Craniocerebral gunshot injuries in preschoolers

Bilateral decompressive craniectomy as a damage control strategy for a preschooler multilobar bihemispheric firearm injury: a case report and systematic review

The absence of guidelines for managing gunshot wounds to the head (GSWH) with bihemispheric lesions in pediatric patients highlights the need for prompt and diverse damage control strategies. This article aims to systematically evaluate the evidence surrounding the management of GSWH in preschoolers and to report a novel approach. We present a case of a 4-year-old girl who sustained a gunshot wound to the left parietal region. She was admitted to a level 1 trauma center 90 min post-injury with stable vital signs, a Glasgow coma scale (GCS) of 12 (E3, V3, M6), and grade III hemiparesis in her right upper limb. Initial surgical management included left hematoma decompression and right frontotemporoparietal decompressive hemicraniectomy in two stages under the same anesthesia. Due to massive brain swelling during the left-sided procedure, it was converted to a left frontotemporoparietal decompressive hemicraniectomy. Both procedures included autologous pericranium augmentation duraplasty and watertight suturing. A right-side decompressive hemicraniectomy followed without exploring bullet lodging, using bilateral Kempe incisions. Bone flaps were stored under cryopreservation. During a 30-day hospital stay, neurological assessments showed a gradual recovery of right upper limb strength to grade IV + , with no other deficits or operative complications. Postoperative CT scans at 7, 14, and 28 days showed minor pseudomeningoceles and a reduction of intraparenchymal edema. Multidisciplinary care continued throughout the stay. The patient showed no signs of endocrinological, infectious, or residual neurological issues and underwent bilateral autologous cranioplasty on day 35. She was discharged on day 38 with a GCS extended of 8 (full recovery/minor deficits not affecting daily activities) and minor right upper limb apraxia. A systematic review identified nine patients under 6 years old with GSWH, with only one previously reported case of a 3-year-old patient with bihemispheric lesions undergoing bilateral craniectomies and achieving positive outcomes. Our case and the review suggest that bilateral decompressive hemicraniectomy is a feasible strategy for managing multilobar bihemispheric GSWH in preschoolers. However, the evidence of management for this population remains of low quality, highlighting the need for further research, and justifying this case report.

Pediatric cranial injuries: the Syrian civil war

OBJECTIVE

Kilis, Turkey, a city near Aleppo, Afrin and Azez, Syria, where conflicts are intense, is one of the cities that provides initial emergency treatment. The aim in this study was to analyze the clinical and radiological characteristics of and treatment methods and results in pediatric patients admitted to Kilis State Hospital with cranial gunshot wounds obtained during the Syrian war.

MATERIALS AND METHODS

In this study, 62 pediatric patients treated for cranial gunshot wounds obtained during the civil war in Syria between December 2011 and May 2017 at the Neurosurgery Clinic of Kilis State Hospital on the Turkish side of the Turkey-Syria border were retrospectively analyzed.

RESULTS

A total of 62 patients were evaluated. Forty-six (74.2%) patients were male and 16 (25.8%) were female. The mean age of the patients was 11.4 ± 6.3 (range: 1 month to 18 years) years. The mean Glasgow coma scale (GCS) score was 7.2 ± 3.8. Surgical treatment was performed in 36 patients (58.1%). Six (16.7%) of the surgically treated patients and 15 (57.7%) of the conservatively treated patients died (p < 0.001). While good clinical results (GOS4-5) were obtained in 24 (66.7%) patients who underwent surgical treatment, only 8 (30.8%) patients who underwent conservative treatment had good clinical results (GOS 4-5). The treatment results in patients with a GCS score of between 9 and 15 who were treated with both methods were significantly better (GOS score of 4-5) (p < 0.05) than those in patients with a GCS score of 8 or lower. The treatment results of the patients aged 10-18 years were significantly better than those of patients aged 0-9 years (GOS 4-5) (p < 0.05).

CONCLUSION

In this study, the GCS score on admission was a significant predictive factor for survival in pediatric patients with cranial gunshot wounds. The outcomes of patients aged 0-9 years with severe neurological damage were worse than those in patients aged 10-18 years. On the basis of the analyses of the treatment methods and GCS and GOS scores of the patients in our study, we conclude that surgical treatment should be performed immediately in all patients with radiological indications and a GCS score higher than 3. Additionally, we conclude that child soldiers exist in Syria.

Firearm-Related Pediatric Head Trauma: A Scoping Review

BACKGROUND

Firearm-related injury is a significant cause of morbidity and mortality in pediatric populations. Despite a disproportionate role in the most morbid outcomes in both traumatic brain injury and firearm-related injury populations, firearm-related traumatic brain injury (frTBI) is an understudied epidemiological entity. There is need to increase understanding and promote interventions that reduce this burden of disease.

