THE SIGNIFICANCE OF SUBARACHNOID HEMORRHAGE AFTER PENETRATING CRANIOCEREBRAL INJURY - CORRELATIONS WITH ANGIOGRAPHY AND OUTCOME IN A CIVILIAN POPULATION

CERTAIN CLINICAL FACTORS are considered to nave an effect on patient outcome after penetrating missile injury. These include bilateral hemispheric injury, ventricular hemorrhage, intracerebral hemorrhage, mass effect, and missile or bony fragmentation. The relationship of subarachnoid hemorrhage (SAH) after penetrating craniocerebral injury and outcome is unknown. In addition, controversy exists regarding the role of angiography and the incidence of traumatic intracranial aneurysm in this population. Finally, can we assume that the incidence of traumatic intracranial aneurysm is equal in military and civilian populations, given the absence of penetrating shrapnel injury in civilian populations? Now that computed tomography has supplanted angiography as the primary diagnostic modality, increasing vigilance on the part of the physician and examination of angiography in high-risk patients should allow for enhanced outcome. We evaluated 100 patients with a diagnosis of cerebral gunshot wound over a 12-month period. All patients were evaluated neurologically at the time of admission and had imaging studies. Thirty-one patients with radiological evidence of SAH on computed tomography underwent angiography. Angiograms were limited to the side of the injury in patients with single-lobe or unilateral multilobe injuries and were bilateral in patients with bilateral hemispheric involvement. One intracranial aneurysm (3.2%) was documented and treated surgically. In those patients who died within 48 hours of admission, 68% had SAH as compared with only 17% of those surviving. Outcome was based upon neurological evaluation at the time of discharge and at the time of clinical follow-up at 3 and 6 months. Of those patients admitted with SAH, one remained vegetative, four were severely disabled, five were moderately disabled, and three had good recovery. Eighteen patients died (68%). We report on a statistically significant correlation between SAH and poor outcome after penetrating injury (P < 0.001). We found no correlation between the presence of intracerebral hemorrhage and outcome. The incidence of traumatic intracranial aneurysm in our civilian series did not differ from that in large military populations, despite the absence of shrapnel injury.