INTRACRANIAL HEMORRHAGE ASSOCIATED WITH TANGENTIAL GUNSHOT WOUNDS TO THE HEAD

Tangential gunshot wounds (TGSWs) to the head are gunshot wounds in wh ich the bullet or bullet fragments do not penetrate the inner table of the skull. Objectives: To determine the occurrence of intracranial he morrhage (ICH) associated with TGSW to the head and to assess the abil ity of selected clinical criteria to predict ICH in this patient popul ation. Methods: A retrospective chart review of patients diagnosed as having TGSWs to the head presenting to the ED of Los Angeles County University of Southern California Medical Center from October 1, 1993, to May 31, 1996. Results: Four hundred twenty patients with gunshot w ounds to the head presented to the ED. CT confirmed the diagnosis of T GSWs in 154 patients (36.7%). Head CT of patients with TGSWs revealed 25 (16.2%) skull fractures and 37 (24.0%) ICHs. Fourteen (56.0%) skull fractures were depressed. Of patients with a CT-documented TGSW to th e head, 23 (16.1%) had a history of a loss of consciousness (LOC), 129 (84.3%) had a normal neurologic examination in the ED, 17 (11.1%) had a Glasgow Coma Scale score (CCS) < 15, and 75 (48.7%) had retained ex tracranial bullets or bullet fragments. Of all patients with TGSWs to the head, 113 had a GCS of 15 with no LOC and a normal neurologic exam ination, with 17 of these 113 patients (15.0%) having ICH. One patient died while hospitalized. Fifty-six (36.6%) patients were released hom e directly from the ED. Five clinical criteria (history of LOG, GCS < 15 on ED presentation, skull fracture, location of TGSW on the skull, and presence of extracranial bullet fragments) were examined to determ ine their ability to predict ICH. None of these criteria either alone or in combination were adequately predictive of ICH. Conclusion: In th is series, 1 in 4 patients with a TGSW to the head had an ICH. All pat ients with TGSWs to the head should undergo head CT to rule out depres sed skull fractures and ICH.