Radiological method and findings in pediatric cranial firearm injuries

Radiological method and findings in pediatric cranial firearm injuries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Radiological method and findings in pediatric cranial firearm injuries İlknur Arslan, Ayşe Selcan Koç, Ahmet Yöntem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5574485/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Firearm Injuries are growing problem due to rising civil wars, terrorist acts, and the spread of personal armament. Notably, there has been a reported rise in firearm injury and fatal cases among children and young people, who are particularly vulnerable to widespread violent behavior. Early diagnosis and treatment, including radiological imaging after initial intervention, can reduce mortality and morbidity in firearm injury cases Objective To explore the demographic characteristics and computerized tomography findings of pediatric patients with cranial firearm injuries and comparing the advantages and disadvantages of conventional radiography and tomography. Materials and methods This study included cases of cranial firearm injuries presented to the pediatric emergency department of XXX City Training and Research Hospital between January 1, 2018, and December 31, 2021. Data recorded for each case included age, gender, clinical course, and weapon type. Cranial tomography images were reviewed for entry and exit wounds, bullet trajectory, brain damage, bone fractures, distribution of bone fragments, bullet core fragments and their distribution. Results Of the 12 cases included in this study, 10 were male, 2 were female, with a mean age of 143 ± 46.5 months. In the five cases injured by a shotgun, subcutaneous pellets were seen in the penetration area at bone and parenchymal doses on cranial tomography axial images. In 2 cases of handgun injury, a subcutaneous bullet core was found in the temporal region while another bullet core had penetrated the skin and bone in the frontal region without causing any brain tissue damage. In four cases with handgun injuries, the bullet core penetrated the skin and cranial bones, causing brain tissue damage. Seven cases with subcutaneous pellets or bullet cores identified radiologically were treated in emergency department. Five patients with firearm injuries required hospitalization, of which two did not survive. Conclusion Cranial tomography has many advantages over x-ray ımaging. Axial images provide essential information on the bullet core, entry and exit wounds, primary and secondary parenchymal damage, hemorrhage, edema, bone fractures, and bullet or pellet residue. This imaging modality aids clinicians in deciding on medical or surgical interventions, selecting treatment types, monitoring treatment efficacy, and predicting mortality. It is an effective, recommended method that offers forensic physicians rapid and reliable insights into weapon type, bullet core trajectory, and skull fractures, thereby facilitating both clinical and forensic assessments. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Introduction Firearm Injuries (FI) are growing problem due to rising civil wars, terrorist acts, and the spread of personal armament. Globally, civilians possess five times more small arms and light firearms than armed forces and law enforcement units. Firearms are associated with murder, suicide, gun accidents, crime, and violent behavior. Notably, there has been a reported rise in firearm injury and fatal cases among children and young people, who are particularly vulnerable to widespread violent behavior ( 1 , 2 ). Given that cranial FI results in higher mortality and morbidity than other causes of head trauma or injuries to other body parts, cases that reach the hospital necessitate rapid diagnosis and treatment. Studies indicate that early diagnosis and treatment, including radiological imaging after initial intervention, can reduce mortality and morbidity in FI cases ( 3 – 6 ). Conventional radiography is the oldest techniques used in forensic medicine ( 7 ). While X-ray imaging has become more common in forensic investigations, the adoption of computerized tomography (CT) and magnetic resonance imaging (MRI) in forensic cases has lagged behind. Tomography, introduced by Hounsfield and Cormak in the early 1970s, was first applied by Wullenweber in 1977 on a patient who died due to cranial FI ( 8 – 11 ). The concept of using advanced imaging specifically for forensic radiology and the VIRTOPSY project emerged in 2000. In a 2003 article, it was noted that radiological methods in forensic cases were limited to X-rays, and that CT and MRI could offer new possibilities in postmortem examinations and the findings from the first eight cases of the VIRTOPSY project were also shared ( 12 ). In subsequent years, the use of CT during postmortem examinations has grown, along with related publications ( 1 , 11 , 13 – 15 ). This study aimed to explore the demographic characteristics and CT findings of pediatric patients with cranial FI admitted to our hospital, while comparing the advantages and disadvantages of conventional radiography and CT. Material and Method This study included cases of cranial FI presented to the pediatric emergency department of XXX City Training and Research Hospital between January 1, 2018, and December 31, 2021. Data recorded for each case included age, gender, clinical course, and weapon type. Cranial CT images were reviewed for entry and exit wounds, bullet trajectory, brain damage, bone fractures, distribution of bone fragments, bullet core fragments and their distribution. The azimuth angle was determined by measuring the angle formed between the