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Semin Plast Surg 2025; 39(01): 037-042
DOI: 10.1055/s-0044-1801737
Review Article

The Approach to Cranioorbital Gunshot Wounds

Winston R. Owens
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
,
Anna J. Skochdopole
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
,
Srinithya R. Gillipelli
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
,
Sarah A. Layon
1   Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
2   Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
,
Kerry P. Latham
3   Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
› Author Affiliations Funding None.
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Abstract

Gunshot wounds to the head result in significant morbidity with a low rate of survival. Current treatment recommendations for penetrating traumatic brain injury (pTBI), established in 2001, are based off techniques used in recent Middle Eastern conflicts. However, many advancements in care have been made and updates in official pTBI treatment guidelines are being formulated. While some penetrating brain injury patients are managed nonoperatively due to poor prognosis, many undergo emergent interventions and delayed reconstruction by various surgical subspecialists. This article explores the management of pTBI and the collaborative roles of neurosurgeons, ophthalmologists, and plastic surgeons.

Keywords

gunshot wounds - penetrating traumatic brain injury - plastic surgery - neurosurgery - ophthalmology - trauma - craniectomy - craniotomy - cranioplasty

Note

USU-WRNMMC Surgery: The opinions or assertions contained herein are the private ones of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences or any other agency of the U.S. Government.




