Outcome and Prognostic Factors of Surgically Treated Patients with Civilian Gunshot Wound to the Head in an Ethiopian Trauma Center

Abstract

Background Cerebral gunshot wounds are among the most lethal forms of traumatic brain injury, with limited literature available from low-income countries. To the best of the authors' knowledge, no studies have been reported in Ethiopia. This study aims to review our experience, patterns, and outcomes of civilian gunshot injuries treated surgically at a major trauma center in Ethiopia's capital.

Methods A single-institution, hospital-based study was conducted at a major trauma center in Ethiopia over 4 years (September 1, 2018–November 30, 2022). This study involved 42 patients with civilian gunshot wounds to the head who underwent surgical treatment. Postoperative functional outcomes were meticulously assessed using the Glasgow Outcome Scale Extended (GOSE), with comprehensive statistical analysis performed using SPSS version 27.0.

Results Among the 42 patients included in this study, 83.3% were male, with a mean age of 26.7 years. Notably, 84% of patients presented to our hospital more than 24 hours postinjury, and 83% of injuries were attributed to interpersonal violence. Glasgow Coma Scale (GCS) scores at presentation ranged as follows: 14.3% of patients had a GCS of 3 to 8, 28.6% had a GCS of 9 to 13, and 57% had a GCS of 14 to 15. The overall mortality rate was 24%, while a favorable outcome, defined as a GOSE score greater than 4, was observed in 62% of patients. Significant prognostic factors for mortality included age over 30 years, a GCS score below 9, pupillary reaction abnormalities, higher Rotterdam computed tomography (CT) scores, bullet trajectory, and surgery duration exceeding 4 hours. Multivariate analysis identified age over 30 years, a GCS score below 9, and surgery duration exceeding 4 hours as significant predictors of unfavorable outcomes.

Conclusion Cerebral gunshot wounds are associated with substantial mortality and morbidity. Our study highlights significant delays in reaching definitive care and identifies key prognostic factors such as age, GCS score, pupillary reaction, Rotterdam CT score, bullet trajectory, and duration of surgery. Targeted interventions and tailored surgical approaches could improve survival rates and functional outcomes for cerebral gunshot wounds. Moreover, violence prevention, rapid medical response, and investment in trauma care systems are crucial for enhancing patient outcomes, especially in low-income countries.

 

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Keywords

gunshot wound to head - low income countries - prognosis - outcome

Introduction

Civilian gunshot wounds to the head (GSWH) are devastating injuries caused by projectiles, such as bullets and fragments from explosives. These injuries can result in a wide range of cranial lesions, from skin openings to severe cerebral bleeding and brainstem damage. While GSWHs are generally uncommon outside military settings, civilian firearm-related violence is a significant global health concern. It poses a substantial socioeconomic burden due to lost productivity, increased health care costs, and reduced life expectancy.[1] [2] [3] [4]

In Ethiopia, although no published studies exist on the prevalence of firearm-related violence, clinical experience indicates that GSWHs are a prevalent cause of severe traumatic brain injury (TBI), leading to higher health care costs and lost productivity.[5] Given the high mortality rate associated with cerebral gunshot injuries, it is crucial to identify predictors of increased risk to aid clinicians in determining optimal treatment strategies early on. With the growing financial strain on health care systems, the allocation of limited resources has become a critical issue, making studies on prognosis and outcomes essential for informed decision-making.

Firearm-related brain injuries are associated with poor outcomes, particularly in resource-limited settings where justifying the use of resources during acute hospitalization and rehabilitation is vital. Despite aggressive management, the grim statistics of mortality and neurological outcomes raise important questions about which patients benefit the most from such interventions.[6] [7] [8] [9] [10] [11] This study aims to address the gap in evidence-based practice for the surgical management of civilian GSWH patients in resource-limited countries. By assessing short-term surgical outcomes and identifying key prognostic factors, we aim to assist neurosurgeons in making informed decisions and providing standard care. Additionally, understanding the sociodemographic patterns and clinical profiles of these patients may aid in formulating effective preventive measures.

 

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Methods

We retrospectively assessed 42 patients who sustained civilian gunshot injuries and presented to the trauma center, undergoing surgical intervention over 4 years from September 1, 2018, to November 30, 2022. All civilian GSWH patients treated surgically during the study period who met the inclusion criteria were included, with their 6-month outcomes assessed using the Glasgow Outcome Scale Extended (GOSE). Exclusion criteria were patients with less than 6 months of follow-up, lost charts, military personnel with war injuries, and nondural piercing GWSH.

