Image guided surgery in the management of craniocerebral gunshot injuries

BACKGROUND A craniocerebral trauma caused by firearms is a complex injury with high morbidity and mortality. One of the most intriguing and controversial part in their management in salvageable patients is the decision to remove the bullet/pellet. A bullet is foreign to the brain and, in principle, should be removed. Surgical options for bullet extraction span from conventional craniotomy, through C-arm-guided surgery to minimally invasive frame or frameless stereotaxy. But what is the best surgical option? METHODS We prospectively followed up a cohort of 28 patients with cranio-cerebral gunshot injury (CCHSI) managed from January to December 2012 in our department of neurosurgery. The missiles were extracted via stereotaxy (frame or frameless), C-arm-guided, or free-hand-based surgery. Cases managed conservatively were excluded. The Glasgow Outcome Score was used to assess the functional outcome on discharge. RESULTS Five of the eight "stereotactic cases" had an excellent outcome after missile extraction while the initially planned stereotaxy missed locating the missile in three cases and were thus subjected to free hand craniotomy. Excellent outcome was obtained in five of the nine "neuronavigation cases, five of the eight cases for free hand surgery based on the bony landmarks, and five of the six C-arm-based surgery. CONCLUSION Conventional craniotomy isn't indicated in the extraction of isolated, retained, intracranial firearm missiles in civilian injury but could be useful when the missile is incorporated within a surgical lesion. Stereotactic surgery could be useful for bullet extraction, though with limited precision in identifying small pellets because of their small sizes, thus exposing patients to same risk of brain insult when retrieving a missile by conventional surgery. Because of its availability, C-arm-guided surgery continues to be of much benefit, especially in emergency situations. We recommend an extensive long-term study of these treatment modalities for CCGSI.