Patient selection: high-velocity gunshot or shrapnel wound to the head
Risk factors for a poor outcome:
(1) low Glasgow Coma Score (GCS) on admission (<= 7)
(2) presence of skull base injury
(3) multi-lobar or bifrontal injuries
(4) involvement of the ventricles
Shrapnel injuries were associated with a lower mortality rate than missile injuries.
Early and aggressive surgical management reduced mortality. This included debridement of potential sources of infection (necrotic tissue, hair, foreign debris, bone) and evacuation of hematomas.
Indications for surgery included:
(1) signs of elevated intracranial pressure
(1a) with or without epidural, subdural or intracerebral hematoma
(1b) with or without neurological deterioration
(1c) with or without shift of midline structures on the head CT scan
(2) presence of a missile or shrapnel trajectory
(3) depressed or fragmented skull fracture
(4) presence of intracranial bony fragments and/or foreign materials
(5) extensive scalp tissue loss with ongoing hemorrhage
