Petridis A K, Doukas A, Barth H, Mehdorn M
Neurosurgery, University Kiel, Schittenhelmstraße 10, Kiel, Germany.
Cent Eur Neurosurg. 2011 Feb;72(1):5-14. doi: 10.1055/s-0029-1241850. Epub 2010 Mar 22.
Gunshot wounds to the head are rare in Europe. They may be inflicted by low-velocity handguns, captive bolt guns and tear gas cartridges and mostly result from suicide attempts. The experience of neurosurgeons with this kind of traumatic injury is decreasing; the aim of this study was therefore to analyse prognostic factors which help to decide whether or not to operate and to discuss treatment options.
Thirty patients with gunshot head injuries treated in our hospital from 1993 to 2008 were retrospectively evaluated. Glasgow Coma Scale (GCS) score, pupil reactivity, lesion localisation, number of bone fragments, intracranial pressure (ICP), midline shift, hypotension, and dural penetration were analysed for their prognostic value. Surgically and non-surgically treated patients were evaluated separately. Complications were registered.
A low GCS of 3-8, fixed pupils, >2 bone fragments, bilobar or posterior fossa/brainstem lesions and ICP >45 mmHg were indicators of a poor prognosis.
Patients with a GCS of 3-8 and two non-reactive pupils should not be operated. If one or both of the pupils are reactive, surgery should be performed irrespective of the GCS score, except in patients with translobar/transventricular wounds. Even if there are no clear contraindications to surgery, the outcome is expected to be poor in patients with a low GCS score, midline shift >10 mm, >2 bone fragments in the brain, and a bilobar, posterior fossa/brainstem or ventricular lesion and ICP >45 mmHg. When surgery is performed the wound and the missile or bone track should be debrided meticulously, the wound and dura should be closed in a watertight fashion and antibiotic prophylaxis as well as tetanus serum should be given.
头部枪伤在欧洲较为罕见。此类枪伤可能由低速手枪、栓式宰牲枪和催泪弹造成，且大多源于自杀未遂。神经外科医生处理这类创伤性损伤的经验日益减少；因此，本研究旨在分析有助于决定是否进行手术的预后因素，并探讨治疗方案。
回顾性评估了1993年至2008年在我院接受治疗的30例头部枪伤患者。分析了格拉斯哥昏迷量表（GCS）评分、瞳孔反应性、损伤部位、骨碎片数量、颅内压（ICP）、中线移位、低血压和硬脑膜穿透情况的预后价值。分别对手术治疗和非手术治疗的患者进行评估。记录并发症情况。
GCS评分为3 - 8分、瞳孔固定、骨碎片>2块、双叶或后颅窝/脑干损伤以及ICP>45 mmHg是预后不良的指标。
GCS评分为3 - 8分且双侧瞳孔无反应的患者不应进行手术。如果一个或两个瞳孔有反应，无论GCS评分如何，均应进行手术，但经叶/经脑室伤口的患者除外。即使没有明确的手术禁忌证，GCS评分低、中线移位>10 mm、脑内骨碎片>2块、双叶、后颅窝/脑干或脑室损伤且ICP>45 mmHg的患者预后也可能较差。进行手术时，应仔细清创伤口和弹道或骨道，严密缝合伤口和硬脑膜，并给予抗生素预防以及破伤风血清。
