Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report

Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10–12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.


Introduction
Firearm-related injuries are a major public health issue in the USA, with over 45,000 firearm-related deaths occurring in 2020 [1], including about 1300 children aged 0 to 17 annually [2]. Males and racial minorities are disproportionately affected [2,3]. Craniocerebral gunshot wounds (GSWs) are among the most lethal, with adult survival rates ranging from 7 to 15% [4] and 66-90% dying before they reach the hospital [5,6].
In patients with survivable injuries, surgical management focuses on wound care, debridement, bone fragment removal, and ICP management [5]. More expansive debridement is indicated in cases with > 5-mm midline shift with evidence of basal cistern compression and necrosis or hematoma [7]. Severe cerebral edema can be treated with hemicraniectomy [15,16]. Bullet fragments are often removed intraoperatively to reduce intracranial abscess formation [6]. Postoperative care includes management of infection, hydrocephalus, ICP, CSF fistulas, and delayed hemorrhage. Incidence of infection is roughly 5-7% in the first 3-5 weeks post injury [12]. Cerebral abscesses occur in 2-3% of patients and are associated with a high mortality [11,17].
Pediatric craniocerebral GSWs are less common than in adults, but outcomes are generally more favorable, with mortality rates around 40-50% (Table 1) [18][19][20]. Younger pediatric patients tend to have higher initial GCS scores and better outcomes [10,19,21,22]. Predictors of increased mortality include low initial GCS score, fixed bilateral pupils, bihemispheric involvement, transventricular projectile trajectory, deep nuclear injury, and clinical features like hypokalemia and hypoglycemia [20][21][22]. Several factors may contribute to improved mortality in children with craniocerebral GSWs. Often, children experience accidental, and thus less severe, injuries compared to adults. They may receive faster, more aggressive intervention due to prompt caregiver action and fewer comorbidities complicating care [23]. Pediatric patients may also exhibit increased functional recovery due to increased neuroplasticity compared to adults [24,25]. However, the limited number of cases in patients under 15 hinders our understanding of their presentation and outcomes, emphasizing the need for further research on pediatric craniocerebral GSWs.

Case presentation
We present a case of a 2-year-old female who suffered a GSW to the left frontal lobe while in a car. Upon EMS arrival, she had fixed pupils, deviated gaze, and agonal breathing. In the emergency department, her GCS score was 3. CT imaging showed a retained projectile in the right temporal-parietal region, slit-like ventricles, bifrontal comminuted, and depressed skull fractures with fragments in the parenchyma, hemorrhages, subarachnoid blood, 5-mm rightto-left midline shift, and parenchymal edema (Figs. 1 and 2). There was downward herniation, but the prepontine cistern remained patent. The injury was considered nonsurvivable, and no surgery or ICP monitoring was planned. Supportive care was provided in the PICU.
Following consultation, the family withdrew supportive care and established a DNR order. The patient lacked gag, cough, and blink reflexes but responded to sternal rub and displayed intermittent flexion and decorticate posturing. Fentanyl was administered for sedation and comfort before removing the endotracheal tube. Cheyne-Stokes respirations were observed, followed by tachypnea and seizure-like movements. On hospital day (HD) 2, midazolam was given for increased tachycardia and erratic right-sided movements. The patient developed a fever and received cefazolin.
Later that day, the patient's GCS score improved to 9, with movements in response to pain, partial left eye opening, purposeful right-sided movements, and spontaneous breathing. The parents requested resumption of medical care, and neurosurgery irrigated and closed the wound at the bedside. A repeat CT revealed decreased left subdural hematoma volume, unchanged midline shift and new right frontal lobe hemorrhagic contusions with surrounding edema and ischemia. The patient received 3% saline to manage edema, and her GCS remained stable at 8-9 the following day, with improved neurological exam results. The DNR order was subsequently rescinded.
By HD 4, the patient's GCS improved to 10-12, and sodium goals were increased with a switch to 7% saline. The patient became communicative on HD 5, and neuroprotective measures were implemented, including head elevation, levetiracetam for seizure prophylaxis, and acetaminophen for normothermia. By HD 8, the patient The patient progressed with physical, occupational, and speech therapy. She responded to commands and was deemed safe for discharge on HD 15, moving to inpatient rehabilitation. Repeat CT imaging 16 days post injury showed bullet migration to the posterior right occipital lobe and decreased edema (Fig. 3). The fragment was removed 1 month post-injury, and at 5 months, the patient exhibited left hemiplegia but could ambulate and speak in short phrases.
In conclusion, we presented the case of a 2-year-old female with a craniocerebral GSW that exhibited downward herniation. Despite the severe nature of the injury and the radiological findings, the patient exhibited a remarkable recovery with significant improvements in neurological function. The precise mechanism behind the patient's initial improvement in clinical status remains unclear; however, it is possible that the patient's initial presentation was partially attributable to transient neurological abnormalities stemming from the trauma [26] Further research is needed to better understand this phenomenon and its implications for clinical practice.