entry wound and the midline on axial images. Statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS 21.0; Chicago, IL). Age was presented as mean ± standard deviation (minimum-maximum), while categorical data (gender, weapon type) were given as frequencies and percentages. Ethical approval for this study was obtained from the Clinical Research Ethics Committee of XXX City Training and Research Hospital on March 14, 2024 (decision no: 3224). Results Of the 12 cases included in this study, 10 were male and 2 were female, with a mean age of 143 ± 46.5 months (60–211 months). Upon reviewing the axial CT images, it was determined that 5 cases involved shotgun injuries and 7 cases involved handgun injuries (Table 1 ). Table 1 Demographic and radiological findings Case Gender Cranial CT Weapon Treatment 1 M 3 subcutaneous pelltes in the penetration area Shotgun ED 2 M Multıple pellets in the penetration area Shotgun ED 3 M Subcutaneous pellet in the frontal cortex Shotgun ED 4 F Subcutaneous pellet in the right frontoparietal cortex Shotgun ED 5 M Subcuaneous pellet in the left frontal cortex Shotgun ED 6 M Subcutaneous bullet core in the right temporal bone, forming a 90° angle with the anteroposterior line Handgun ED 7 M 10 mm entry wound in the left frontal bone, bone penetration by bullet core forming a 60,2° angle with the anteroposterios line Handgun ED 8 M Damage and cavitation in the soft tissue and muscle structures in the right cervical region Handgun Hospital 9 M Multıple fracture in the maxillary sinus anterior and lateral wall, temporoparietal hemorrhage, bullet core in the left parietal lobe Handgun Hospital 10 M 6.3 mm entry wound in the right frontal bone, hemorrhage and edema in the brain parenchyma, exit wound in the right parietal bone Handgun Hospiatl 11 M Entry wound in the C4 vertebra level, exit wound in the left maxillary sinüs wall Handgun Hospital 12 F 6.8 mm entry wound in the left frontal bone, hemorrhage in the frontal lobe, 9.6 mm exit wound in the right occipital bone Handgun Hospital M: Male, F: Female, ED: Emergency department In the five cases injured by a shotgun, subcutaneous pellets were seen in the penetration area at bone and parenchymal doses on cranial CT axial images (Figs. 1 – 5 ). In one case of handgun injury, a subcutaneous bullet core was found in the right temporal region on the bone dose axial CT images (Fig. 6 ). Another case of handgun injury revealed that the bullet had penetrated the skin and bone, creating a 10 mm entry wound in the left frontal bone and forming a 60.2° angle with the anteroposterior line, without causing any brain tissue damage (Fig. 7 ). In the cranial CT axial images of a patient wounded with handgun, it was observed that the bullet core entered posteriorly at the level of the C4 vertebra, creating a 7.2 mm entry wound on the skin. The bullet core traveled anteriorly through the soft tissues and muscle structures in the right cervical region, causing tissue damage and cavitation before exiting the anterior neck with a 6.2 mm exit wound (Fig. 8 ). In four cases with handgun injuries, the bullet core penetrated the skin and cranial bones, causing brain tissue damage. In the first case, the bullet core entered the left maxillary region, causing multiple fractures in the anterior and lateral walls of the left maxillary sinus. It traveled through the temporal and parietal lobes, remaining lodged in the left parietal lobe and resulting in intracerebral hemorrhage, edema, and midline shift (Fig. 9 ). In the second case, the bullet core entered through the right frontal region, creating a 6.3 mm entry wound in the frontal bone, and exited from the right parietal region after causing parenchymal hemorrhage (Fig. 10 ). In the third case, the bullet core entered at the level of the C4 vertebra in the neck, fracturing vertebral bones, and traveled anteriorly through the skull base before exiting via the left maxillary sinus (Fig. 11 ). In the final case, the bullet core entered through the left frontal region, traveled caudally through the left frontoparietal region, and exited from the right occipital region, leaving a 9.6 mm exit wound. This trajectory caused bleeding from the right frontoparietal region to the lateral ventricles and mesencephalon (Fig. 12 ). Seven cases with subcutaneous pellets or bullet cores identified radiologically were treated in emergency department. Five patients with firearm injuries required hospitalization, of which two did not survive. Discussion Firearm injuries are major traumas with high mortality and morbidity across all age groups. Our study indicates a predominance of male cases in pediatric cranial FI, with shotguns causing injuries more frequently than handguns. A multicenter study in our country similarly reported a higher occurrence in males, with an average age of 13.6 years. Cranial injuries (27.4%) were the second most common type after extremity injuries (49.5%), and despite being less frequent, cranial injuries have a higher mortality rate than extremity injuries ( 6 , 16 ). The frequent use and associated fatalities of firearms can be attributed to factors like the availability of shotgun cartridges with varying diameters and properties, modifications made by users to fit specific needs, the easy access to firearms in rural areas, and the unsafe storage of firearms in homes, especially where children are present ( 17 , 18 , 19 ). Cranial FI cases can be evaluated radiologically with direct radiography and cranial CT. Direct radiographs should be taken from at least two angles to identify the presence and location of bullets within the cranium and to detect bone fractures ( 20 , 21 ). However, CT scans are prone to