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Bullet in the Brain

It may be the title of your favorite Rage Against the Machine song, but it’s also a grim reality in our society. Although the murder rate in many of our major cities has recently been on the decline, the United States still leads the world in civilian gun violence. Even some of our nation’s smaller cities—like its capitol, Washington, DC—have held the title of “Murder Capitol of the World” by boasting the highest annual number of murders per capita.

The “upside” to these circumstances is that, in times of relative peace, our military surgeons in training can visit major trauma centers to receive experience in treating “penetrating” trauma (gunshot and knife wounds); it’s the sort of life-saving experience these doctors cannot otherwise obtain when there is no battlefield.

In contrast to penetrating trauma, “blunt” trauma refers to more common injuries like those incurred in motor vehicle accidents and falls from heights. The distinct mechanical nature of these types of injuries requires that they receive different methods of treatment. Most severe trauma calls for the expertise of specially trained surgeons who can find and control internal bleeding and resuscitate patients who suffer from blood loss.

Gunshot wounds (GSW) to the head have lately been prevalent in the media, following the shooting of Arizona Congresswoman Gabriel Giffords, members of her staff, and constituents. No less disturbing was the recent school shooting in Los Angeles in which a female student was struck in the head by a bullet fired, apparently by accident, from a gun carried in another student’s backpack.

As I listened to the media report on these two incidents, it occurred to me that most people have limited or no understanding of the treatment and conditions of those whose brains have been injured by handgun projectiles. My training as a neurosurgeon in Washington, DC and my work in Oakland, California in major “inner city” trauma centers has given me the opportunity to treat more than my fair share of penetrating head injuries. Let me do my best to shed some light on the repercussions of cranial gunshot wounds.

Several things make GSWs to the head different from, say, the damage done by striking one’s head on a windshield at 75 miles per hour. In the latter case, the damaging energy transmitted through the head is distributed throughout the brain. In cases of GSWs, however, “cavitation” is created as a bullet passes through the brain.

Cavitation denotes the large column of damaging energy that surrounds the course of a much smaller missile as it travels at a high velocity through solid matter. Almost all GSWs that cross the brain from the entry point to the opposite side of the head end in death. Naturally, highvelocity military grade weapons are even more devastating than the handguns that pollute our city streets. Even a “grazing” injury from an M16 can emit enough force through the brain to cause death.

Since the presence of a resting bullet in the brain seldom causes harm, removing the bullet is not a recommended surgical treatment—in fact, such a procedure may result in more damage. The same holds true for most GSW cases throughout the body. This is why a number of gunshot victims continue to walk around with bullets lodged inside of them.

It is recommended, in cases of GSWs to the head, that the entry and exit points simply be debrided (cleaned up) and closed (sewn up). Bone fragments should be removed if near the surface and easily accessible, and the dense covering of the brain (called the dura mater) should be repaired to keep spinal fluid from leaking. Any aid beyond this will not help the brain recover.

The similarity between penetrating and blunt brain trauma lies in the fact that destroyed brain cells cannot regenerate. While “stunned” brain cells can recover function, there is no way to predict how much a person can improve after an injury. It generally takes three to six months for a GSW patient to reach maximum improvement. Few treatments are available for brain injury and most of them have little effect on outcome.

Because nothing can be done to aid brain cells destroyed by the initial injury, modern treatment focuses instead on salvaging those cells that hold the potential to recover. One of the reasons the brain is particularly sensitive to the effects of trauma is because it is confined within a rigid box: the skull. All tissues swell when they are injured, but the skull leaves the brain no room to swell. As a result, pressure rises inside the head and makes it more difficult for blood to reach the brain.

In light of this fact, the focus of acute brain injury treatment is on reducing swelling or “intracranial pressure” while maintaining enough blood supply to meet the demands of the brain’s healing tissue. A number of medical treatments are applied to achieve these ends. First, the patient’s ventilator rate is increased to lower carbon dioxide (CO 2 ) in the blood stream and decrease the volume of blood vessels in the brain. This must be done carefully to avoid restriction of blood flow. Intravenous solutions of a drug called mannitol or highly concentrated salt solutions are also used to reduce swelling.

As in the case of Ms. Giffords, the patient might also be placed in a “medical coma”—deep general anesthesia—for several days. While asleep, the brain requires less oxygen and nutrients, and is thus less vulnerable if blood flow is inadequate. In dire situations of brain swelling, one or both halves of the skull can be temporarily removed to allow the brain more room to swell. Typically, about one week after injury, swelling resolves on its own.

It’s worth noting that some glaring absences occurred in the media reports about Giffords’ condition. It is what the doctors were not saying that concerned those of us “in the know”. The bullet reportedly struck Giffords in the left temple and exited on the same side of her head, near the forehead. The good news here is that the bullet did not cross through the center of the brain— had it done so, the injury would likely have been fatal. However, the left temporal and frontal regions of the brain not only control movement on the right side of the body, but also, in most of us, the ability to speak and understand speech. As of yet, the media has not fully disclosed the true gravity of Ms. Giffords’ injuries.

Ms. Gifford was recently moved to a rehabilitation facility, and it’s reported she will receive intensive therapy from speech, occupational, and physical therapists. Their goals will be to facilitate the recovery of use of Giffords’ right arm and leg, as well as her ability to speak and understand speech. Our thoughts are with her and those injured or killed in the incident, as well as with their families and loved ones.

by Thomas Chappell, MD

BIA USA

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Excerpts from the Kathy Ireland Issue Feb/Mar 2011:

Kathy Ireland — Interview

Blind Fishing Boat — New Fishermen Take the Bait

Yahoo — Expanding the Digital Highway

Heart Transplant — An Uncommon Cardiac Connection

Sean Forbes —Not Hard To Hear

ABILITY Best Practices Award — Sprint

Gunshot Wounds — Bullet Points

Articles in the Kathy Ireland Issue; Humor — Love Hurts; Ashley’s Column — Back in the Saddle; Sean Forbes— Not Hard To Hear; Gunshot Wounds — Bullet Points; ABILITY Best Practices Award — Sprint; Blind Fishing Boat — New Fishermen Take the Bait; Yahoo — Expanding the Digital Highway; Rehabilitation — Hitting New Strides; Terri Cheney — A Plea for Innocence, growing up Bi-Polar; Kathy Ireland — A Model Businesswoman; Heart Transplant — An Uncommon Cardiac Connection; Leigh Brill — Excerpt From A Dog Named Slugger; ABILITY's Crossword Puzzle; Events and Conferences... subscribe

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