Penetrating cerebrovascular injuries in a pediatric cohort with intracranial gunshot wounds: incidence, characterization of injury type, and clinical outcomes.

Objective: Firearm injuries are now the leading cause of death in children and adults younger than 25 years in the United States and are associated with high morbidity and mortality. However, literature on penetrating cerebrovascular injuries (PCVIs) after intracranial gunshot wound (GSW) injury in the pediatric population is limited. The authors investigated the incidence, radiological characteristics, and clinical outcomes associated with PCVI in children and young adults with intracranial GSW injuries.

Methods: This was a retrospective cohort study of patients younger than 21 years admitted with an intracranial GSW from August 2012 to December 2022 at a single, metropolitan, level I trauma center. Univariate and multivariate logistic regression models were used.

Results: A total of 147 patients presented with intracranial GSW injuries. A cohort of 96 patients (65.3%) met the inclusion criteria, of which 38 (39.6%) underwent vascular cranial imaging and were included in the analysis. The median age was 18 years (range 1-21 years), with 29 (76.3%) males and 9 (23.7%) females. The incidence of PCVI in this cohort was 44.7% (17/38), with an inpatient mortality of 47.1%. A total of 22 vascular injuries (19 [86.4%] arterial, 3 [13.6%] venous) were identified on vascular imaging, including 7 pseudoaneurysms (31.8%), 7 occlusions (31.8%), 5 transections (22.7%), 2 dissections (9.1%), and 2 arteriovenous fistulas (AVFs) (9.1%). Thirteen of 38 patients (34.2%) underwent both CT angiography (CTA) and digital subtraction angiography (DSA) during admission, and 3 of 13 (23.1%) had results that were negative on screening CTA but positive on DSA for PCVI. Patients with PCVI had twice the mortality rate compared with those without (47.1% vs 23.8%, p = 0.133). Patients without PCVI were more likely to have a favorable functional outcome (Glascow Outcome Scale score ≥ 4) compared with those with PCVI (76.2% vs 41.2%, p = 0.028). Multivariate logistic regression, adjusting for age and admission GCS score, showed injury to ≥ 3 lobes was independently associated with PCVI (adjusted OR 6.2, 95% CI 1.05-36.6, p = 0.044).

Conclusions: PCVI occurred in nearly half (44.7%) of children and young adults with intracranial GSW injuries who underwent vascular imaging. PCVI could have a negative impact on functional outcomes in survivors. Early screening, repeat vascular imaging, and informed management are essential to improve outcomes.