1. Successful delayed treatment of the Gunshot Wound to the Head after initial Treatment that was followed by deterioration of the General and Neurological State Novaković N., Minić Lj., Lepić M., Stojšić R. Dpt. of Neurosurgery, Military Medical Academy, Belgrade

2. Introduction Gunshot wounds to the head are the most lethal type of head injury, ca. two thirds are dying at the scene, and in more then 90% of victims the wound itself acts as a proximal cause of death. This paper describes a male patient with a penetrating gunshot wound to the head of civilian firearms that was at first treated in Clinical Center in Priština, where the first Surgery was performed. Due to deterioration of the general state, on the next day he was transferred to Military Medical Academy for further diagnostic and surgical treatment.

3. Case Report The patient was admitted comatose through the ER as an emergency. On admission, the patient is unconscious, not answering to vocal stimuli, opening eyes and extends limbs on the left side of the body to painful stimuli. Left pupil mydriasis is present. GCS 5. Hemodynamically unstable, with tachycardia, almost immeasurable peripheral pulses, and blood pressure of 90/60 mmHg. Therapeutic and diagnostic procedures were conducted urgently. MSCT examination of the head presented signs of penetrating gunshot wound and massive intracerebral haemathoma that compromises medio-sagital and vital structures (Picture 1)

4. Picture 1: MSCT of the Head showing state after Gunshot wound to the Head with massive Intracerebral Haemathoma that compromises Mediosagital Structures

5. Patient underwent urgent surgery. During the surgery, both the bullet and metal particles were removed, intracerebral haemathoma was extirpated and the injury canal was explored and debridement of both the wound and the canal was made, followed by complete hemostasis, reconstruction of the dura matris, and cranioplasty. 10 days after surgery, patient breaths spontaneously, executes orders moves both left arm and leg, milder paresis of right leg and plegia of the right arm are present. Picture 2: MSCT of the Head showing state Two days after the Surgery was performed. No signs of Bullet particles are present. Porencephalic space is visible with signs of Brain re-expansion towards the space.

6. The postoperative course leads to the development of septic condition, which was successfully treated and the patient was discharged from the hospital after 24 days of treatment with persisting right upper limb monoplegia, right lower limb monoparesis and maceration of the scalp in the occipital region. Now days three years later, only the mild paresis of the right arm is persisting while patient is able to act as he did before the injury.

7. Picture 3: MSCT of the Head showing state Nine months after the Surgery was performed.

8. Conclusion Any gunshot wound to the head that doesn’t directly interfere with vital functions, should be treated surgically as soon as possible, despite of initial status. Bad initial status of the patient, low GCS score hemodynamic instability, and delayed treatment in severe brain injury is followed by even higher rate of mortality and postoperative complications then usual, however the proper surgery is probably never too late and the patient reacted contrary to the expected outcome.