TO THE EDITOR: I have read with great interest the article by Gressot et al.1(Gressot LV, Chamoun RB, Patel AJ, et al: Predictors of outcome in civilians with gunshot wounds to the head upon presentation.J Neurosurg 121:645–652, September 2014). The authors concluded that several factors, including patient age, Glasgow Coma Scale score, nonreactive pupils, and the path of the bullet and its fragments on CT scans, have predictive value for patient survival, and they created a scoring system based on these parameters. In their series of 119 patients 19% had good functional survival. We published an article in 1979 dealing with the same issues.2在我们的研究中枪伤苏的82名患者stained in civilian life, we evaluated the same presentation parameters as the authors and we assessed functional outcome. We also evaluated surgical findings, specifically the incidence of hematomas either at surgery or at autopsy in all patients who did not survive. Although we evaluated the importance of the same criteria, we concluded that the only truly meaningful parameter predicting patient survival was the state of consciousness on admission. While all the other parameters had some value, they were of secondary importance in predicting survival and its quality. There were 4 groups of patients based on the state of consciousness at the time of presentation: I) alert, awake; II) obtundation with or without neurological deficit; III) unresponsive to all but noxious stimulation in appropriate or semi-appropriate fashion; and IV) comatose inappropriate or no response at all.
We have found that this system provides as useful information as the point system proposed by the authors, although it is substantially simpler. Adding additional information did not increase the accuracy or reliability of our basic scale. For instance, while a bihemispheric bullet path generally indicates a poor prognosis, if the examination results fall into Group I or II, it is the state of consciousness that determines the prognosis rather than the path of the bullet. Similarly, if a patient has fixed, dilated pupils, the prognosis is poor, but patients in this case will undoubtedly be comatose with, at best, a decerebrate posture, which would place them in Group IV in which there are no survivors. Again, it is the state of consciousness that determines outcome. This simplified neurological examination makes it easier to rapidly assess patients with gunshot wounds, particularly if non-neurosurgeons in the emergency department triage the patients. It provides rapid and accurate early information for patients and their families.
I was intrigued by the fact that in our study, 39% of patients achieved a functional survival status compared to 19% in the authors’ study. The extent of injury caused by a bullet is determined to the greatest degree at the time of impact and is dependent on bullet mass and exit muzzle velocity squared. Passage of the bullet through brain tissue creates waves of massive increases in intracranial pressure in the wake of the bullet. Based on the above formula, the damage is greater with a greater bullet mass and greater muzzle exit velocity such as that seen in military grade weapons. Thus, the degree of neurological deficit is determined at time of impact in most instances. The development of mass lesions, such as hematomas, is rare and was seen in only 10% of our cases. Admitting that neither the authors nor we have studied the ballistic profile of the guns used, it is tempting to think that the difference in functional survival between our studies most likely reflects the currently greater availability of better quality weapons with larger bullet sizes and greater muzzle exit velocities. These cause much more damage than the “Saturday night specials” commonly used at the time of our study and could explain this discrepancy.
The authors are to be congratulated for continuing to study the problem of gunshot injuries, which are becoming more and more serious, particularly with easier access to higher-grade weapons in the civilian population.
References
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1 ↑
GressotLV,,ChamounRB,,PatelAJ,,ValadkaAB,,SukiD,&罗伯逊CS,et al.:Predictors of outcome in civilians with gunshot wounds to the head upon presentation.J Neurosurg121:645–652,2014
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2 ↑
HubschmannO,,ShapiroK,,BadenM,&ShulmanK:Craniocerebral gunshot injuries in civilian practice—prognostic criteria and surgical management: experience with 82 cases.J Trauma19:6–12,1979