Publication History

Article published online:
26 March 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Selden BS, Goodman JM, Cordell W, Rodman Jr. GH, Schnitzer PG. Outcome of self-inflicted gunshot wounds of the brain. Ann Emerg Med 1988; 17 (03) 247-253
    CrossrefPubMedSearch in Google Scholar
  • 2 Alao T, Munakomi S, Waseem M. Penetrating Head Trauma. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024
    Search in Google Scholar
  • 3 Grinshteyn E, Hemenway D. Violent death rates: the US compared with other high-income OECD countries, 2010. Am J Med 2016; 129 (03) 266-273
    CrossrefPubMedSearch in Google Scholar
  • 4 Shaffrey ME, Polin RS, Phillips CD, Germanson T, Shaffrey CI, Jane JA. Classification of civilian craniocerebral gunshot wounds: a multivariate analysis predictive of mortality. J Neurotrauma 1992; 9 (Suppl. 01) S279-S285
    PubMedSearch in Google Scholar
  • 5 Cavaliere R, Cavenago L, Siccardi D, Viale GL. Gunshot wounds of the brain in civilians. Acta Neurochir (Wien) 1988; 94 (3–4): 133-136
    CrossrefPubMedSearch in Google Scholar
  • 6 Part 1: Guidelines for the management of penetrating brain injury. Introduction and methodology. J Trauma 2001; 51 (02) S3-S6
    PubMedSearch in Google Scholar
  • 7 Ditkofsky N, Nair JR, Frank Y. et al. Understanding ballistic injuries. Radiol Clin North Am 2023; 61 (01) 119-128
    CrossrefPubMedSearch in Google Scholar
  • 8 Bruner D, Gustafson CG, Visintainer C. Ballistic injuries in the emergency department. Emerg Med Pract 2011; 13 (12) 1-30 , quiz 31
    PubMedSearch in Google Scholar
  • 9 Dougherty PJ, Eidt HC. Wound ballistics: Minié ball vs. full metal jacketed bullets–a comparison of Civil War and Spanish-American War firearms. Mil Med 2009; 174 (04) 403-407
    CrossrefPubMedSearch in Google Scholar
  • 10 von See C, Bormann KH, Schumann P, Goetz F, Gellrich NC, Rücker M. Forensic imaging of projectiles using cone-beam computed tomography. Forensic Sci Int 2009; 190 (1–3): 38-41
    CrossrefPubMedSearch in Google Scholar
  • 11 Hawryluk GWJ, Selph S, Lumba-Brown A. et al. Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury. Neurotrauma Rep 2022; 3 (01) 240-247
    CrossrefPubMedSearch in Google Scholar
  • 12 Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: a decision-tree algorithm based on a single trauma center. J Clin Neurosci 2020; 75: 71-79
    CrossrefPubMedSearch in Google Scholar
  • 13 Muehlschlegel S, Ayturk D, Ahlawat A. et al. Predicting survival after acute civilian penetrating brain injuries: the SPIN score. Neurology 2016; 87 (21) 2244-2253
    CrossrefPubMedSearch in Google Scholar
  • 14 Marshall LF. Evoked potentials: a decade later. Crit Care Med 1991; 19 (11) 1337
    CrossrefPubMedSearch in Google Scholar
  • 15 Jain S, Iverson LM. Glasgow Coma Scale. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024
    Search in Google Scholar
  • 16 Karras CL, Texakalidis P, Nie JZ. et al. Outcomes following penetrating brain injuries in military settings: a systematic review and meta-analysis. World Neurosurg 2022; 166: 39-48
    CrossrefPubMedSearch in Google Scholar
  • 17 Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 2001; 59 (03) 277-282
    CrossrefPubMedSearch in Google Scholar
  • 18 Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017. JAMA Intern Med 2021; 181 (02) 237-244
    CrossrefPubMedSearch in Google Scholar
  • 19 Demetriades D, Chahwan S, Gomez H, Falabella A, Velmahos G, Yamashita D. Initial evaluation and management of gunshot wounds to the face. J Trauma 1998; 45 (01) 39-41
    CrossrefPubMedSearch in Google Scholar
  • 20 McLean JN, Moore CE, Yellin SA. Gunshot wounds to the face–acute management. Facial Plast Surg 2005; 21 (03) 191-198
    Thieme ConnectPubMedSearch in Google Scholar
  • 21 Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock 2011; 4 (03) 395-402
    CrossrefPubMedSearch in Google Scholar
  • 22 Neuroimaging in the management of penetrating brain injury. J Trauma 2001; 51 (02) S7-S11
    PubMedSearch in Google Scholar
  • 23 Aarabi B. Comparative study of bacteriological contamination between primary and secondary exploration of missile head wounds. Neurosurgery 1987; 20 (04) 610-616
    CrossrefPubMedSearch in Google Scholar
  • 24 Chaudhri KA, Choudhury AR, al Moutaery KR, Cybulski GR. Penetrating craniocerebral shrapnel injuries during “Operation Desert Storm”: early results of a conservative surgical treatment. Acta Neurochir (Wien) 1994; 126 (2–4): 120-123
    CrossrefPubMedSearch in Google Scholar
  • 25 Helling TS, McNabney WK, Whittaker CK, Schultz CC, Watkins M. The role of early surgical intervention in civilian gunshot wounds to the head. J Trauma 1992; 32 (03) 398-400
    CrossrefPubMedSearch in Google Scholar
  • 26 Levi L, Borovich B, Guilburd JN. et al. Wartime neurosurgical experience in Lebanon, 1982-85. I: penetrating craniocerebral injuries. Isr J Med Sci 1990; 26 (10) 548-554
    PubMedSearch in Google Scholar
