The penetrating intracranial injury can be divided into gunshot wounds or stab wounds based on the mechanisms of injury.

Pediatric penetrating intracranial injury are of major concern as many parental and social factors may be involved in the causation.

Muballe et al describe the penetrating cranial injuries in pediatric patient subgroups at risk and presenting to the Department of Neurosurgery at the University of KwaZulu-Natal, by assessment of the Glasgow Coma Scale (GCS) score and review of the common neurological manifestations including cranial nerve abnormalities.

The authors performed a retrospective chart review of children who presented with penetrating TBIs between 1985 and 2007 at a university teaching hospital. Descriptive statistical analysis with univariate and multivariate logistic regression was used to assess the variables.

Out of 223 children aged 16 years and younger with penetrating TBIs seen during the study period, stab wounds were causal in 127 (57%) of the patients, while gunshot injuries were causal in 96 (43%). Eighty-four percent of the patients were male. Apart from abnormal GCS scores, other neurological abnormalities were noted in 109 (48.9%) of the patients, the most common being cranial nerve deficits (22.4%) and hemiparesis. There was a strong correlation between left-sided stab wounds and development of seizures. The mean age of patients with neurological abnormalities was 11.72 years whereas that of patients with no neurological abnormalities was 8.96 years.

Penetrating head injuries in children are not as uncommon as previously thought. There was no correlation between the age group of the patients and the mechanism of injury, which implies that stab or gunshot injuries could occur in any of our pediatric population with the same frequency. While gunshot injuries accounted for 56% of the patient population, stab injuries still accounted for 44%. Following penetrating head injuries, neurological abnormalities tend to occur in the older subgroup of the pediatric patients. The most common neurological abnormalities were hemiparesis followed by cranial nerve palsy. Facial nerve deficits were the most commonly seen cranial nerve abnormality. Immediate seizures were a significant feature in patients with stab injuries to the head compared to those with gunshot injuries ¹⁾.

Thirty-three children ranging in age from 8 months to 15 years were treated for gunshot wounds to the brain. Half of the children were less than 10 years old. Fifty-eight percent died. Mortality was influenced by the trajectory of the bullet, intent to commit suicide, and the neurological status immediately after injury. The age and sex of the child and the caliber of the bullet did not influence survival. Three-fourths of the deaths occurred within 24 hours of injury, suggesting these patients had a mortal wound from the onset. Eleven of the children were attempting suicide, 9 of whom died; 13 were playing with a gun, 5 of whom died; 2 were shot as innocent bystanders to crimes in progress; 1 was shot while involved in a criminal act; 1 was shot in a hunting accident; and in 2 who died within minutes of arrival, the circumstances of the shooting were not documented. Of the survivors, none was left vegetative after 6 months, 3 had severe disabilities, 9 were moderately disabled, and 2 had a good outcome. The mortality rate is strikingly similar to that of adults with similar injuries; however, the morbidity appears to be less. On the other hand, with simple preventative measures, virtually each injury would have been avoided ²⁾.

During a 6-year period, 14 consecutive children with penetrating craniocerebral gunshot wounds (GSW) were studied. Eleven patients were comatose on admission. Five had an admission Glasgow Coma Scale (GCS) score of 4 or less and developed clinical signs of brain death within 12 hours despite maximum therapeutic efforts. The remaining six patients, all of whom had three or more of the previously described unfavorable prognostic features, were aggressively managed with prophylaxis and treatment of intracranial hypertension. Intracranial pressure (ICP) was controlled with mechanical hyperventilation, mannitol osmotherapy, pentobarbital, and surgical decompression. Substantial intracranial hypertension occurred for up to 10 days after admission. There were four survivors. Neurobehavioral and intellectual functions were evaluated over a period of 1 to 2 years. Although serious cognitive deficits were noted, all survivors had sufficient functional recovery to warrant aggressive cardiopulmonary resuscitation and measures to control ICP in the management of comatose victims of craniocerebral GSW ³⁾.