Gunshot to the Head

  • Sheharyar Raza
    Department of Medicine, University of Toronto, Ontario, Canada
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  • Donald A. Redelmeier
    Requests for reprints should be addressed to Donald A. Redelmeier, MD, FRCPC, MSHSR, FACP, Sunnybrook Health Sciences Centre, G-151, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada.
    Department of Medicine, University of Toronto, Ontario, Canada

    Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada

    Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

    Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

    Center for Leading Injury Prevention Practice Education & Research, Toronto, Ontario, Canada
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      A 19-year-old university student presented to the hospital with a gunshot to the head. Imaging showed an entry wound at the right parietal bone, exit wound at the left frontal bone, and fragments along the pathway (Figure). Emergency surgery for impending cerebral herniation involved bilateral decompressive craniectomies and removal of several projectile fragments. After 3 days his brain showed bilateral infarcts, extensive edema, midline shift, and artifacts from metallic beam scatter. After 10 weeks his brain was remodeled with widespread encephalomalacia, ex-vacuo enlargement of the ventricles, and a concave overlying scalp. After 7 months the patient remained alive in the hospital, breathing spontaneously, and receiving total nursing care (Glasgow Coma Scale score = 4). This case shows that mortality statistics about gun violence understate the full extent of losses because many patients remain alive with permanent deficits.
      FigureSerial computed tomography scans of the brain obtained on arrival (A), 3 days afterward (B), and 10 weeks afterward (C). Major finding shows a transcranial gunshot wound where the bullet clearly crosses the midline. Historically, such a gunshot wound was associated with a 100% acute mortality rate.
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