Outcomes of civilian pediatric craniocerebral gunshot wounds: A systematic review.

BACKGROUND Pediatric craniocerebral gunshot injuries (CGI) occur both in the context of accidental and intentional trauma. The incidence and physiology of pediatric CGI merit re-examination of prognostic factors and treatment priorities. This study characterizes the current understanding of mortality and prognostic factors in this patient population. METHODS A systematic search was conducted. Selection criteria included all studies published since 2000 which described civilian isolated CGI in pediatric patients. Data was analyzed qualitatively and quantitatively to identify factors prognostic for the primary outcome of mortality. Secondary outcomes included functional outcome status, requirement for surgery, and injury complications. Study quality was assessed with the Newcastle-Ottawa Scale. This study was registered with PROSPERO (CRD42019134231). RESULTS Initial search revealed 349 unique studies. Forty underwent full text screening and eight studies were included in the final synthesis. The overall mortality rate was 44.8%. Most CGI occurred in older teenagers. Aggressive surgical treatment was recommended by one author while remaining studies emphasized clinical judgement. Reported prognostic factors include initial Glasgow Coma Scale (GCS), pupil reactivity, involvement of multiple lobes or deep nuclei, and bi-hemispheric injuries. Reported complications from CGI included seizure, meningitis, abscess, CSF leak, bullet migration, focal neurological deficits, endocrine abnormalities, cognitive deficits, and neuropsychological deficits. The Glasgow Outcome Scale was the predominant measure of function and demonstrated a moderate recovery in 17.4% and a good recovery in 27.3% of patients. CONCLUSIONS This systematic review analyzed the existing evidence for prognostic factors in the context of pediatric CGI. Significant long-term clinical improvement is possible with interventions including urgent surgical therapy. Fixed bilateral pupils and low initial GCS correlate with mortality but do not predict all patient outcomes. Patients under age 15 are under-reported and may have differences in outcome. The literature on pediatric CGI is limited and requires further characterisation. LEVEL OF EVIDENCE Level IV Systematic Review Evidence: prognostic.