Patient characteristics studied included age, sex, GCS after resuscitation, time from injury to surgery, mean arterial pressure/systolic blood pressure on arrival, SaO2 at presentation, episodes of hypotension, hypoxia, fever, random blood sugar, pupillary condition at presentation, midline shift, midline crossing/bihemispheric penetration, ventricular involvement, motive/intention of injury, postoperative complications, mode of injury, unilateral or multilobar involvement, and Rotterdam CT score. Data were obtained retrospectively through chart reviews and patient phone interviews using structured questionnaires. Collected information encompassed demographic data, clinical data from initial emergency room evaluations, computed tomography (CT) scan findings, details of the surgical procedure, and postoperative outcomes. Functional outcomes at the time of the study were assessed using the GOSE.

Statistical Analysis

Descriptive analyses were conducted, and the chi-square test was utilized when appropriate. The binary logistic regression model identified factors associated with unfavorable functional outcomes. Both bivariate and multivariate odds ratios and their 95% confidence intervals were calculated. A p-value of ≤0.05 was considered statistically significant. Statistical analysis was performed using IBM SPSS software version 27.

 

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Results

Between September 2018 and November 2022, a total of 130 patients with a diagnosis of penetrating TBI were operated on at the Department of Neurosurgery in AaBET hospital, which is the major trauma center in the country. The majority of these patients sustained a nonmissile penetrating brain injury. Among those operated on with civilian GSWH, 42 patients fulfilled the inclusion criteria and were retrospectively reviewed. All received prophylactic broad-spectrum triple antibiotics (vancomycin, ceftriaxone, and metronidazole) and antiseizure medication. Based on each patient's clinical and radiologic indication, appropriate emergency surgical intervention was taken. Surgeries include debridement and duraplasty of entry and/or exit wounds, craniotomy and evacuation of extra-axial or intracerebral hematoma, or decompressive craniectomy. Duraplasty was performed with pericranial tissue. Due to the unavailability of artificial dura in the country, it was not utilized in any of the procedures.

Sociodemographic Characteristics

Of the 42 patients included in this study ([Table 1]), 35 were males (83%) and 7 females (17%), with a male-to-female ratio of 5:1. The mean age was 26.7 ± 12.1 years (range: 8–70 years). Most injuries occurred in the 2nd, 3rd, and 4th decades, thus revealing a predominantly affected younger population. A total of 67% of patients were between the ages of 19 and 40 years, whereas children under the age of 18 accounted for 26%.

 

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Clinical and Radiographic Findings

The mean GCS score at presentation was 12, with a range of 6 to 15. Patients with a GCS of 13 to 15 constituted 64% of the cohort ([Table 2]). Eight patients (14%) presented with an initial GCS of ≤ 9. A GCS score below 9 was linked to significantly higher mortality and unfavorable outcomes (odds ratio [OR]: 45, p = 0.03). Patients with a GCS of 9 or less experienced a mortality rate of 38% and an overall unfavorable outcome rate of 88%. Conversely, those with a GCS of 10 to 15 had a mortality rate of 21% and an overall unfavorable outcome rate of 27%. A GCS score of 10 to 15 was significantly associated with favorable outcomes. Our series revealed that 83% of patients arrived at our center more than 24 hours posttrauma, and 70% of deaths occurred in these patients with a >24-hour injury-to-surgery interval.

Of the patients, 71.5% exhibited normal pupillary light reactions, whereas 9.5% had unilateral abnormalities and 19% had bilateral abnormalities. Abnormal pupillary reactions, either unilateral or bilateral, were significantly associated with increased mortality on bivariate analysis (OR: 63; p = 0.001). Notably, 75% of patients with unilateral or bilateral pupillary abnormalities succumbed, compared with a 3% mortality rate among those with normal responses. Interestingly, there was no significant difference in mortality or functional outcomes between patients with bilateral nonreactive pupils and those with unilateral abnormalities.

All patients underwent CT scans, and their Rotterdam scores were calculated ([Table 3]). Among the participants, 76% had Rotterdam scores of 1 to 3, whereas the remaining 24% had scores of 4 to 6. Bivariate analysis demonstrated a strong correlation between Rotterdam scores of 4 to 6 and unfavorable functional outcomes (OR: 12, 95% confidence interval [CI]: 2.1–68; p = 0.005), although this association was not significant in multivariate analysis. Patients with Rotterdam scores of 4 to 6 exhibited a 50% mortality rate, compared with 15% in the 1 to 3 group.

