Elsevier

World Neurosurgery

Volume 79, Issues 5–6, May–June 2013, Pages 749-755
World Neurosurgery

Peer-Review Report
Risk Factors for Intracranial Infection Secondary to Penetrating Craniocerebral Gunshot Wounds in Civilian Practice

https://doi.org/10.1016/j.wneu.2012.06.025Get rights and content

Objective

To determine risk factors for intracranial infection secondary to penetrating craniocerebral gunshot wounds (PCGWs) in civilian practice, in patients who underwent surgery with removal of bullet fragments, wound debridement, and watertight dural closure.

Methods

An observational, analytical, prospective, cohort-type study was conducted with follow-up in a group of patients with PCGWs caused by a low-velocity projectile admitted between January 2000 and November 2010. There were 160 patients, 59 of whom were administered prophylactic antibiotics based on the decision of the treating neurosurgeon. Average follow-up time was 39 months (range, 3–92 months).

Results

Infection occurred in 40 patients (25%); 20 patients received antibiotics (20 of 59 [33.9%]), and 20 patients did not receive antibiotics (20 of 101 [19.8%]). Three variables were independent risk factors for infection: (i) persistence of parenchymal osseous or metallic fragments after surgery (P < 0.0001, relative risk [RR] 7.45); (ii) projectile trajectory through a natural cavity with contaminating flora (P = 0.03, RR 2.84); and (iii) prolonged hospitalization time (P < 0.0001, RR 3.695).

Conclusions

Administration of prophylactic antibiotics was not associated with the incidence of intracranial infection secondary to PCGWs. Projectile trajectory through potentially contaminating cavities, persistence of intraparenchymal osseous or metallic fragments after surgery, and prolonged hospital stay were independent risk factors for intracranial infection.

Introduction

Craniocerebral trauma accounts for 70% of emergency services in Colombia (13); in 2009, violent deaths (homicide, suicide, car accident, and others) accounted for 18% of total deaths in the country (9). In civilian practice, mortality secondary to penetrating craniocerebral gunshot wounds (PCGWs) is >50% (10, 26). Intracranial infection is a major problem among patients with PCGWs who survive and receive medical treatment (5); infection is due to contamination with fragments of skin, scalp, bone, and metal, which are disseminated on the brain parenchyma following the projectile trajectory. Other factors, such as the projective trajectory through paranasal sinuses, wound dehiscence, and cerebrospinal fluid (CSF) fistulas can increase infection risk (5).

Infection frequency related to PCGWs varies among several series. In the preantibiotic age, during World War I, infection frequency was 58.8% (24), which promoted the use of prophylactic antibiotics as part of a therapeutic approach; from World War II on, prophylactic antibiotics were used for all PCGW cases. There are no controlled randomized clinical trials supporting the use of prophylactic antibiotics in PCGWs; clinical practice guidelines have been developed based on descriptive studies of case series, the opinion of experts, and observations conducted in the battlefield (5). However, the nature of trauma, type of firearm, seriousness of lesion, contamination probability, and access to medical services are different in civilian and military environments. In a nonmilitary context, most wounds caused by firearms involve low-velocity projectiles with lesions secondary to the crushing effect of the pressure wave following the projectile in its way through the brain tissue; in contrast, in a military context, most wounds are caused by high-velocity projectiles that cause a secondary shock wave and a big cavitation resulting in destruction of tissues away from the projectile trajectory, tissue necrosis, serious destruction of the brain parenchyma, and more secondary contamination and infection (5, 27). It follows that therapeutic approaches should not be the same when the PCGW occurs in a military versus a civilian environment.

This article reports the results of a prospective follow-up analytical study of a cohort of patients with PCGWs who underwent surgery for wash, debridement, and removal of osseous and metallic fragments from the brain tissue. The purpose of this study is to identify risk factors of intracranial infection secondary to PCGWs. It is a prospective cohort-type study of patients seen in a civilian medical practice at San Vicente de Paúl University Hospital in Medellin City, Colombia.

Section snippets

Study Population, Sampling Size, and Admission Criteria

An observational, analytical, prospective cohort study was conducted. The study population consisted of patients >15 years old with PCGWs caused by low-velocity projectiles and admitted to the emergency department of Hospital Universitario San Vicente de Paúl in Medellin, Colombia, between January 2000 and November 2010. Criteria to be admitted to the study were as follows: PCGW; treatment consisting of wound debridement, removal of osseous and metallic fragments of brain tissue, and watertight

Results

Most patients (145 [90.6%]) were men; mean age was 28.9 years (range 15–61 years). Average hospital stay was 17.3 days (range 1–77 days). All wounds were caused by low-velocity firearm projectiles. Intracranial infection was documented in 40 of 160 patients (25%). In 95% of cases, intracranial infection emerged during the first 30 days of follow-up; the latest infection was diagnosed on day 64. A major comorbidity was present in 5 of 160 patients: 3 had diabetes, and 2 were immunosuppressed (1

Discussion

Few studies have been published concerning the risk factors for infection associated with PCGW, and most have been descriptive studies derived from the battlefield during wartime (3, 5). Technically speaking, there is a high risk of intracranial infection in patients with PCGWs, and it probably results from the presence of contaminated foreign bodies (i.e., metallic fragments, skin pieces, hair, osseous fragments) that penetrate the skull and touch brain tissue following the projectile

Conclusions

Persistence of osseous or metallic fragments in the brain parenchyma after a surgical procedure, projectile trajectory through the paranasal sinuses or oral cavity, and prolonged hospital stay are three variables independently associated with the risk of posttraumatic intracranial infection in patients with PCGWs attended in a civilian practice who have been injured with low-velocity projectiles. Use of prophylactic antibiotics does not seem to be effective in these patients; prophylactic

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    Conflict of interest statement: This research was conducted with funds of the Neurosurgery Service of the University of Antioquia, Colombia.

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