Cranial gunshot wounds: comparative analysis of management and outcomes in a United Kingdom Major Trauma Centre and the United States

Objectives: Cranial gunshot wounds (CGSW) are a rare subtype of traumatic brain injury in the UK without recognised guidelines. We aimed to investigate and compare the emergency surgical management of such injuries and their outcomes between the UK and US.

Methods: A retrospective analysis of CSGW presenting to an adult Major Trauma Centre in the UK between 1999 and 2024 was conducted. Demographic data, clinical presentation, radiological findings, treatment methods, and Glasgow Outcome Scale Extended at three months (GOS-E) were collated and examined to highlight any trends in the surgical management and review favourable outcomes for this cohort. Results were compared to data from the US.

Results: Thirteen patients were identified (all male aged between 16 and 82). Self-inflicted GSW was the most common aetiology (seven patients). Presenting Glasgow Coma Score (GCS) was >8 in seven patients with non-dilated reactive pupils. There were four (30%) deaths in our series, all with GCS <8 and dilated unreactive pupils at presentation. Seven patients had right sided fronto-parietal entry wounds without exit wounds. Six patients had bullet fragments crossing the midline, including all four mortalities. Of the survivors, two patients underwent decompressive craniectomy, one underwent external ventricular drain insertion, five underwent wound debridement and craniotomy to remove bullet fragments, and one patient underwent ICP bolt insertion only. GOS-E at three months for the survivors was 8 for six patients and 6 for the remaining patients. Multivariable regression analysis revealed GCS at presentation (p  = .005) and pupil reactivity (p  = .001) were significant in determining favourable outcomes.

Conclusions: CGSWs are associated with significant mortality. In our series, surgery was undertaken for wound debridement including removal of foreign body and to treat high ICP. Favourable GCS (>8) and pupil reactivity on presentation were significant determinators of functional outcome. Therefore, any future clinical guidelines established in the UK should account for these factors.