artifacts—image distortions due to various factors—which can limit their utility. These artifacts can appear as linear artifacts, partial volume effects, ring artifacts, noise, motion artifacts, and more (Fig. 13 ). In cases where bullet core fragments create artifacts that hinder CT evaluation, MRI may offer a superior alternative. However, due to the ferromagnetic nature of most bullet cores, MRI is generally avoided in FI cases, as strong magnetic fields can cause bullet cores to move, potentially causing further harm ( 1 , 22 ). Although direct radiography and cranial CT each have their advantages and limitations, cranial CT is now widely recommended for FI cases (Table 2 ) ( 1 , 4 , 7 , 10 , 12 , 14 , 23 – 26 ). Table 2 Advantages, disadvantages of conventional radiography and tomography Conventional radiography Tomography Advantages Foreign bodies and bullet core can be detected Cranial bone fractures canbe detected Simple, easy, fast and costeffective Easy accessible, easy to apply Advantages Enrty wound of bullet core/pellet can be detected Skin or bone defect of bullet core/pellet can be detected Diameter of entry wounds can be measured Azimuth angle of enry w can be calculated Bullet core residue and location can be shown Fragmnented bullet core distrubution can be shown Bullet core trajactory can be determined Brain damage and cavitation can be shown Intracerebral, intraventricular, epidural, subdural, subarachnoid hemorrhage can be determined Brain edema, shift and herniation can be determined Pneumoceohalus can be determined Bone fragmentation, fragmented bone distrubution can be detected Foreign bodies and location can be shown Entry and exit wounds can be differentiated Exit wounds location and diameter can be determined Hounsfiled unit can be measured Cause of death can be determined Noninvasive Imaging is repeatable as body integrity is preserved Date can be stored digitally Images can be reevaluated and opinions can be obtained by different people and platforms Low risk of infection and transmission Disadvantage Restrictive information about soft tissues Süperposition of tissues makes interpretation diffucult Radiation risk Disadvantage Restrictive information about sudden death Device, computer, hardware are required Artifacts reduce image quality Radiation risk Cost is high Experience required for report and comment In this study, cranial CT axial images were used to evaluate the number, location, and distribution of intracranial pellets, as well as their relationship with the skull and brain parenchyma. The entry site, entry wound size, angle, bullet core trajectory, bone and tissue damage, bullet core residue, and exit wound findings were also assessed. Bullet cores produce two angles within the target tissue: a vertical angle indicating the bullet's path up or down, and an azimuth angle representing its right-left or lateral path, similar to a compass direction. A perpendicular shot to the target has an azimuth angle of 90° ( 27 ). In addition to standard axial images, advanced reformatting in sagittal, coronal, or complex planes can be employed for more detailed evaluations ( 28 ). In 7 cases where shotguns and handguns were used, and the pellets or bullets did not penetrate the bone but remained subcutaneous, it is likely the projectiles expended all energy upon entering the skin. These patients were treated in emergency department. In five cases with handgun injuries, bullet cores penetrated the skull and caused brain damage, resulting in severe injuries. Two of these patients, who had a Glasgow Coma Scale score of less than 5 and suffered intracerebral hemorrhage, did not survive. Low Glasgow Coma scores, multiple skull fractures, hemorrhage, and edema are all associated with high mortality in cranial FI cases ( 4 , 6 ). The study is limited by its retrospective, single-center design, and by relying solely on axial images for radiological evaluation. Despite this, we believe the small sample size did not significantly impact the findings. Modern CT technology enables the creation of sagittal and coronal reformats in addition to axial images. However, only axial images were available for retrospective analysis in our hospital's PACS system. Moving forward, clinicians should request radiological imaging that includes axial, sagittal, and coronal views to enhance the diagnostic capabilities and utilize available technology more effectively. In conclusion, cranial CT axial images provide essential information on the bullet core, entry and exit wounds, primary and secondary parenchymal damage, hemorrhage, edema, bone fractures, and bullet or pellet fragments. This imaging modality aids clinicians in deciding on medical or surgical interventions, selecting treatment types, monitoring treatment efficacy, and predicting mortality. It is an effective, recommended method that offers forensic physicians rapid and reliable insights into weapon type, bullet core trajectory, and skull fractures, thereby facilitating both clinical and forensic assessments. Declarations Clinical trial number and Consent to parcipate declaration was not to obtained due to study disayn. Ethical approval: Ethical approval for this study was obtained from the Clinical Research Ethics Committee of XXX City Training and Research Hospital on March 14, 2024 (decision no: 3224). Presentation This work has not been published before, that is not under consideration for publication anywhere. Use of AI- assisted technologies AI was nor used Conflict of interest statement: The authors declare that there are no financial or nonfinancial intersts that are directly or indirectly related to the work submitted. Funding: no funding request for study. Author Contribution Conceptualization: İA.Formal analysis: İA, AY.Funding acquisition: NoneInvestigation: İA, AY, ASKMethodology: İA, ASKProject administration: İA, AY, ASKResources: İA, AYSoftware: noneSupervision: İAValidation: İA, AY, ASKVisualization: İA, ASKWriting-original draft: İA, ASK, AYWriting-review and editing: İA Data availability: All data analeysed during the study are avaliable from the corresponding author on reasonable request. References Oktay K (2020) Kranial Ateşli Silah Yaralanmaları. 