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Abstract
Background and Objectives Cerebrovascular injury (CVI) following civilian gunshot wound to the head (GSWH) is likely a significant contributor to poor outcomes, but little supporting evidence exists. The purpose of this study was to determine whether intracranial CVI from GSWH and secondary vascular insult (stroke or re-hemorrhage) were associated with poor outcomes in a large civilian population.
Methods This was a single-institution, retrospective cohort study between January 2014 and July 2022, at a large, metropolitan, level-1 trauma center. Multivariate regression models and propensity score matching were used to balance baseline features including age, gender, isolated GSWH, admission Glasgow Coma Scale (GCS), trajectory type, dural penetration, bihemispheric injury, lobes involved, and intraventricular hemorrhage.
Results A total of 512 civilian patients presented with GSWH and a cohort of 172 (33.5%) met inclusion criteria with 143 (83.1%) males and a mean (SD) age of 34.3 (±14.2) years. The incidence of intracranial CVI was 50.6% (87/172 patients), including 40 (23.2%) venous sinus injuries, 32(18.6%) arterial intimal injuries/dissections, 12(7.0%) pseudoaneurysms, 10(5.8%) large vessel occlusions, 13(7.6%) transections, and 3(1.7%) high flow carotid-cavernous fistulas (Figure). Bifrontal trajectories (adjusted odds ratio [aOR] 13.11; 95% confidence interval [CI] 2.45-70.25; p=0.003) and the number of lobes traversed by the projectile (aOR 3.18; CI 1.77-5.71; p<0.001) were associated with increased odds of resultant CVI. In both the overall and propensity matched cohorts, patients with CVI were less likely to discharge home (20% vs 51%; OR 0.23; CI 0.09-0.62; p=0.015), less likely to achieve a good functional outcome of Glasgow Outcome Score (GOS) of 4-5 (34% vs. 68%; OR 0.24; CI 0.1-0.6; p=0.004), and suffered higher rate of mortality (34% vs. 20%; OR 2.1; CI 0.78-5.85; p=0.015). Among patients with a primary CVI, 28(32.2%) patients had a secondary vascular insult, which included re-hemorrhage (5[5.7%]) or delayed stroke (23[26.4%]), attributable to the underlying CVI. When compared to patients with CVI but without secondary vascular insult, patients with CVI who suffered secondary vascular insult were significantly less likely to achieve a good functional outcome GOS 4-5 (16.7% vs 39.0%; aOR 0.012; CI 0.001-0.169, p=0.001).
Conclusion These data suggest that intracranial CVI from GSWH and associated secondary vascular insult are associated with poor outcomes. Given the high prevalence and potentially reversible nature of these secondary injuries, early screening with vascular imaging and treatment of underlying cerebrovascular injury may prove critical to improve outcomes by reducing the rate of stroke and re-hemorrhage.
Disclosures J. Lamanna: None. J. Gutierrez: None. A. Alawieh: None. C. Funk: None. R. Rindler: None. F. Ahmad: None. B. Howard: None. S. Gupta: None. D. Gimbel: None. R. Smith: None. G. Pradilla: None. J. Grossberg: None.