Acute Development of Traumatic Intracranial Aneurysms in Civilian Gunshot Wounds to the Head

Introduction: In a previous prospective study, when war casualties had non-DSA angiography a mean of 17 days after penetrating traumatic brain injury, the incidence of traumatic intracranial aneurysms (TICAs) was close to 3%. We hypothesized that a significant fraction of TICAs are missed on delayed imaging, and resolves spontaneously in the first days post-injury. This investigation was designed to look for TICAs in civilian gunshot wounds to the head (cGSWH) using admission CT angiography (aCTA).

Objective: This retrospective investigation was designed to look for early TICAs using aCTAs after cGSWH.

Methods: Over a 5-year period, 341 patients with cGSWH were admitted to this Level I Trauma center of which 136 had aCTA a mean: of 3 (SD 3.5) hours following trauma. The demographics, clinical findings, contrast studies, endovascular and surgical interventions and clinical outcome of these patients were analyzed.

Results: Mean age was 34.7 (SD: 13.1) and 120 patients were male. Admission GCS was 6 (SD 3.9). Site of penetration was frontal in 40, temporal in 50, frontobasal-temporal in 1, other in 46 (parietal in 19, occipital in 6, suboccipital in 9). Projectiles crossed multiple dural compartments in 76 (55%) subjects. Projectiles crossed an average of 1.66 planes in patients with TICAs, compared to 2.22 planes in patients without TICAs. Eighty patients harbored ICHs. Overall 35 TICAs were discovered in 28 patients (21%). 25 TICAs were along the MCA, 5 in the ACA, 3 in the ICA, 1 in the PCA, 1 in the MMA. Eleven TICAs in 9 patients resolved without intervention during a mean of 8 days. Eight TICAs were managed by endovascular means, one by endovascular and surgical means. Forty-nine patients died in this series, of which 10 harbored 15 TICAs. On multiple regression models, presence of intracerebral hematoma was the main predictor of presence of TICAs in cGSWH.

Conclusion: This study provides evidence that intracerebral hematomas in patients with cGSWH are an indicator of hidden TICAs. Nearly 30 percent of patients had spontaneous aneurysmal resolution within a week. When CTA was performed within 2.5 hours of trauma, TICAs were ten times more frequent in cGSWH compared to the military literature. Almost one third of patients in this series died from the devastating effects of cGSWH.

Publication History

Article published online:
05 February 2024