Cerebrovascular Injury From Gunshot to the Head in a 12-Year-Old Child During the COVID-19 Pandemic.

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References

Gressot L, Chamoun R, Patel A, Valadka A, Suki D, Robertson C . Predictors of outcome in civilians with gunshot wounds to the head upon presentation. J Neurosurg. 2014; 121(3):645-52. DOI: 10.3171/2014.5.JNS131872. View

Bodanapally U, Krejza J, Saksobhavivat N, Jaffray P, Sliker C, Miller L . Predicting arterial injuries after penetrating brain trauma based on scoring signs from emergency CT studies. Neuroradiol J. 2014; 27(2):138-45. PMC: 4202862. DOI: 10.15274/NRJ-2014-10024. View

Tunthanathip T, Phuenpathom N, Sae-Heng S, Oearsakul T, Sakarunchai I, Kaewborisutsakul A . Traumatic cerebrovascular injury: clinical characteristics and illustrative cases. Neurosurg Focus. 2019; 47(5):E4. DOI: 10.3171/2019.8.FOCUS19382. View

Frosen J, Frisk O, Raj R, Hernesniemi J, Tukiainen E, Barner-Rasmussen I . Outcome and rational management of civilian gunshot injuries to the brain-retrospective analysis of patients treated at the Helsinki University Hospital from 2000 to 2012. Acta Neurochir (Wien). 2019; 161(7):1285-1295. PMC: 6581925. DOI: 10.1007/s00701-019-03952-y. View

Yevich S, Lee S, Scott B, Shaltoni H, Mawad M, Benndorf G . Emergency endovascular management of penetrating gunshot injuries to the arteries in the face and neck: a case series and review of the literature. J Neurointerv Surg. 2012; 6(1):42-6. DOI: 10.1136/neurintsurg-2012-010574. View

Ares W, Jankowitz B, Tonetti D, Gross B, Grandhi R . A comparison of digital subtraction angiography and computed tomography angiography for the diagnosis of penetrating cerebrovascular injury. Neurosurg Focus. 2019; 47(5):E16. DOI: 10.3171/2019.8.FOCUS19495. View

Cox M, Whittaker D, Martinez C, Fox C, Feuerstein I, Gillespie D . Traumatic pseudoaneurysms of the head and neck: early endovascular intervention. J Vasc Surg. 2007; 46(6):1227-33. DOI: 10.1016/j.jvs.2007.08.021. View

Loggini A, Vasenina V, Mansour A, Das P, Horowitz P, Goldenberg F . Management of civilians with penetrating brain injury: A systematic review. J Crit Care. 2020; 56:159-166. DOI: 10.1016/j.jcrc.2019.12.026. View

Berryman H . A systematic approach to the interpretation of gunshot wound trauma to the cranium. Forensic Sci Int. 2019; 301:306-317. DOI: 10.1016/j.forsciint.2019.05.019. View

10.

Alvis-Miranda H, Rubiano A, Agrawal A, Rojas A, Moscote-Salazar L, Satyarthee G . Craniocerebral Gunshot Injuries; A Review of the Current Literature. Bull Emerg Trauma. 2016; 4(2):65-74. PMC: 4897986. View

11.

Young L, Rule G, Bocchieri R, Walilko T, Burns J, Ling G . When physics meets biology: low and high-velocity penetration, blunt impact, and blast injuries to the brain. Front Neurol. 2015; 6:89. PMC: 4423508. DOI: 10.3389/fneur.2015.00089. View

12.

Carney N, Totten A, OReilly C, Ullman J, Hawryluk G, Bell M . Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016; 80(1):6-15. DOI: 10.1227/NEU.0000000000001432. View

13.

Kazim S, Shamim M, Tahir M, Enam S, Waheed S . Management of penetrating brain injury. J Emerg Trauma Shock. 2011; 4(3):395-402. PMC: 3162712. DOI: 10.4103/0974-2700.83871. View

14.

Deng H, Yue J, Winkler E, Dhall S, Manley G, Tarapore P . Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers. J Neurotrauma. 2018; 36(2):322-337. DOI: 10.1089/neu.2017.5591. View

15.

Temple N, Donald C, Skora A, Reed W . Neuroimaging in adult penetrating brain injury: a guide for radiographers. J Med Radiat Sci. 2015; 62(2):122-31. PMC: 4462984. DOI: 10.1002/jmrs.101. View

16.

Vakil M, Singh A . A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol. 2017; 24(3):301-309. DOI: 10.1007/s10140-016-1477-z. View

17.

Bodanapally U, Shanmuganathan K, Boscak A, Jaffray P, van der Byl G, Roy A . Vascular complications of penetrating brain injury: comparison of helical CT angiography and conventional angiography. J Neurosurg. 2014; 121(5):1275-83. DOI: 10.3171/2014.7.JNS132688. View

18.

Bodanapally U, Saksobhavivat N, Shanmuganathan K, Aarabi B, Roy A . Arterial injuries after penetrating brain injury in civilians: risk factors on admission head computed tomography. J Neurosurg. 2014; 122(1):219-26. DOI: 10.3171/2014.9.JNS14679. View

19.

Prat N, Daban J, Voiglio E, Rongieras F . Wound ballistics and blast injuries. J Visc Surg. 2017; 154 Suppl 1:S9-S12. DOI: 10.1016/j.jviscsurg.2017.07.005. View

20.

Aljuboori Z, Meyer K, Ding D, James R . Endovascular Treatment of a Traumatic Middle Cerebral Artery Pseudoaneurysm with the Pipeline Flex Embolization Device. World Neurosurg. 2019; 133:201-204. DOI: 10.1016/j.wneu.2019.10.008. View