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subcutaneous bullet core in the right temporal bone, forming a 90° angle with the anteroposterior line\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/30247e48bfeeaa30c9fa93ba.png"},{"id":72284809,"identity":"48dd01ec-67da-4614-9730-af162cecb946","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":154491,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial images, bone doses, 10 mm entry wound in the left frontal bone, bone penetration by bullet core forming a 60,2° angle with the anteroposterior line\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/6b1831719cb6939098f6f72c.png"},{"id":72284803,"identity":"dc36eb21-1311-4e18-9b41-53a612b54f51","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":331122,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial images, bone doses, damage and cavitation in the soft tissue and muscle structures in the right cervical region\u003c/p\u003e","description":"","filename":"floatimage8.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/558a8081c7c72e61f4f39e58.png"},{"id":72284808,"identity":"7aad3428-794d-45fe-a202-8a8d59c73f4d","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":73023,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial image, parenchymal dose, bullet core in the left parietal lobe\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/8b48ca4075e811bb7bec3560.png"},{"id":72284801,"identity":"79bcb33c-bce8-4b7d-b562-ee38ffbc0394","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":258522,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial images, bone and parenchymal dose, 6.3 mm entry wound in the right frontal bone, hemorrhage and edema in the brain parenchyma, 4 ° azimuth angle with the anteroposterior line, exit wound in the right parietal bone, bullet core in the right parietal lobe forming 100° \u0026nbsp;angle with the anteroposterior line\u003c/p\u003e","description":"","filename":"floatimage10.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/66b853878660d6462dc90d78.png"},{"id":72284793,"identity":"3c453389-48a2-4d90-bc01-727fa51fd0c0","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":232323,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial images, bone doses, entry and exit wound\u003c/p\u003e","description":"","filename":"floatimage11.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/748921caf8a8d1923d708b1d.png"},{"id":72284799,"identity":"fa5dbc1f-f63a-4304-b8c6-0c2e013edec1","added_by":"auto","created_at":"2024-12-24 16:49:29","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":228461,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial images, parenchymal and bone doses, 6.8 mm entry wound in the left frontal bone, hemorrhage in the frontal lobe, 9.6 mm exit wound in the right occipital bone\u003c/p\u003e","description":"","filename":"floatimage12.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/1545260d4bd7271e0b68f51d.png"},{"id":72286050,"identity":"882e1c8f-d84a-470f-9663-139aa1fc74c1","added_by":"auto","created_at":"2024-12-24 16:57:29","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":102148,"visible":true,"origin":"","legend":"\u003cp\u003eCranial CT axial image, paranchymal dose, artifact due to bullet core in the occipital lobe\u003c/p\u003e","description":"","filename":"floatimage13.png","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/b355a1a9a370a266c4e8822b.png"},{"id":82598313,"identity":"278c7115-f9bb-43e3-a3a8-c5af13b5b4b2","added_by":"auto","created_at":"2025-05-13 09:09:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3218267,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5574485/v1/7ab92f3f-b9f3-4ce3-b768-8929170e7fc7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radiological method and findings in pediatric cranial firearm injuries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFirearm Injuries (FI) are growing problem due to rising civil wars, terrorist acts, and the spread of personal armament. Globally, civilians possess five times more small arms and light firearms than armed forces and law enforcement units. Firearms are associated with murder, suicide, gun accidents, crime, and violent behavior. Notably, there has been a reported rise in firearm injury and fatal cases among children and young people, who are particularly vulnerable to widespread violent behavior (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Given that cranial FI results in higher mortality and morbidity than other causes of head trauma or injuries to other body parts, cases that reach the hospital necessitate rapid diagnosis and treatment. Studies indicate that early diagnosis and treatment, including radiological imaging after initial intervention, can reduce mortality and morbidity in FI cases (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConventional radiography is the oldest techniques used in forensic medicine (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). While X-ray imaging has become more common in forensic investigations, the adoption of computerized tomography (CT) and magnetic resonance imaging (MRI) in forensic cases has lagged behind. Tomography, introduced by Hounsfield