Department of Neurosurgery.
J Neurosurg. 2014 May;120(5):1138-46. doi: 10.3171/2014.1.JNS131869. Epub 2014 Feb 7.
Civilian gunshot wounds to the head (GSWH) are often deadly, but some patients with open cranial wounds need medical and surgical management and are potentially good candidates for acceptable functional recovery. The authors analyzed predictors of favorable clinical outcome (Glasgow Outcome Scale scores of 4 and 5) after GSWH over a 24-month period.
The authors posited 2 questions: First, what percentage of civilians with GSWH died in the state of Maryland in a given period of time? Second, what were the predictors of favorable outcome after GSWH? The authors examined demographic, clinical, imaging, and acute care data for 786 civilians who sustained GSWH. Univariate and logistic regression analyses were used to analyze the data.
Of the 786 patients in this series, 712 (91%) died and 74 (9%) completed acute care in 9 trauma centers. Of the 69 patients admitted to one Maryland center, 46 (67%) eventually died. In 48 patients who were resuscitated, the Injury Severity Score was 26.2, Glasgow Coma Scale (GCS) score was 7.8, and an abnormal pupillary response (APR) to light was present in 41% of patients. Computed tomography indicated midline shift in 17%, obliteration of basal cisterns in 41.3%, intracranial hematomas in 34.8%, and intraventricular hemorrhage in 49% of cases. When analyzed for trajectory, 57.5% of bullet slugs crossed midcoronal, midsagittal, or both planes. Two subsets of admissions were studied: 27 patients (65%) who had poor outcome (25 patients who died and 2 who had severe disability) and 15 patients (35%) who had a favorable outcome when followed for a mean period of 40.6 months. Six patients were lost to follow-up. Univariate analysis indicated that admission GCS score (p < 0.001), missile trajectory (p < 0.001), surgery (p < 0.001), APR to light (p = 0.002), patency of basal cisterns (p = 0.01), age (p = 0.01), and intraventricular bleed (p = 0.03) had a significant relationship to outcome. Multivariable logistic regression analysis indicated that GCS score and patency of the basal cistern were significant determinants of outcome. Exclusion of GCS score from the regression models indicated missile trajectory and APR to light were significant in determining outcome.
Admission GCS score, trajectory of the missile track, APR to light, and patency of basal cisterns were significant determinants of outcome in civilian GSWH.
民用枪击头部（GSWH）通常是致命的，但一些开放性颅骨损伤的患者需要医疗和外科治疗，并且是功能恢复可接受的潜在良好候选者。作者分析了 24 个月内 GSWH 后临床预后良好（格拉斯哥结局量表评分 4 分和 5 分）的预测因素。
作者提出了两个问题：第一，在给定时间段内，马里兰州有多少民用枪击头部患者死亡？第二，GSWH 后的良好预后的预测因素是什么？作者检查了 786 名民用枪击头部患者的人口统计学、临床、影像学和急性护理数据。使用单变量和逻辑回归分析对数据进行分析。
在本系列的 786 名患者中，712 名（91%）死亡，74 名（9%）在 9 个创伤中心完成急性护理。在 69 名被收治到马里兰州一个中心的患者中，46 名（67%）最终死亡。在 48 名接受复苏的患者中，损伤严重程度评分（ISS）为 26.2，格拉斯哥昏迷量表（GCS）评分为 7.8，41%的患者存在异常瞳孔对光反应（APR）。计算机断层扫描显示中线移位 17%，基底池闭塞 41.3%，颅内血肿 34.8%，脑室出血 49%。当分析弹道时，57.5%的弹丸穿过中冠状面、中矢状面或两者的平面。对两个亚组进行了研究：27 名（65%）预后不良（25 名死亡，2 名严重残疾）的患者和 15 名（35%）预后良好的患者，平均随访 40.6 个月。6 名患者失访。单变量分析表明，入院时的 GCS 评分（p < 0.001）、弹丸轨迹（p < 0.001）、手术（p < 0.001）、对光的 APR（p = 0.002）、基底池通畅（p = 0.01）、年龄（p = 0.01）和脑室出血（p = 0.03）与结果有显著关系。多变量逻辑回归分析表明，GCS 评分和基底池通畅是预后的重要决定因素。从回归模型中排除 GCS 评分表明，弹道轨迹和对光的 APR 是决定结果的重要因素。
入院时的 GCS 评分、弹丸轨迹、对光的 APR 和基底池通畅是民用 GSWH 后结局的重要决定因素。
