"Time is brain" the Gifford factor - or: Why do some civilian gunshot wounds to the head do unexpectedly well? A case series with outcomes analysis and a management guide

Review of intracranial gunshot wounds (GSWs) undergoing emergent neurosurgical intervention despite a very low Glasgow Coma Scale (GCS) score on admission in order to identify predictors of good outcome, with correlates to recent literature.A retrospective review of select cases of GSWs presenting to our trauma center over the past 5 years with poor GCS requiring emergent neurosurgical intervention and a minimum of 1-year follow-up.Out of a total of 17 patients who went to the operating room (OR) for GSW to the head during this period, 4 cases with a GCS < 5 on admission were identified. All cases required a hemicraniectomy to alleviate cerebral swelling. Two cases presented with a unilaterally blown pupil due to raised intracranial pressure. The remaining 2 cases had equal and reactive pupils. One patient with a GCS of 3 and a significant bilateral pattern of parenchymal bullet injury was initially assessed in moribund status but rallied and received a delayed hemicraniectomy on day 7. Three out of 4 patients are functionally independent at 1-year follow-up. The fourth patient who received a delayed decompression remains wheelchair dependent.Victims of GSWs can have good outcomes despite having a very poor admission GCS score and papillary abnormalities. Factors predicting good outcomes include the following: time from injury to surgical intervention of < 1 h; injury to noneloquent brain; and absence of injury to midbrain, brainstem, and major vessels.