Pediatric Head Gunshot Wounds, Clinical, Radiological, and Laboratory Findings: A Comprehensive Systematic Review and Meta-Analysis of 4012 Patients.

Abstract

Gunshot wounds to the head (GSWH) constitute a significant cause of mortality among children. The present management of these firearm injuries is derived from adult traumatic brain injury guidelines. This study systematically evaluates the clinical, radiological, and laboratory findings in pediatric patients with GSWH using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A comprehensive literature search was conducted across four databases. Proportions and 95% confidence intervals were calculated using random-effects or common-effects models, and binary and continuous outcomes were analyzed using odds ratios (ORs) and standardized mean differences, respectively. We included 23 studies with 4012 pediatric patients with GSWH. The overall mortality rate, bilateral fixed pupils, hydrocephalus, St. Louis Scale (SLS) ≥ 5, bihemispheric injuries, and vascular injury on cerebral angiography were reported in 39.6%, 21.5%, 14.4%, 50.6%, 22.6%, and 22.8% of patients, respectively. Patients who died were significantly more likely (OR 25.56, p value = 0.0199) to have an admission Glasgow Coma Scale score of ≤ 8, a higher rate of bilateral fixed pupils (OR 50.98, p value < 0.0001), a higher mean SLS (standardized mean difference 0.98, p value < 0.0001), and greater number of patients with an SLS ≥ 5 (OR 9.97, p value < 0.0001) to receive no neurosurgical intervention (OR 9.03, p value < 0.0001) than those who survived. Radiologic and laboratory findings demonstrated a significant association with a transventricular projectile trajectory (OR 17.25, p value < 0.0001), midline shift (OR 2.27, p value = 0.0039), and deep nuclear or third ventricular injury (OR 9.73, p value < 0.0001), base deficit less than - 5.0 mEq/L (OR 3.67, p value = 0.0016), international normalized ratio > 1.5 (OR 4.28, p value = 0.029), and hematocrit < 30% (OR 2.7, p value = 0.016) compared with those who survived. Our meta-regression findings showed that only age was significantly associated with a higher mortality rate. This is the first and largest meta-analysis of pediatric GSWH. Our meta-analysis provides clinical, radiological, and laboratory factors associated with mortality in pediatric patients.