and Cormak in the early 1970s, was first applied by Wullenweber in 1977 on a patient who died due to cranial FI (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The concept of using advanced imaging specifically for forensic radiology and the VIRTOPSY project emerged in 2000. In a 2003 article, it was noted that radiological methods in forensic cases were limited to X-rays, and that CT and MRI could offer new possibilities in postmortem examinations and the findings from the first eight cases of the VIRTOPSY project were also shared (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). In subsequent years, the use of CT during postmortem examinations has grown, along with related publications (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aimed to explore the demographic characteristics and CT findings of pediatric patients with cranial FI admitted to our hospital, while comparing the advantages and disadvantages of conventional radiography and CT.\u003c/p\u003e"},{"header":"Material and Method","content":"\u003cp\u003eThis study included cases of cranial FI presented to the pediatric emergency department of XXX City Training and Research Hospital between January 1, 2018, and December 31, 2021. Data recorded for each case included age, gender, clinical course, and weapon type. Cranial CT images were reviewed for entry and exit wounds, bullet trajectory, brain damage, bone fractures, distribution of bone fragments, bullet core fragments and their distribution. The azimuth angle was determined by measuring the angle formed between the entry wound and the midline on axial images.\u003c/p\u003e \u003cp\u003eStatistical analysis was conducted using the Statistical Package for Social Sciences (SPSS 21.0; Chicago, IL). Age was presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (minimum-maximum), while categorical data (gender, weapon type) were given as frequencies and percentages.\u003c/p\u003e \u003cp\u003eEthical approval \u003c/strong\u003efor this study was obtained from the Clinical Research Ethics Committee of XXX City Training and Research Hospital on March 14, 2024 (decision no: 3224).\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 12 cases included in this study, 10 were male and 2 were female, with a mean age of 143\u0026thinsp;\u0026plusmn;\u0026thinsp;46.5 months (60\u0026ndash;211 months). Upon reviewing the axial CT images, it was determined that 5 cases involved shotgun injuries and 7 cases involved handgun injuries (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and radiological findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCranial CT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeapon\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 subcutaneous pelltes in the penetration area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShotgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eED\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultıple pellets in the penetration area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShotgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcutaneous pellet in the frontal cortex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShotgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcutaneous pellet in the right frontoparietal cortex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShotgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcuaneous pellet in the left frontal cortex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShotgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubcutaneous bullet core in the right temporal bone, forming a 90\u0026deg; angle with the anteroposterior line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 mm entry wound in the left frontal bone, bone penetration by bullet core forming a 60,2\u0026deg; angle with the anteroposterios line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDamage and cavitation in the soft tissue and muscle structures in the right cervical region\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultıple fracture in the maxillary sinus anterior and lateral wall, temporoparietal hemorrhage, bullet core in the left parietal lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.3 mm entry wound in the right frontal bone, hemorrhage and edema in the brain parenchyma, exit wound in the right parietal bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospiatl\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e11\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEntry wound in the C4 vertebra level, exit wound in the left maxillary sin\u0026uuml;s wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8 mm entry wound in the left frontal bone, hemorrhage in the frontal lobe, 9.6 mm exit wound in the right occipital bone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHandgun\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eM: Male, F: Female, ED: Emergency department\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the five cases injured by a shotgun, subcutaneous pellets were seen in the penetration area at bone and parenchymal doses on cranial CT axial images (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In one case of handgun injury, a subcutaneous bullet core was found in the right temporal region on the bone dose axial CT images (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Another case of handgun injury revealed that the bullet had penetrated the skin and bone, creating a 10 mm entry wound in the left frontal bone and forming a 60.2\u0026deg; angle with the anteroposterior line, without causing any brain tissue damage (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the cranial CT axial