  • 27 Nagib MG, Rockswold GL, Sherman RS, Lagaard MW. Civilian gunshot wounds to the brain: prognosis and management. Neurosurgery 1986; 18 (05) 533-537
    CrossrefPubMedSearch in Google Scholar
  • 28 Crockard HA. Early intracranial pressure studies in gunshot wounds of the brain. J Trauma 1975; 15 (04) 339-347
    CrossrefPubMedSearch in Google Scholar
  • 29 Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12 (12) CD003983
    PubMedSearch in Google Scholar
  • 30 Le Roux P. Intracranial pressure monitoring and management. In: Laskowitz D, Grant G. eds. Translational Research in Traumatic Brain Injury. Frontiers in Neuroscience. Boca Raton, FL:: CRC Press/Taylor and Francis Group;; 2016
    Search in Google Scholar
  • 31 Pinto VL, Tadi P, Adeyinka A. Increased Intracranial Pressure. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024
    Search in Google Scholar
  • 32 Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrating and blast injury to the central nervous system. World J Surg 2015; 39 (06) 1352-1362
    CrossrefPubMedSearch in Google Scholar
  • 33 Rish BL, Dillon JD, Caveness WF, Mohr JP, Kistler JP, Weiss GH. Evolution of craniotomy as a debridement technique for penetrating craniocerebral injuries. J Neurosurg 1980; 53 (06) 772-775
    CrossrefPubMedSearch in Google Scholar
  • 34 Bell RS, Mossop CM, Dirks MS. et al. Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurg Focus 2010; 28 (05) E1
    CrossrefPubMedSearch in Google Scholar
  • 35 Hubschmann O, Shapiro K, Baden M, Shulman K. Craniocerebral gunshot injuries in civilian practice–prognostic criteria and surgical management: experience with 82 cases. J Trauma 1979; 19 (01) 6-12
    CrossrefPubMedSearch in Google Scholar
  • 36 Esposito DP, Walker JB. Contemporary management of penetrating brain injury. Neurosurg Q 2009; 19 (04) 249
    CrossrefPubMedSearch in Google Scholar
  • 37 Hammon WM. Analysis of 2187 consecutive penetrating wounds of the brain from Vietnam. J Neurosurg 1971; 34 (2, Pt 1): 127-131
    CrossrefPubMedSearch in Google Scholar
  • 38 Surgical management of penetrating brain injury. J Trauma 2001; 51 (02) S16-S25
    PubMedSearch in Google Scholar
  • 39 Antiseizure prophylaxis for penetrating brain injury. J Trauma 2001; 51 (02) S41-S43
    PubMedSearch in Google Scholar
  • 40 Aarabi B, Taghipour M, Haghnegahdar A, Farokhi M, Mobley L. Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service. Neurosurg Focus 2000; 8 (01) e1
    CrossrefPubMedSearch in Google Scholar
  • 41 Antibiotic prophylaxis for penetrating brain injury. J Trauma 2001; 51 (02) S34-S40
    PubMedSearch in Google Scholar
  • 42 Gutiérrez-González R, Boto GR, Rivero-Garvía M, Pérez-Zamarrón A, Gómez G. Penetrating brain injury by drill bit. Clin Neurol Neurosurg 2008; 110 (02) 207-210
    CrossrefPubMedSearch in Google Scholar
  • 43 Ganga A, Leary OP, Sastry RA. et al. Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature. Acta Neurochir (Wien) 2023; 165 (02) 303-313
    CrossrefPubMedSearch in Google Scholar
  • 44 Cho RI, Bakken HE, Reynolds ME, Schlifka BA, Powers DB. Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom. J Trauma 2009; 67 (03) 516-520 , discussion 519–520
    PubMedSearch in Google Scholar
  • 45 Lee HJ, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol 2004; 10 (04) 168-172
    CrossrefPubMedSearch in Google Scholar
  • 46 Blair K, Alhadi SA, Czyz CN. Globe Rupture. In: StatPearls. Treasure Island, FL:: StatPearls Publishing;; 2024
    Search in Google Scholar
  • 47 Zhou Y, DiSclafani M, Jeang L, Shah AA. Open globe injuries: review of evaluation, management, and surgical pearls. Clin Ophthalmol 2022; 16: 2545-2559
    CrossrefPubMedSearch in Google Scholar
  • 48 Ahmed Y, Schimel AM, Pathengay A, Colyer MH, Flynn Jr HW. Endophthalmitis following open-globe injuries. Eye (Lond) 2012; 26 (02) 212-217
    CrossrefPubMedSearch in Google Scholar
  • 49 Andreoli CM, Andreoli MT, Kloek CE, Ahuero AE, Vavvas D, Durand ML. Low rate of endophthalmitis in a large series of open globe injuries. Am J Ophthalmol 2009; 147 (04) 601-608.e2
    CrossrefPubMedSearch in Google Scholar
  • 50 Fujikawa A, Mohamed YH, Kinoshita H. et al. Visual outcomes and prognostic factors in open-globe injuries. BMC Ophthalmol 2018; 18 (01) 138
    CrossrefPubMedSearch in Google Scholar
  • 51 Eballé AO, Dohvoma VA, Koki G, Oumarou A, Bella AL, Mvogo CE. Indications for destructive eye surgeries at the Yaounde Gynaeco-Obstetric and Paediatric Hospital. Clin Ophthalmol 2011; 5: 561-565
    CrossrefPubMedSearch in Google Scholar
  • 52 Yousuf SJ, Jones LS, Kidwell Jr ED. Enucleation and evisceration: 20 years of experience. Orbit 2012; 31 (04) 211-215
    CrossrefPubMedSearch in Google Scholar
  • 53 Rasmussen MLR, Prause JU, Johnson M, Kamper-Jørgensen F, Toft PB. Review of 345 eye amputations carried out in the period 1996-2003, at Rigshospitalet, Denmark. Acta Ophthalmol 2010; 88 (02) 218-221
