title: Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Neurological Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, Missouri 63110, USA. bandtk@wudosis.wustl.edu
authors.forename: S Kathleen
authors.initials: SK
authors.lastname: Bandt
authors.forename: Jacob K
authors.initials: JK
authors.lastname: Greenberg
authors.forename: Chester K
authors.initials: CK
authors.lastname: Yarbrough
authors.forename: Kenneth B
authors.initials: KB
authors.lastname: Schechtman
authors.forename: David D
authors.initials: DD
authors.lastname: Limbrick
authors.forename: Jeffrey R
authors.initials: JR
authors.lastname: Leonard
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D020197:Head Injuries, Penetrating / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D008297:Male; D008499:Medical Records; D008923:Missouri; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D014948:Wounds, Gunshot / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*