Cranial falling bullet injuries, a series of 30 cases in Iraq

Purpose: The purpose of this study is to highlight the importance of cranial falling bullet injuries and raise awareness about them. We studied the clinical and radiological findings, and their relation to the treatment and outcome. There are limited studies in this field.Materials and methods: Thirty patients, (aged 8-55 years) with cranial falling bullet injury were included in this study. They were followed during their hospitalization and up to 6 months thereafter. Post-resuscitation clinical findings, unenhanced brain CT scan findings, treatment and outcome (Glasgow Outcome Scale) were studied.Results: Male to female ratio was (1.73:1). Median age of all patients was: 17.5 years. 20(66.7%) patients had a GCS of 13-15, 3(10%) had 9-12, 2(6.7%) had 6-8, and 5(16.6%) had 3-5 at presentation. 23(76.7%) patients had normal pupillary reaction and symmetry whereas 7(23.3%) had poor reaction and/or asymmetry. On CT scan, 13 had a unilobar injury, six had multilobar or bihemispheric injuries, 10 had a bullet through the deep midline structures of the brain, seven had transventricular with IVH, four had SAH, none had large intracranial hematomas. All patients received medical treatment. Local wound care and/or extraction of extracranial subgaleal bullets were performed in 24 patients (80%). More extensive surgery was performed in six patients (20%). There was significant correlation (using Correlation Coefficient) between GCS, pupillary reaction/symmetry and CT imaging findings with the patient outcome. Low GCS, poor pupillary reaction and/or asymmetry, CT findings of central area injury, transventricular, IVH, or multilobar injury were associated with poor outcome.Conclusions: Cranial falling bullet injuries are uncommon, but they can cause significant morbidity and mortality. More studies are needed to document the impact of these injuries and to raise awareness among the society to support the efforts aiming at controlling the irrational use of guns in different countries of the world.