    CrossrefPubMedSearch in Google Scholar
  • 54 Jordan DR, JDutton J. The ruptured globe, sympathetic ophthalmia, and the 14-day rule. Ophthalmic Plast Reconstr Surg 2022; 38 (04) 315-324
    CrossrefPubMedSearch in Google Scholar
  • 55 Blanch RJ, McMaster D, Patterson TJ. Management of open globe injury: a narrative review. Eye (Lond) 2024; 38 (16) 3047-3051
    CrossrefPubMedSearch in Google Scholar
  • 56 Hihara M, Kakudo N, Mitsui T, Kuro A, Kusumoto K. The anatomic classification of the anophthalmic eye socket (Types 0-V): a high-level taxonomy classification system. J Plast Reconstr Aesthet Surg 2022; 75 (09) 3491-3498
    CrossrefPubMedSearch in Google Scholar
  • 57 Khaw PT, Georgoulas S, Dahlmann AH. et al. CHAPTER 15 - Tissue repair and regeneration. In: Yorio T, Clark AF, Wax MB. eds. Ocular Therapeutics. New York, NY:: Academic Press;; 2008: 333-366
    Search in Google Scholar
  • 58 Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol 2009; 54 (04) 441-449
    CrossrefPubMedSearch in Google Scholar
  • 59 Turgut B, Karanfil FC, Turgut FA. Orbital compartment syndrome. Beyoglu Eye J 2019; 4 (01) 1-4
    PubMedSearch in Google Scholar
  • 60 Shiose Y. Intraocular pressure: new perspectives. Surv Ophthalmol 1990; 34 (06) 413-435
    CrossrefPubMedSearch in Google Scholar
  • 61 Fulcher TP, McNab AA, Sullivan TJ. Clinical features and management of intraorbital foreign bodies. Ophthalmology 2002; 109 (03) 494-500
    CrossrefPubMedSearch in Google Scholar
  • 62 Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997; 104 (01) 96-103
    CrossrefPubMedSearch in Google Scholar
  • 63 Gil Z, Abergel A, Leider-Trejo L. et al. A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base 2007; 17 (01) 25-37
    Thieme ConnectPubMedSearch in Google Scholar
  • 64 Nakano T, Yoshikawa K, Kunieda T. et al. Treatment for infection of artificial dura mater using free fascia lata. J Craniofac Surg 2014; 25 (04) 1252-1255
    CrossrefPubMedSearch in Google Scholar
  • 65 De Cola MC, Corallo F, Pria D, Lo Buono V, Calabrò RS. Timing for cranioplasty to improve neurological outcome: a systematic review. Brain Behav 2018; 8 (11) e01106
    CrossrefPubMedSearch in Google Scholar
  • 66 Aydin S, Kucukyuruk B, Abuzayed B, Aydin S, Sanus GZ. Cranioplasty: review of materials and techniques. J Neurosci Rural Pract 2011; 2 (02) 162-167
    Thieme ConnectPubMedSearch in Google Scholar
  • 67 Chan DYC, Mok YT, Lam PK. et al. Cryostored autologous skull bone for cranioplasty? A study on cranial bone flaps' viability and microbial contamination after deep-frozen storage at -80°C. J Clin Neurosci 2017; 42: 81-83
    CrossrefPubMedSearch in Google Scholar
  • 68 Morales-Gómez JA, Garcia-Estrada E, Leos-Bortoni JE. et al. Cranioplasty with a low-cost customized polymethylmethacrylate implant using a desktop 3D printer. J Neurosurg 2018; 130 (05) 1721-1727
    CrossrefPubMedSearch in Google Scholar
  • 69 Zhang J, Tian W, Chen J, Yu J, Zhang J, Chen J. The application of polyetheretherketone (PEEK) implants in cranioplasty. Brain Res Bull 2019; 153: 143-149
    CrossrefPubMedSearch in Google Scholar
  • 70 Yang J, Sun T, Yuan Y, Li X, Yu H, Guan J. Evaluation of titanium cranioplasty and polyetheretherketone cranioplasty after decompressive craniectomy for traumatic brain injury: a prospective, multicenter, non-randomized controlled trial. Medicine (Baltimore) 2020; 99 (30) e21251
    CrossrefPubMedSearch in Google Scholar
  • 71 Yao S, Zhang Q, Mai Y. et al. Outcome and risk factors of complications after cranioplasty with polyetheretherketone and titanium mesh: a single-center retrospective study. Front Neurol 2022; 13: 926436
    CrossrefPubMedSearch in Google Scholar
  • 72 Alkhaibary A, Alharbi A, Alnefaie N, Oqalaa Almubarak A, Aloraidi A, Khairy S. Cranioplasty: a comprehensive review of the history, materials, surgical aspects, and complications. World Neurosurg 2020; 139: 445-452
    CrossrefPubMedSearch in Google Scholar
  • 73 Oliver JD, Banuelos J, Abu-Ghname A, Vyas KS, Sharaf B. Alloplastic cranioplasty reconstruction: a systematic review comparing outcomes with titanium mesh, polymethyl methacrylate, polyether ether ketone, and norian implants in 3591 adult patients. Ann Plast Surg 2019; 82 (5S, suppl 4): S289-S294
    CrossrefPubMedSearch in Google Scholar
  • 74 Caro-Osorio E, De la Garza-Ramos R, Martínez-Sánchez SR, Olazarán-Salinas F. Cranioplasty with polymethylmethacrylate prostheses fabricated by hand using original bone flaps: technical note and surgical outcomes. Surg Neurol Int 2013; 4: 136
    CrossrefPubMedSearch in Google Scholar
  • 75 Lam S, Kuether J, Fong A, Reid R. Cranioplasty for large-sized calvarial defects in the pediatric population: a review. Craniomaxillofac Trauma Reconstr 2015; 8 (02) 159-170
    CrossrefPubMedSearch in Google Scholar
  • 76 Lozada KN, Cleveland PW, Smith JE. Orbital trauma. Semin Plast Surg 2019; 33 (02) 106-113
    Thieme ConnectPubMedSearch in Google Scholar