OBJECTIVE

To assess the evidence characterizing pediatric frTBI to highlight trends and gaps regarding burden of disease and interventions to reduce frTBI.

METHODS

We conducted a scoping review under Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review (PRISMA-ScR) guidelines on peer-reviewed studies across 5 databases (Medline OVID, EMBASE, Web of Science Legal Collection, PsychINFO, and Academic Search Complete). English studies examining pediatric frTBI epidemiology, prevention, and/or social or legal policy advocacy were included. Articles were excluded if they more generally discussed pediatric firearm-related injury without specific analysis of frTBI.

RESULTS

Six studies satisfied inclusion criteria after screening and full-text assessment. Limited studies specifically addressed the burden of disease caused by frTBI. There was an increased risk for both injury and death from frTBI in men, preteenage and teenage youths, minorities, and individuals in firearm-owning households. Further study is required to ascertain if suggested methods of targeted patient screening, firearm-injury prevention counseling, and advocacy of safety-oriented policy tangibly affect rates or outcomes of pediatric frTBI.

CONCLUSION

By understanding published epidemiological data and areas of intervention shown to reduce frTBIs, neurosurgeons can become further engaged in public health and prevention rather than strictly treatment after injury.

Pediatric craniocerebral gunshot injuries: A National Trauma Database study

BACKGROUND

We aimed to determine the outcomes and prognostic factors in pediatric craniocerebral gunshot injury (CGI) patients. Pediatric patients may have significantly different physiology, neuroplasticity, and clinical outcomes in CGI than adults. There is limited literature on this topic, mainly case reports and small case series.

METHODS

We queried the National Trauma Data Bank for all pediatric CGI between 2014 and 2017. Patients were identified using International Classification of Diseases, Ninth Revision, codes. Demographic, emergency department, and clinical data were analyzed. Subgroup analysis was attempted for groups with Glasgow Coma Scale (GCS) scores of 9 to 15 and ages 0 to 8 years.

RESULTS

In a 3-year period, there were 209 pediatric patients (aged 0-18 years) presenting to American hospitals with signs of life. The overall mortality rate was 53.11%. A linear relationship was demonstrated showing a mortality rate of 79% by initial GCS in GCS score of 3, 56% in GCS scores of 4 to 8, 22% in GCS scores of 9 to 12, and 5% in GCS scores of 13 to 15. The youngest patients, aged 0 to 8 years, had dramatically better initial GCS and subsequently lower mortality rates. Regression analysis showed mortality benefit in the total population for intracranial pressure monitoring (odds ratio, 0.267) and craniotomy (odds ratio, 0.232).

CONCLUSION

This study uses the National Trauma Data Bank to quantify the prevalence of pediatric intracranial gunshot wounds, with the goal to determine risk factors for prognosis in this patient population. Significant effects on mortality for invasive interventions including intracranial pressure monitoring and craniotomy for all patients suggest low threshold for use of these procedures if there is any clinical concern. The presence of a 79% mortality rate in patients with GCS score of 3 on presentation suggests that as long as there is not a declared neurologic death, intracranial pressure monitoring and treatment measures including craniotomy should be considered by the consulting clinician.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Pediatric Gunshot Wound to Visual Cortex with Retained Bullet: Case Report and Review of the Literature

INTRODUCTION

Pediatric gunshot wounds (GSWs) to the head are not well studied in the literature, especially in civilians. With a dearth of case-based and clinically relevant information, pediatric neurosurgeons may be challenged when considering the risks and benefits of removing retained bullet fragments in different intracranial locations. We explore the literature and highlight the key factors in the surgical decision-making case of a 16-year-old girl with GSW to the visual cortex.

CASE REPORT

A 16-year-old girl was shot in the head in a parieto-occipital trajectory with the bullet crossing midline, lodging in the occipital lobe into the straight sinus. Her initial Glasgow Coma Scale was 7, and she was urgently stabilized with intracranial pressure monitoring and external ventricular drainage. She underwent craniectomy, debridement, and irrigation and then a reoperation for further debridement and culture 2 weeks later for persistent fevers; cultures remained negative. The retained bullet was not removed. At 18 months post-injury, she had normal speech and motor function, moderate memory dysfunction, and 3-quadrant field loss with retained macular vision.

DISCUSSION/CONCLUSION

Pediatric penetrating GSWs to the head may be challenging to manage since literature is sparse. In this case, the primary focus of management was to maintain normal intracranial pressure, reduce risk of infection, and preserve potentially viable visual cortex. In the civilian context of available antibiotics and serial imaging, it may be possible to manage retained bullets conservatively without delayed complications.

Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review

BACKGROUND

Pediatric craniocerebral gunshot injuries (CGIs) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGIs merit reexamination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population.

METHODS

A systematic search was conducted. Selection criteria included all studies published since 2000, which described civilian isolated CGIs in pediatric patients. Data were analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231).

RESULTS

Initial search revealed 349 unique studies. Forty underwent full text screening, and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGIs occurred in older teenagers. Aggressive surgical treatment was recommended by one author, while remaining studies emphasized clinical judgment. Reported prognostic factors include initial Glasgow Coma Scale, pupil reactivity, involvement of multiple lobes or deep nuclei, and bihemispheric injuries. Reported complications from CGIs included seizure, meningitis, abscess, cerebrospinal fluid leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients.

CONCLUSION

This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGIs. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial Glasgow Coma Scale correlate with mortality but do not predict all patient outcomes. Patients younger than 15 years are underreported and may have differences in outcome. The literature on pediatric CGIs is limited and requires further characterization.

LEVEL OF EVIDENCE

Systematic Review, level IV.

Pediatric firearm-related traumatic brain injury in United States trauma centers

OBJECTIVE

Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death.

METHODS

All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003-2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at α < 0.001 accounting for multiple comparisons.

RESULTS

In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 ± 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3-8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 ± 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3-8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7-3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2-5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2-0.5, p < 0.001).

CONCLUSIONS

From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.

Fetal gunshot brain injury leading to late postnatal hydrocephalus

A male fetus was delivered by emergent caesarean section after a term pregnant mother was caught in crossfire and sustained gunshot injury to her abdomen. Examination of the infant was unremarkable except for a small laceration of the scalp at the anterior fontanelle. Skull radiography showed a dense bullet shaped opacity in the brain. He was managed conservatively and was discharged home on full feeds with normal neurological examination. He developed seizures and progressive hydrocephalus, and underwent a ventriculoperitoneal (VP) shunt placement at 5 weeks of age. At 13 months of age the bullet was removed. To our knowledge this is the first report of fetal brain injury with intact bullet in the brain with survival. This case provides the context for a discussion about factors that contribute to survival and favorable prognosis of infants with fetal penetrating gunshot brain injury.

Pediatric gunshot penetrating head injury: a case report with 2-year follow-up

Gunshot is a rare subset of penetrating head injury, and generally the victim dies before arriving at the hospital. This paper reported a case of an intracranial gunshot injury in a 12 year-old boy that was shot by his friend, whose primary intention was to play around, using a revolver. A missile projectile penetrated from mid frontal and came out from right occipital. Vital signs were stable with GCS 8 from physical examination. A rational management strategy should permit a good outcome. The only complications that occured were hydrocephalus, yet it was managed by VP–shunt. Skull defect was closed using titanium mesh. A two-year follow-up showed a good result. The patient was able to do daily activity and back to school again.

Pediatric intracranial gunshot wounds: the Memphis experience

OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.

Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: a retrospective single center study from Pakistan

OBJECTIVE

This study aimed to determine the risk factors associated with poor outcome of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) in pediatric patients.

METHODS

This retrospective study is conducted on pediatric population (age 1-15 years) presenting with TBI who underwent DC at our institute between January 2000 and 2010. Based on Glasgow outcome score (GOS) at a minimum follow-up of 5 months, patients were divided into two groups, namely poor outcome (GOS 1, 2, and 3) and good outcome (GOS 4 and 5). Records were reviewed and analyzed for preoperative and intraoperative predictors.

RESULTS

We found 25 patients who were eligible as per selection criteria. Mean age at presentation was 6 ± 4 years and there was male preponderance (84%). Fall (60%) was the most common mechanism of injury followed by gunshots and road traffic accident. On univariate analysis, presenting GCS ≤5 (p value = 0.009), delay in presentation of more than 150 min (p value = 0.010), DC performed after more than 4 h of arrival in hospital (p value = 0.042), and intraoperative blood loss exceeding 300 ml (p value = 0.001) were significant predictors of poor outcome.

CONCLUSION

Our study suggests that DC in children is not only a life-saving procedure, but also leads to a good functional outcome after severe injury. However, patient selection still remains an important aspect, and the above-mentioned factors should be considered while deciding for DC to improve survival. Further prospective studies on larger sample size are warranted to validate our results.

Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm

OBJECT

There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population.

METHODS

The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated.

RESULTS

Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries.

CONCLUSIONS

The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.

Pediatric head trauma

Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.