Prognostic factors and treatment of penetrating gunshot wounds to the head.
BACKGROUND
In an attempt to evaluate the predictive factors of morbidity and mortality in patients who suffered from civilian gunshot wounds to the head, we reviewed a series of 319 patients admitted to the Hospital Santa Marcelina, São Paulo, Brazil, between 1994 and 2000.


METHODS
Clinical and cranial computed tomography (CT) results are described. The initial Glasgow Coma Scale (GCS), the presence of an unilateral dilated pupil or medium fixed pupils, and five different findings in the CT scan were considered as variables. The Qui-Square Fisher test was utilized to verify the correlation between the presence of the variables and the occurrence of an increased mortality rate and of an unfavorable outcome (Glasgow Outcome Scale = 2 and 3).


RESULTS
In 265 cases the missile penetrated the dura (83%). In our study there was a significant correlation between the low GCS scores on admission and a higher mortality (p < 0.001). This kind of correlation was also noted with patients admitted with unilateral dilated pupil and medium fixed pupil. There were 187 patients (70.5%) evaluated by CT scan. There was a significant correlation between the presence of transventricular or bihemispheric central type trajectory and high mortality. The patients admitted with unilobar supratentorial wounds resulted in better outcome when compared to those with bilobar or multilobar wounds (p < 0.001). A group of 156 patients was submitted to an aggressive surgical protocol. The best results were seen in patients admitted with initial GCS score higher than 8.


CONCLUSIONS
We conclude that low GCS scores at admission, unilateral dilated pupil or medium fixed pupil, transventricular or bihemispheric central type trajectory, and bilobar or multilobar wounds noted through CT scan are predictive factors of high morbidity and mortality in patients with gunshot wounds to the head, in our clinical experience. We also conclude that surgical treatment is not recommended for patients with penetrating wounds and GCS score of 3 to 5 in the absence of hematoma causing a mass effect.
Martins
Roberto S
RS
Department of Neurosurgery, Hospital Santa Marcelina, São Paulo, SP, Brazil
Siqueira
M G
MG
Santos
M T S
MT
Zanon-Collange
N
N
Moraes
O J S
OJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D006233:Persons with Disabilities / Q000706:statistics & numerical data; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D014948:Wounds, Gunshot / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*