There were 71 patients evaluated with a mean age of 14 years (ranging from 19 months to 18 years), and surgery was performed on 39 patients (55%). The primary outcome was the Glasgow Outcome Scale score (1 = death; 2 = persistent vegetative state; 3 = severe disability; 4 = moderate disability; and 5 = good recovery).

The researchers examined a variety of clinical, laboratory, and computed tomography (CT) findings to see if they were predictive of death, and identified 9 factors statistically associated with mortality: bilateral fixed and dilated pupils; systolic blood pressure lower than 100 mm Hg; anemia (an initial hematocrit lower than 30%); intravascular volume depletion (a base deficit of less than –5 mEq/L); Glasgow Coma Scale score of 5 or lower; and brain injuries involving the deep nuclei or third ventricle, three or more brain lobes, or a projectile passing through the ventricles (transventricular injury) or affecting both brain hemispheres (bihemispheric injury).

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The researchers caution that only finding bilateral fixed and dilated pupils can be relied on alone to predict mortality, and the other factors should be examined in combination to determine the chance of survival: “Bilateral fixed pupils is a very ominous sign,” Dr Klimo told Clinical Pain Advisor. “It indicates brain herniation with severe brainstem compromise; not something that is readily reversible or recoverable.”

The researchers also tested the accuracy of the St. Louis Scale, developed by Bandt et al2 in 2012, which separates predictive factors into categories and rates them based on severity; the points are added together, with the worst possible score totaling 18. According to the initial developers, a score of 5 or higher is associated with death, and a score of 4 or lower is associated with survival.

In the present study, the researchers found that 9 survivors had been assigned a St. Louis Score of 5 or higher. “Some survivors with the potential for a favorable outcome may be missed if judged using the St. Louis Scale alone,” the authors wrote, concluding that the St. Louis Scale was better at predicting favorable outcomes than mortality.


1. DeCuypere M, Muhlbauer MS, Boop FA, Klimo P Jr: Pediatric intracranial gunshot wounds: the Memphis experience. J Neurosurg Pediatr. 2016; doi:10.3171/2015.7.PEDS15285.

2. Bandt SK, Greenberg JK, Yarbrough CK, Schechtman KB, Limbrick DD, Leonard JR. Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm. J Neurosurg Pediatr 10:511–517, 2012.