In this series, penetrating injuries were the most prevalent type of wound (69%), followed by perforating injuries (21%). Perforating bullet injuries were associated with poorer outcomes; of the nine patients with this type of injury, four died (44%) compared with a 21% mortality rate (6 of 23 patients) for penetrating bullet injuries, and no mortality for tangential brain injuries. The most common motive of injury was homicide (83% of patients), followed by accidental (10%) and suicide (7%).

Although patients with bihemispheric involvement had a 35% mortality rate (7 of 13 patients) compared with 14% in those with only one hemispheric injury (3 of 19 patients), this difference was not statistically significant. Among survivors, 50% of those with bilateral hemispheric injury had favorable outcomes compared with 73% in those without bihemispheric involvement. The ventricular injury did not show a significant association with mortality or unfavorable outcomes; however, patients with trans ventricular bullet trajectories had a 63% overall rate of unfavorable outcomes (five out of eight patients), whereas those without ventricular involvement had a 32% rate (11 of 23 patients). The mortality rate for patients with ventricular injuries was 50%. However, among the survivors with ventricular involvement, only 38% had favorable functional outcomes.

 

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Management

All 42 patients underwent surgical procedures tailored to the specific characteristics of each case. The types and durations of surgeries are summarized in [Table 4]. Debridement and duraplasty of entry and/or exit wounds were performed on 67% of patients, whereas decompressive craniectomy was performed on 19%. A surgery duration of 4 hours or more was significantly associated with unfavorable outcomes in multivariate analysis (OR: 13, 95% CI: 1.2–155; p = 0.037). Notably, 75% of decompressive craniectomies, 67% of craniotomies, and none of the debridement and duraplasty procedures lasted 4 hours or longer. Patients undergoing surgeries lasting 4 hours or more had a 50% mortality rate, compared with a 16% mortality rate for those with surgeries lasting less than 4 hours. Postoperatively, 28% of patients were admitted to the intensive care unit for various reasons. The mean length of hospital stay was 19.3 days, with a range of 2 to 108 days. [Table 4] provides a detailed summary of the management-related findings.

Table 1 Sociodemographic features of study participants in AaBET (n = 42)

Variables		N (%)
Sex	Male	35(83.3)
	Female	7(16.7)
Age	<18	11(26.2)
	19-30	19(45.2)
	31-40	9(21.4)
	>41	3(7.1)
Intention of Injury	Suicide	3(7.1)
	Homicide	35(83.3)
	Accidental	4(9.5)

Table 2 Preoperative clinical characteristics of study participants in AaBET (n = 42)

Variables		N (%)
Time from injury to surgery	> = 24hrs	35 (83.3%)
	< 24 hours	7 (16.7%)
GCS	3-8	6 (14.3%)
	9-13	12 (28.6%)
	14-15	24 (57.1%)
Pupillary condition	Bilateral abnormality	8 (19.0%) 4 (9.5%)
	Unilateral abnormality	4(9.5%)
	normal	30 (71.4%)
Mode of injury	penetrating	29 (69.0%)
	perforating	9 (21.4%)
	tangential	4 (9.5%)

Table 3 Preoperative radiologic findings of study participants in AaBET (N = 42)

Variables		N (%)
Rotterdam CT score	4–6	10 (23.8%)
	≤3	32 (76.2%)
Retained material*	Yes	39 (92.9%)
	No	3 (7.1%)
Bihemispheric penetration	Yes	20 (47.6%)
	No	22 (52.4%)
Ventricular involvement	Yes	8 (19.0%)
	No	34 (81.0%)

Table 4 Management-related findings of study participants in AaBET (42)

Variables		N (%)
Surgery done	Decompressive craniectomy	8 (19.0)
	Craniotomy	6 (14.3)
	Entry/exit site debridement and duraplasty	28 (66.7)
Duration of surgery	≥4 h	10 (23.8)
	<4 h	32 (76.2)
Admission to intensive care unit		12 (28.6)
Length of in-hospital stay, mean (range, standard deviation [SD])		19.3 d (range 2–108, SD = 21.5)
Length of in-hospital	> 30 d	10 (23.8)
	5–30 d	27 (64.3)
	<5 d	5 (11.9)

 

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Postoperative Outcome

The overall mortality rate was 24%, with 10 of the 42 patients succumbing to their injuries. Of these, 7 (17%) died in-hospital, whereas 3 (7%) patients died postdischarge during follow-up. A favorable outcome, defined as a GOSE score greater than 4, was observed in 26 patients (62%). Six patients (14%) survived but had poor outcomes, defined as GOSE scores of 2 to 4 ([Fig. 1]). The mean follow-up period was 4 months (range: no follow-up to 9 months).

