Patterns and Predictors of Cerebrovascular Injury in Patients with Self-Inflicted Gunshot Wounds
Selim G. Gebran, MD1, Samantha Day, BS2, Adekunle Elegbede, MD, PhD3, Philip J. Wasicek, MD4, Ledibabari M. Ngaage, MB BChir5, Michael P. Grant, MD, PhD1, Arthur J. Nam, MD1, Fan Liang, MD1.
1Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, MD, USA, 3Department of Plastic and Reconstructive Surgery, The Johns Hopkins University, Baltimore, MD, USA, 4Department of General Surgery, University of Maryland School of Medicine, Baltimore, MD, USA, 5Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
PURPOSE: While cerebrovascular injury from blunt head trauma has been described, little is known about the incidence of similar occult vascular injuries in patients with penetrating head trauma. At our Level I trauma center, we have noticed a high incidence of craniocervical vascular injuries in patients with self-inflicted gunshot wounds (SIGSW) occurring distantly from the bullet tract, which have led to significant neurologic morbidity and mortality. The purpose of this study is to identify risk factors leading to cerebrovascular injury in the SIGWS population, and to describe our patient outcomes.
METHODS: An institutional review board-approved retrospective study was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSW between 2007 and 2016. Vascular injuries distant from the bullet trajectory were categorized by location, type, and associated neurologic deficits. Demographic data, associated injuries and outcomes were collected. A multivariate analysis determining independent predictors of cerebrovascular injury was performed.
RESULTS: Seventy-three patients with SIGSW were identified. The average age was 43 (IQR: 29-55), with a large male predominance (M:F ratio of 9.4:1). 51 patients (70%) received a CTA at admission, of whom 17 (28%) had vascular injury distant to the bullet tract. Four patients (5%) with no lesion detected on initial imaging developed vascular findings on subsequent CTA or angiography performed for worsening neurologic deficits. Injuries in the external carotid vessels were not considered clinically significant with regard to neurologic outcomes, and were excluded (n=7, 10%). The majority of the cerebrovascular injuries were vasospasm (n=6, 43%) and pseudoaneurysms (n=4, 29%), and involved the intracerebral vessels (11, 79%) and internal carotid artery (3, 21%). Of the patients with radiographic evidence of cerebrovascular injury, four (29%) were treated with anticoagulation or interventional repair and of of those not treated 78% expired in the hospital. The most common cause of death was TBI (55%), followed by ABI (44%). A binary regression model showed that female gender (OR=24 , P=0.010), a side to side gunshot wound (OR=9.4 , P=0.019) and a base of skull fracture (OR=6.8 , P=0.039) were associated with cerebrovascular injury.
CONCLUSION: Cerebrovascular injury unrelated to vessel transection, seen in patients with SIGSW is associated with high morbidity and mortality. In this study we found that female gender, bullet trajectory and the presence of sull base fracture are siginificantly associated with an increased risk of cerebrovascular injury in this patient population.
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