Surgical versus nonsurgical management of civilian craniocerebral gunshot injuries

Introduction

Craniocerebral gunshot wounds in the civilian population constitute a devastating subset of traumatic brain injuries (TBI). The aim of this study was to determine the association of mortality, intensive care unit length of stay (ICU LOS), and the Glasgow Outcome Scale Extended (GOS-E) among craniocerebral gunshot patients based on timing and type of intervention.

Methods

The trauma database was queried for GSWH patients ages 15 and older who received neurosurgical intervention from January 1st 2016 to June 1st 2023. Operative notes were reviewed and patients were then divided into three groups; intracranial pressure monitor only with medical treatment (ICP), primary decompressive craniectomy (pDC), or secondary decompressive craniectomy (sDC). The Surviving Penetrating Injury to the Brain (SPIN) score was calculated. Outcomes included mortality, ICU LOS, and GOS-E.

Results

Overall, 72 patients were identified who underwent either decompressive craniectomies or ICP monitoring. Mean SPIN scores were similar: ICP, pDC and sDC (30.5, 32.67, 31.55 (p = 0.4252)). When comparing two groups, the odds of death was higher in the ICP group compared to the pDC group (OR = 3.71, 95 % CI = 1.06, 14.35). With regard to hospital trajectory, ICU LOS (mean days) was different among the groups: ICP, pDC, sDC (16.7, 17.4, 23.4; p = 0.0002).

Conclusion

Mortality was reduced with primary decompressive craniectomy when compared to ICP monitoring with medical management alone and is associated with shorter ICU LOS compared to secondary decompressive craniectomy. In the appropriately selected patient, early and aggressive decompression should be considered.