title: Predictors of outcome in civilians with gunshot wounds to the head upon presentation.
abstract: OBJECTIVE
  Prediction of outcome from initial presentation after a gunshot wound to the head (GSWH) is essential to further clinical decision making. The authors' goals are to report the survival and functional outcomes of these patients, to identify prognostic factors, and to propose a scoring system that can predict their outcome.
  
  
  METHODS
  The records of 199 patients admitted with a GSWH with dural penetration between 1990 and 2008 were retrospectively reviewed. The inclusion criterion was a CT scan available for review. Patients declared brain dead on presentation were excluded, which yielded a series of 119 patients. Statistical analysis was performed using a logistic regression model.
  
  
  RESULTS
  Fifty-eight (49%) of the 119 patients died. Twenty-three patients (19%) had a favorable outcome defined as a 6-month Glasgow Outcome Scale (GOS) score of moderate disability or good recovery, 35 (29%) had a poor outcome (GOS of persistent vegetative state or severe disability), and 3 (3%) were lost to follow-up. Significant prognostic factors for mortality were age older than 35 years, nonreactive pupils, bullet trajectory of bihemispheric (excluding bifrontal), and posterior fossa involvement compared with unihemispheric and bifrontal. Factors that were moderately associated with higher mortality included intracranial pressure (ICP) above 20 mm Hg and Glasgow Coma Scale (GCS) score at presentation of 3 or 4. Upon multivariate analysis, the significant factors for mortality were bullet trajectory and pupillary response. Variables found to be significant for good functional outcome were admission GCS score greater than or equal to 5, pupillary reactivity, and bullet trajectory of unihemispheric or bifrontal. Factors moderately associated with good outcome included age of 35 years or younger, initial ICP 20 mm Hg or lower, and lack of transventricular trajectory. In the multivariate analysis, significant factors for good functional outcome were bullet trajectory and pupillary response, with age moderately associated with improved functional outcomes. The authors also propose a scoring system to estimate survival and functional outcome.
  
  
  CONCLUSIONS
  Age, pupils, GCS score, and bullet trajectory on CT scan can be used to determine likelihood of survival and good functional outcome. The authors advocate assessing patients based on these parameters rather than pronouncing a poor prognosis and withholding aggressive resuscitation based upon low GCS score alone.
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, Houston, Texas;
authors.forename: Loyola V
authors.initials: LV
authors.lastname: Gressot
authors.forename: Roukoz B
authors.initials: RB
authors.lastname: Chamoun
authors.forename: Akash J
authors.initials: AJ
authors.lastname: Patel
authors.forename: Alex B
authors.initials: AB
authors.lastname: Valadka
authors.forename: Dima
authors.initials: D
authors.lastname: Suki
authors.forename: Claudia S
authors.initials: CS
authors.lastname: Robertson
authors.forename: Shankar P
authors.initials: SP
authors.lastname: Gopinath
mesh_terms: D000270:Adie Syndrome / Q000150:complications / Q000175:diagnosis; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002648:Child; D006259:Craniocerebral Trauma / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality*; D004185:Disability Evaluation; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D020300:Intracranial Hemorrhages / Q000150:complications / Q000175:diagnosis; D019586:Intracranial Hypertension / Q000150:complications / Q000175:diagnosis; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D014948:Wounds, Gunshot / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality*; D055815:Young Adult
keywords: AIS = Abbreviated Injury Scale; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; GSWH = gunshot wound to the head; Glasgow Coma Scale; ICP = intracranial pressure; gunshot wound to the head; outcome; penetrating head injury; traumatic brain injury