Introduction: Gunshot wounds to the head are usually mortal injuries. Their frequency has been increasing in the last years because of increasing crime rates. Gunshot wounds to the head require close clinical and diagnostic cooperation of the neurosurgeon and radiologist, detailed assessment of skull and brain damage, and finally prompt treatment. Emergency Computed Tomography (CT) makes a useful tool for depicting bullet course and brain damage, and thus helps plan treatment. We investigated the CT signs of subdural hematoma, lacerocontusive focus, subarachnoid hemorrhage, hemoencephalus, skull bone fracture and thecal hollow and report them as an aid to the neurosurgeon and the radiologist, for best treatment planning, and in an attempt to establish useful prognostic criteria.
Material and methods: We retrospectively reviewed 23 cases of gunshot injuries to the head studied with CT at the Emergency Unit of Loreto Mare Hospital in Naples, Italy. Twenty patients were men and 3 women; their mean age was 31 years (range: 18-49). Three women and 2 men had been injured accidentally by wandering bullets, and one case was an attempted suicide; all the other cases resulted from shootings. CT slices were 10 mm thick, with 8 mm gap (5 mm in complex injuries and when posterior cranial fossa was involved); all scans were unenhanced.
Results: We found 22 penetrating gunshot wounds: 13 of them with thecal entry hole and intracranial bullet retention and 9 with an entry and an exit hole. One case was a superficial wound. Crash skull fractures were seen in 22 cases and they were fragmented in 12, with overlapping thecal fragments in 4, and with deep fragments in 2 cases. There were scattered bone splinters in 3 cases and the bullet was retained in the mastoid bone in one case. Lacerocontusive foci were assessed in 22 cases, brain swelling in 20, subarachnoid hemorrhage in 19, brain hematoma in 15, blood in the ventricular system in 9, pneumoencephalus in 7, air bubbles along the bullet course in 7, impression on ventricula and linear structures in 7, interhemispheric blood in 5, and finally blood effusion in Sylvian scissure in 4 cases.
Discussion and conclusions: Gunshot wounds to the head are complex and severe traumas with high mortality rates because of both early and late effects and complications. CT provides the neurosurgeon with abundant findings for diagnosis and surgical planning, which may result in improved survival rates. In these patients emergency CT plays a fundamental diagnostic role in depicting brain damage and thus remains the method of choice for thorough, rapid and accurate brain and skull studies, as well as to detect possible injury to the chest and abdomen.