Fig. 1 Final GOSE at the time of study of study participants in AaBET (N = 42).

Significant factors associated with mortality and unfavorable outcomes included age over 30 years, initial GCS below 9, abnormal pupillary reactions, Rotterdam CT scores of 4 or higher, surgery duration exceeding 4 hours, surgical site infections, and chest infections. Retained bone, metal fragments, or both were visible in the initial CT scans of 93% (39 out of 42) of the patients. Surgical site infections, ranging from superficial SSS to subdural empyema and brain abscess, occurred in 11 patients (26%), leading to prolonged hospital stays, with 64% experiencing stays longer than 30 days compared with 10% in those without surgical site infections (SSI). Six patients who developed SSI (55%) required reoperation for debridement and abscess drainage.

The overall reoperation rate was 17% (7 out of 42 patients), with six reoperations for SSI treatment and one for bone flap replacement. Postoperative chest infections resulted in a 9-fold increase in mortality, with a 63% mortality rate (3 out of 5 patients) compared with a 15% mortality rate in those without chest infections (p = 0.01 on bivariate analysis), although this was not statistically significant on multivariate analysis. Noninfectious complications included electrolyte imbalances (12%), posttraumatic seizures (10%), and coagulopathy (5%), none of which showed significant associations with mortality or morbidity ([Table 5]).

Table 5 Postoperative complications of study participants in AaBET (n = 42)

Variables	N (%)
Complications
Surgical site infection	11 (26.2)
Chest infection	8 (19.0)
Electrolyte disturbance	6 (13)
Posttraumatic seizure	4 (9.5)
Coagulopathy	2 (4.7)
In-hospital death	7 (16.7)
Reoperation	7 (16.7)
Death during follow-up	3 (7.1)
Overall complication rate	16 (38)

Multivariate analysis included variables that were strongly significant in bivariate analysis. Factors found to be strong prognostic indicators of unfavorable outcomes were age over 30 years, a GCS score of 9 or less, and surgery duration of 4 hours or longer ([Table 6]). Nonreactive pupils on arrival, ventricular involvement, and midline crossing were not significantly associated with increased mortality or unfavorable outcomes on multivariate analysis.

Table 6 Multivariate analysis of factors associated with unfavorable outcome

Variables		N (%)	Multivariate p-value	Odds ratio	95% confidence interval
Age	>30	12 (28.6)	0.036	12.57	1.177–134.39
	≤30	30 (71.4)
GCS postresuscitation	3–9 10–15	8 (19.0) 34 (81.0)	0.030	45.65	1.45–143.64
Duration of surgery	≥4 h <4 h	10 (23.8) 32 (76.2)	0.037	13.46	1.17–155.69

Abbreviation: CI, confidence interval.

 

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Discussion

Cerebral gunshot wounds (GSWs) present a formidable clinical challenge, especially in low- and middle-income countries (LMICs) where health care resources are often limited.[6] [12] [13] [14] Our study provides insights into the demographics, clinical outcomes, and prognostic factors of GSWs, echoing findings from various global studies while highlighting specific challenges in LMICs.

Our study revealed a predominantly young male population (N = 35, 83.3%) who were victims of interpersonal violence, with self-harming and accidental injuries being uncommon, consistent with other reports.[6] [12] [15] This underscores the social and public health issues prevalent in regions like ours, where violence significantly impacts young adults. Most GSWH patients in our series were in their second, third, and fourth decades of life, aligning with other studies. Patients over 30 years old had increased mortality and unfavorable outcome rates (58 vs. 30%). Gressot et al. also reported increased mortality in patients over 35 years, with a mortality rate of 66.7%.[2]

GWSH are devastating, with mortality rates ranging from 7.7 to 93%.[6] [7] [9] [16] [17] [18] [19] [20] Our series of 42 GSWH victims reported an overall mortality rate of 23.8%, comparable to the 25% reported by Ambrossi et al. and the 22% reported by a South African series.[12] [21] Among survivors, 6 patients (14%) had unfavorable functional outcomes (GOSE 1–4) at the time of this study. The high prehospital mortality rate, with over 90% of victims dying before reaching medical facilities, emphasizes a critical gap in emergency medical services (EMS) and trauma care infrastructure in LMICs.[12] These delays likely contribute to the selection bias observed in our study, where only those sustaining relatively less severe injuries reached hospital care.

