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TO THE EDITOR: We read with interest the article by Kumar et al.3 (Kumar R, Kumar R, Mallory GW, et al: Penetrating head injuries in children due to BB and pellet guns: a poorly recognized public health risk. J Neurosurg Pediatr 17:215–221, February 2016). The authors retrospectively collected the data of 14 victims of what they called air-gun pellet injuries who were referred to 3 different centers. They highlighted their findings in Table 2 of their manuscript. Their review of the muzzle velocity performance is very informative for readers of the neurosurgical literature who are interested in the field of penetrating head injuries. Interestingly enough, our group published a collection of 16 pediatric cases injured by 0.177-caliber lead pellets with a diabolo-style shape in 1997.1 The summary of our findings is reproduced from that communication and added as a table in this letter to show that our results were rather similar to those of Kumar et al., although with some important differences. We would like to highlight some of them and also comment on some other issues as well. 1) The entrance points of the pellets into the skull are mentioned by the authors, but the weak roof of the orbit as the main avenue of entrance to the cranium for these lowvelocity pellets should be better emphasized. The point is that the rifles or guns shooting these kinds of missiles are not engineered in standard industries and do not hold for example International Organization for Standardization numbers in every aspect. These guns and projectiles are produced by home-made manufacturers, lack advanced compressed gas technology (which means that the pellets are shot at different velocities), and are distributed by local sellers among the youngsters. So, the speed of pellets is nearly always less than the amount mentioned in Kumar et al.3 The skull entry site in the Kumar et al. series was frontal in 8 patients (57%), temporal in 2 (14%), orbital in only 3 (21%), and parietal in 1 (7%). The injury types overlapped among many patients, and some of them were not driven into the skull. Injuries included subarachnoid hemorrhage in 7 patients (50%), depressed skull fracture in 4 (29%), parenchymal contusion in 4 (29%), cerebral edema in 3 (21%), intraparenchymal hemorrhage in 2 (21%), subdural hematoma in 1 (7%), intraventricular hemorrhage in 1 (7%), and pseudoaneurysm formation in 1 (7%). Among them, 10 of the 14 patients required an operative intervention. This is quite different from our findings (Table 1), with the entrance through the orbit in 11/16 (69% orbital entrances). It shows that such missiles cannot easily penetrate through the skull bone, and need special circumstances to happen accidentally between the offender and the victim. 2) Considering passage of the missile through the skull base region in most of the cases, the shell often can be stopped in and around the sella. Damage to the cavernous sinus and its neurovascular structures was predictable, and we insist on some kind of vascular study in nearly all similar cases. We encountered both traumatic aneurysm and carotid cavernous fistula in our series (Table 1). 3) Even though it might not seem necessary to remove the BB pellets in all cases, because of the higher chance of development of late infection in these penetrating injuries (Table 1) in contrast to high-velocity war injuries,2 we deem early and complete debridement a mandatory procedure. 4) Advising the use of helmets for children playing with BB guns can be a good suggestion on the part of pediatric neurosurgeons, although it is of benefit only for the shooter and helmet manufacturer (because children who were not shooting BB guns wouldn’t be wearing a helmet). Considering that these events are accidental and not preplanned, the use of helmets cannot possibly prevent all injuries to the victim.

Letter to the Editor: Air-gun pellet injuries to the head and neck: what are the mechanisms of injury and optimal steps in management?