Penetrating Cerebrovascular Injuries in a Pediatric Cohort of Intracranial Gunshot Wounds: Incidence, Characterization of Injury Type, and Clinical Outcomes

Introduction: Firearm injuries are now the leading cause of death in children and young adults under 25 in the United States. However, literature on penetrating cerebrovascular injuries (PCVI) after intracranial gunshot wound (GSW) injury in the pediatric population is limited. This study investigates the incidence, radiological characteristics, and clinical outcomes associated with PCVI in children and young adults with intracranial GSW injuries.

Methods: Single-institution, retrospective cohort study on patients under 21 years-old admitted with an intracranial GSW between 2012 to 2022 at a level-1 trauma center. Univariate and multivariate logistic regression models were used.

Results: 96 patients met the inclusion criteria, of which 38 (39.6%) underwent vascular cranial imaging and were included in the analysis. Most (76.3%) were males and the median (range) age of 18 years (1-21). The incidence of PCVI in this cohort was 44% (17/38) with an inpatient mortality of 47.1%. A total of 22 vascular injuries (19 [86.4%] arterial and 3 [13.6%] venous) were identified on vascular imaging including: 7 (31.8%) pseudoaneurysms, 7 (31.8%) occlusions, 5 (22.7%) transections, 2 (9.1%) dissections, and 2 (9.1%) arteriovenous fistulas (AVF). 13 of 38 (34.2%) patients with CTA had DSA performed during admission. 3 of 13 (23.1%) had a negative screening CTA but positive PCVI in DSA. Patients with PCVI tended to have twice the mortality rate compared to those without (47.1% vs 23.8%, p=0.133). Patients without PCVI were more likely to have a favorable functional outcome (GOS ≥4) compared to those with PCVI, 76.2% vs 41.2%, p=0.028. On multivariate logistic regression, adjusting for age and admission GCS, injury to ≥3 lobes was independently associated with PCVI (aOR=6.2, 95% CI: 1.05 - 36.6, P=0.044).

Conclusion : PCVI is a complication occurring in almost half (44.0%) of children and young adults with intracranial GSW injuries who underwent vascular imaging. PCVI may have a negative impact on the functional outcomes in the survivors. Early screening, repeat vascular imaging, and informed management are essential to improve outcomes.