images of a patient wounded with handgun, it was observed that the bullet core entered posteriorly at the level of the C4 vertebra, creating a 7.2 mm entry wound on the skin. The bullet core traveled anteriorly through the soft tissues and muscle structures in the right cervical region, causing tissue damage and cavitation before exiting the anterior neck with a 6.2 mm exit wound (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn four cases with handgun injuries, the bullet core penetrated the skin and cranial bones, causing brain tissue damage. In the first case, the bullet core entered the left maxillary region, causing multiple fractures in the anterior and lateral walls of the left maxillary sinus. It traveled through the temporal and parietal lobes, remaining lodged in the left parietal lobe and resulting in intracerebral hemorrhage, edema, and midline shift (Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e9\u003c/span\u003e). In the second case, the bullet core entered through the right frontal region, creating a 6.3 mm entry wound in the frontal bone, and exited from the right parietal region after causing parenchymal hemorrhage (Fig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e10\u003c/span\u003e). In the third case, the bullet core entered at the level of the C4 vertebra in the neck, fracturing vertebral bones, and traveled anteriorly through the skull base before exiting via the left maxillary sinus (Fig.\u0026nbsp;\u003cspan refid=\"Fig11\" class=\"InternalRef\"\u003e11\u003c/span\u003e). In the final case, the bullet core entered through the left frontal region, traveled caudally through the left frontoparietal region, and exited from the right occipital region, leaving a 9.6 mm exit wound. This trajectory caused bleeding from the right frontoparietal region to the lateral ventricles and mesencephalon (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeven cases with subcutaneous pellets or bullet cores identified radiologically were treated in emergency department. Five patients with firearm injuries required hospitalization, of which two did not survive.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFirearm injuries are major traumas with high mortality and morbidity across all age groups. Our study indicates a predominance of male cases in pediatric cranial FI, with shotguns causing injuries more frequently than handguns. A multicenter study in our country similarly reported a higher occurrence in males, with an average age of 13.6 years. Cranial injuries (27.4%) were the second most common type after extremity injuries (49.5%), and despite being less frequent, cranial injuries have a higher mortality rate than extremity injuries (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The frequent use and associated fatalities of firearms can be attributed to factors like the availability of shotgun cartridges with varying diameters and properties, modifications made by users to fit specific needs, the easy access to firearms in rural areas, and the unsafe storage of firearms in homes, especially where children are present (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCranial FI cases can be evaluated radiologically with direct radiography and cranial CT. Direct radiographs should be taken from at least two angles to identify the presence and location of bullets within the cranium and to detect bone fractures (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, CT scans are prone to artifacts\u0026mdash;image distortions due to various factors\u0026mdash;which can limit their utility. These artifacts can appear as linear artifacts, partial volume effects, ring artifacts, noise, motion artifacts, and more (Fig.\u0026nbsp;\u003cspan refid=\"Fig13\" class=\"InternalRef\"\u003e13\u003c/span\u003e). In cases where bullet core fragments create artifacts that hinder CT evaluation, MRI may offer a superior alternative. However, due to the ferromagnetic nature of most bullet cores, MRI is generally avoided in FI cases, as strong magnetic fields can cause bullet cores to move, potentially causing further harm (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Although direct radiography and cranial CT each have their advantages and limitations, cranial CT is now widely recommended for FI cases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdvantages, disadvantages of conventional radiography and tomography\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConventional radiography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTomography\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdvantages\u003c/b\u003e\u003c/p\u003e \u003cp\u003eForeign bodies and bullet core can be detected\u003c/p\u003e \u003cp\u003eCranial bone fractures canbe detected\u003c/p\u003e \u003cp\u003eSimple, easy, fast and costeffective\u003c/p\u003e \u003cp\u003eEasy accessible, easy to apply\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAdvantages\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEnrty wound of bullet core/pellet can be detected\u003c/p\u003e \u003cp\u003eSkin or bone defect of bullet core/pellet can be detected\u003c/p\u003e \u003cp\u003eDiameter of entry wounds can be measured\u003c/p\u003e \u003cp\u003eAzimuth angle of enry w can be calculated\u003c/p\u003e \u003cp\u003eBullet core residue and location can be shown\u003c/p\u003e \u003cp\u003eFragmnented bullet core distrubution can be shown\u003c/p\u003e \u003cp\u003eBullet core trajactory can be determined\u003c/p\u003e \u003cp\u003eBrain damage and cavitation can be shown\u003c/p\u003e \u003cp\u003eIntracerebral, intraventricular, epidural, subdural, subarachnoid hemorrhage can be determined\u003c/p\u003e \u003cp\u003eBrain edema, shift and herniation can be determined\u003c/p\u003e \u003cp\u003ePneumoceohalus can be determined\u003c/p\u003e \u003cp\u003eBone fragmentation, fragmented bone distrubution can be detected\u003c/p\u003e \u003cp\u003eForeign bodies and location can be shown\u003c/p\u003e \u003cp\u003eEntry and exit wounds can be differentiated\u003c/p\u003e \u003cp\u003eExit wounds location and diameter can be determined\u003c/p\u003e \u003cp\u003eHounsfiled unit can be measured\u003c/p\u003e \u003cp\u003eCause of death can be determined\u003c/p\u003e \u003cp\u003eNoninvasive\u003c/p\u003e \u003cp\u003eImaging is repeatable as body integrity is preserved\u003c/p\u003e \u003cp\u003eDate can be stored digitally\u003c/p\u003e \u003cp\u003eImages can be reevaluated and opinions can be obtained by different people and platforms\u003c/p\u003e \u003cp\u003eLow risk of infection and transmission\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisadvantage\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRestrictive information about soft tissues\u003c/p\u003e \u003cp\u003eS\u0026uuml;perposition of tissues makes interpretation diffucult\u003c/p\u003e \u003cp\u003eRadiation risk\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisadvantage\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRestrictive information about sudden death\u003c/p\u003e \u003cp\u003eDevice, computer, hardware are required\u003c/p\u003e \u003cp\u003eArtifacts reduce image quality\u003c/p\u003e \u003cp\u003eRadiation risk\u003c/p\u003e \u003cp\u003eCost is high\u003c/p\u003e \u003cp\u003eExperience required for report and comment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this study, cranial CT axial images were used to evaluate the number, location, and distribution of intracranial pellets, as well as their relationship with the skull and brain parenchyma. The entry site, entry wound size, angle, bullet core trajectory, bone and tissue damage, bullet core residue, and exit wound findings were also assessed. Bullet cores produce two angles within the target tissue: a vertical angle indicating the bullet's path up or down, and an azimuth angle representing its right-left or lateral path, similar to a compass direction. A perpendicular shot to the target has an azimuth angle of 90\u0026deg; (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). In addition to standard axial images, advanced reformatting in sagittal, coronal, or complex planes can be employed for more detailed evaluations (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 7 cases where shotguns and handguns were used, and the pellets or bullets did not penetrate the bone but remained subcutaneous, it is likely the projectiles expended all energy upon entering the skin. These patients were treated in emergency department. In five cases with handgun injuries, bullet cores penetrated the skull and caused brain damage, resulting in severe injuries. Two of these patients, who had a Glasgow Coma Scale score of less than 5 and suffered intracerebral hemorrhage, did not survive. Low Glasgow Coma scores, multiple skull fractures, hemorrhage, and edema are all associated with high mortality in cranial FI cases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study is limited by its retrospective, single-center design, and by relying solely on axial images for radiological evaluation. Despite this, we believe the small sample size did not significantly impact the findings. Modern CT technology enables the creation of sagittal and coronal reformats in addition to axial images. However, only axial images were available for retrospective analysis in our hospital's PACS system. Moving forward, clinicians should request radiological imaging that includes axial, sagittal, and coronal views to enhance the diagnostic capabilities and utilize available technology more effectively.\u003c/p\u003e \u003cp\u003eIn conclusion, cranial CT axial images provide essential information on the bullet core, entry and exit wounds, primary and secondary parenchymal damage, hemorrhage, edema, bone fractures, and bullet or pellet fragments. This imaging modality aids clinicians in deciding on medical or surgical interventions, selecting treatment types, monitoring treatment efficacy, and predicting mortality. It is an effective, recommended method that offers forensic physicians rapid and reliable insights into weapon type, bullet core trajectory, and skull fractures, thereby facilitating both clinical and forensic assessments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number and Consent to parcipate declaration was not to obtained due to study disayn.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Clinical Research Ethics Committee of XXX City Training and Research Hospital on March 14, 2024 (decision no: 3224).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work has not been published before, that is not under consideration for publication anywhere.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of AI- assisted technologies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAI was nor used\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no financial or nonfinancial intersts that are directly or indirectly related to the work submitted.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eno funding request for study.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization: İA.Formal analysis: İA, AY.Funding acquisition: NoneInvestigation: İA, AY, ASKMethodology: İA, ASKProject administration: İA, AY, ASKResources: İA, AYSoftware: noneSupervision: İAValidation: İA, AY, ASKVisualization: İA, ASKWriting-original draft: İA, ASK, AYWriting-review and editing: İA\u003c/p\u003e\n\u003ch2\u003eData availability:\u003c/h2\u003e\n\u003cp\u003eAll data analeysed during the study are avaliable from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOktay K (2020) Kranial Ateşli Silah Yaralanmaları. 