The GCS score upon presentation is a well-established predictor of mortality and functional outcome.[18] [22] [23] [24] [25] In our series, 64% of patients had a GCS of 13 to 15, which appears unusually high. This can be attributed to the exclusion of patients with a GCS of 3 who were not surgical candidates, potentially introducing selection bias. Additionally, the protracted delay in patient referral to our center likely meant only those with better levels of consciousness survived to receive care. In our study, a GCS of less than 9 was strongly correlated with increased mortality and unfavorable outcomes (OR: 45, p = 0.03). The overall survival rate of 63% in these patients was better than other series due to the absence of patients with a GCS of less than 6. However, most (87%) of those with a GCS of 9 or less had poor functional outcomes (GOSE 2–4).

Abnormal pupillary reactivity is a negative prognostic indicator, corroborated by our findings and other studies. Multiple studies including Polin et al. reported that 79% of patients with bilaterally fixed and dilated pupils died, compared with 50% with unilateral abnormalities and 5% with bilaterally reactive pupils.[9] [23] [26] In our study, 75% of patients with unilateral or bilateral pupillary abnormalities died, compared with a 3% mortality rate in those with normal responses. Interestingly, there was no difference in mortality or functional outcomes between patients with bilateral nonreactive pupils and those with unilateral abnormalities. This relationship highlights the importance of detailed neurological assessments upon admission for GSW victims.

Projectile trajectory significantly impacts mortality and morbidity from GSWH, with midline crossing associated with poor outcomes in several studies. In our series, bihemispheric involvement had a 35% fatality rate, which is better than the 50% reported by Helling, 85% by Kaufman, and 98% by Cavaliere et al.[1] [16] [27] [28] Ventricular involvement showed a strong correlation with functional outcome and mortality in many reports.[18] [29] [30] The 50% mortality rate for ventricular injury in our study was lower than the 86% reported by Polin et al and 91% by Siccardi et al.[8] [31] Rapid surgical intervention and specialized trauma care are essential for improving outcomes in these patients.

Despite the critical role of timely evacuation and transport to trauma centers, our data revealed that 83% of patients arrived at our center more than 24 hours posttrauma, far exceeding the mean times reported in other studies.[12] [13] [17] [31] [32] This delay, indicative of the underdeveloped EMS infrastructure in LMICs, underscores the need for improving prehospital care and timely surgical interventions to enhance survival rates.

Infection control remains a significant challenge, with 26% of patients in our study developing SSI.[15] [33] The rate of reoperation for SSI (17%) underscores the need for stringent perioperative protocols and comprehensive postsurgical care. Additionally, respiratory complications like chest infections significantly increased mortality (63% in affected patients), highlighting gaps in postoperative care and monitoring in resource-limited settings.

Our study stresses the necessity for developing robust trauma systems, enhancing EMS, and improving access to timely surgical care in LMICs. Implementing standardized treatment protocols and investing in training for health care providers can significantly improve outcomes for GSW patients. Moreover, our findings suggest the need for continued research and collaboration to address the unique challenges faced by LMICs in managing severe trauma cases.

 

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Conclusion

Despite being better than other reports, mortality from GSWH in our setting remains high. The majority of victims are individuals of productive age. The delay to definitive care is unacceptably long, yet those who survive this prehospital delay and reach our center generally have better functional outcomes. Despite the generally negative outlook for patients with GSWH, our series revealed an unusually high GCS, with 64% of patients having a GCS of 13 to 15 and a reasonably lower mortality rate, even in our severely resource-limited setting. Due to the lack of patients with a GCS of 3 to 5 in this series, no conclusions or recommendations can be drawn regarding whether these patients should be candidates for aggressive surgical treatment or conservative management.

 

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Conflict of Interest

None declared.

Ethical Approval Statement

A permission letter was obtained from the SPHMMC Ethical Clearance Committee. Confidentiality of every study participant during data collection, analysis, and dissemination was kept.

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Publication History

Received: 17 November 2024

Accepted: 06 March 2025

Accepted Manuscript online:
11 March 2025

Article published online:
01 April 2025