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Ankara, T\u0026uuml;rkiye Klinikleri, pp 8\u0026ndash;12\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAydın F, Yavuz MS (2020) İzmir ve \u0026Ccedil;evre İllerde Meydana Gelen Ateşli Silah Yaralanmasına Bağlı \u0026Ccedil;ocukluk \u0026Ccedil;ağı \u0026Ouml;l\u0026uuml;mleri. Bull Leg Med 25(1):36\u0026ndash;43\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemirci Ş, Dogan KH, Deniz İ, B\u0026uuml;ken B, Erkol Z (2009) The Deaths Related to Firearm Injuries During the Age of Childhood in Konya. Bull Leg Med 14:22\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma V, Sharma R, Kast S, Tiwari T, Goyal S, Kritika K (2023) vd. Evaluating the Role of a Radiologist in the Firearm Injuries: A Case Series of Important Medico-legal and Health Prospects. 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Neuroimaging Clin 12(2):229\u0026ndash;248\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026uuml;rmen HK (2022) Biilgisayarlı tomografi ile \u0026uuml;\u0026ccedil; boyutlu (3B) tarama. UM\u0026Uuml;FED 4(2):1\u0026ndash;21\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbert LC, Franckenberg S, Sieberth T, Schweitzer W, Thali M, Ford J (2021) vd. A review of visualization techniques of post-mortem computed tomography data for forensic death investigations. Int J Legal Med 135(5):1855\u0026ndash;1867\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGardner RM, Bevel T (2009) Practical crime scene analysis and reconstruction. CRC Press. Taylor\u0026amp;Francis Group\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eT\u0026uuml;rk Radyoloji Derneği MRG ve BT inceleme standartları 2012. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.turkrad.org\u003c/span\u003e\u003cspan address=\"https://www.turkrad.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5574485/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5574485/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eFirearm Injuries are growing problem due to rising civil wars, terrorist acts, and the spread of personal armament. Notably, there has been a reported rise in firearm injury and fatal cases among children and young people, who are particularly vulnerable to widespread violent behavior. Early diagnosis and treatment, including radiological imaging after initial intervention, can reduce mortality and morbidity in firearm injury cases\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo explore the demographic characteristics and computerized tomography findings of pediatric patients with cranial firearm injuries and comparing the advantages and disadvantages of conventional radiography and tomography.\u003c/p\u003e\u003ch2\u003eMaterials and methods\u003c/h2\u003e \u003cp\u003eThis study included cases of cranial firearm injuries presented to the pediatric emergency department of XXX City Training and Research Hospital between January 1, 2018, and December 31, 2021. Data recorded for each case included age, gender, clinical course, and weapon type. Cranial tomography images were reviewed for entry and exit wounds, bullet trajectory, brain damage, bone fractures, distribution of bone fragments, bullet core fragments and their distribution.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 12 cases included in this study, 10 were male, 2 were female, with a mean age of 143\u0026thinsp;\u0026plusmn;\u0026thinsp;46.5 months. In the five cases injured by a shotgun, subcutaneous pellets were seen in the penetration area at bone and parenchymal doses on cranial tomography axial images. In 2 cases of handgun injury, a subcutaneous bullet core was found in the temporal region while another bullet core had penetrated the skin and bone in the frontal region without causing any brain tissue damage. In four cases with handgun injuries, the bullet core penetrated the skin and cranial bones, causing brain tissue damage. Seven cases with subcutaneous pellets or bullet cores identified radiologically were treated in emergency department. Five patients with firearm injuries required hospitalization, of which two did not survive.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCranial tomography has many advantages over x-ray ımaging. Axial images provide essential information on the bullet core, entry and exit wounds, primary and secondary parenchymal damage, hemorrhage, edema, bone fractures, and bullet or pellet residue. This imaging modality aids clinicians in deciding on medical or surgical interventions, selecting treatment types, monitoring treatment efficacy, and predicting mortality. It is an effective, recommended method that offers forensic physicians rapid and reliable insights into weapon type, bullet core trajectory, and skull fractures, thereby facilitating both clinical and forensic assessments.\u003c/p\u003e","manuscriptTitle":"Radiological method and findings in pediatric cranial firearm injuries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-24 16:49:24","doi":"10.21203/rs.3.rs-5574485/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"585032f6-2971-4249-9e43-83aa314bbe76","owner":[],"postedDate":"December 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-13T09:08:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-24 16:49:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5574485","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5574485","identity":"rs-5574485","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}