Volume 1, Issue 1, Case Report – Jun 12, 2025, Pages 1028-1036

Ayhan Yildirim¹, René Hertach², Vedat Yildirim¹

¹ Hochschule Zurich, Department of Medicine, Albisstrasse 80, 8038 Zurich, Switzerland
² Hochschule Zurich, Department of Dentistry, Albisstrasse 80, 8038 Zurich, Switzerland

Received 15 October 2024, Revised 25 March 2025, Accepted 20 Mai 2025, Available online 16 July 2025, Version of Record 18 July 2025.

Abstract

Suicide attempts are disturbing and complex events that often need immediate, interdisciplinary, and often complex treatment with interdisciplinary management to ensure a good outcome. We present a 57-year-old male patient with a self-inflicted assault rifle gunshot fired in the presence of his family. He had been suffering from depression over a long period of time and refused to take his prescribed medication. After a conflict within his family he made the suicide attempt with the bullet entering the submental area, shattering the mandible, missing the maxilla, but destroying most of the nasal and frontonasal structures and exiting through the frontal brain lobe and frontal bone. Case reports of this nature are nowadays rare.

We describe the immediate and interdisciplinary management of a tragic and severe craniofacial injury due to a suicidal gunshot wound.

Introduction

More than 800,000 people worldwide die from suicide every year, according to the World Health Organization website, which corresponds to one death every 40 seconds. Many more people attempt suicide each year. Suicide worldwide has been estimated to contribute to 1.3% of the total global burden of disease in 2004. Mental disorders (particularly depression, and alcohol and other addiction disorders) are major risk factors for suicide in Europe and North America; however, in Asian countries, impulsiveness plays an important role. Suicide is complex with psychological, social, biological, cultural and environmental factors playing a role[1].

Gunshot suicide attempts are relatively common in Switzerland as men are allowed to keep their military assault rifles at home. Fortunately this trend is decreasing as the Swiss government now allows men to hand in their rifles for safe keeping.

Case report

Background:

The patient had a resume of professional overload situations for years, and this was apparently exacerbated in the weeks preceding the incident. The patient consumed 1 litre of wine and 1 to 2 packages of cigarettes per day. His wife reported that he had a tendency to neglect his personal hygiene, and showed disinterest in his surroundings and assistance. He was taking antidepressants for a while, but stopped taking his medications after a short period of use.

Initial presentation:

A 57-year-old man was transferred to the emergency room at the Seeklinik Zürich, a Specialist clinic for oral, maxillofacial and plastic facial surgery by air borne emergency services in a critical state with a facial suicidal gunshot wound in the face by an assault rifle. He was not intubated on the scene, but was transferred in the prone position due to a compromised airway and the apparent extent of his injuries, and was categorised as Glasgow Coma Scale (GCS) 12. Upon arrival, he was heavily sedated (Blood alcohol level 56.8 mmol / l (~ 2.6 ‰)) and no further comprehensive neurological assessment was possible. Clinically, it appeared as if the bullet entered the submental area, splitting the lower lip and comminuting the mandible, missed the maxilla and split the upper lip and nasal area, causing comminution of the nasal and frontal area with frontal lobe injury and exposure. Bleeding was minimal and was managed by local compression bandages. Ophthalmological examination showed a corneal perforation on the left with already completely empty contents of the left eye, probably representing globe rupture.

Despite extensive injuries, the patient was haemodynamically stable, could move all his extremities, and even speak a few isolated words. The patient was intubated orally in the emergency room to protect the airway, and diagnostic imaging was performed.

Computed-tomography showed comminution of the frontal skull base with interhemispheric distribution of the disrupted bone fragments, bifrontal bleeding in the brain with pneumancephalon, especially frontal and intratentorial, with extension to the vertex, complex midface fractures and comminution of both orbits as well as countless fragments along and around the bullet trajectory. The nasal structures on either side were nearly completely destroyed and dislocated, along with the nasal septum. Multiple mandibular fractures were present with bone loss, and the left eye showed loss of volume with trapped air. Due to the extent as well as the intracranial injuries, antibiotic prophylaxis with Cephtriaxone (®Rocephin) was started. A discussion with the family was held and they supported further life supportive and interventional care.

Management:

An interdisciplinary team was assembled, which included emergency surgeons, anaesthetists, neurosurgeons and maxillofacial and oral surgeons to discuss further management. The on-call ophthalmologist was informed of the patient and was placed on standby. The patient was transferred to the theatre where a tracheotomy was performed, and the neurosurgeons performed frontobasal craniotomy, debridement, and a large vascularised pericranial flap based on the right supraorbital vessels. As the closure of the dural defect was still problematic, and due to significant dead space, a bilateral transverse temporal muscle flap was performed with suturing in the midline by the maxillofacial surgeons. Despite the massive craniofacial injuries, there was limited brain swelling due to the open nature of the injuries, and the interdisciplinary team decided that an intracranial pressure catheter was not indicated. The maxillofacial team first performed a conservative debridement, removing and preserving only non-pedicled bone fragments. By using mini-plates and titanium mesh, both medial orbital rims and walls were reconstructed with splinting both lacrimal canals with silicone tubes. The mandible was also comminuted and the fracture was simplified by using miniplates and lag screws. Then a defect bridging by a reconstruction plate was used on which the other fragments were fixed. Finally, the soft tissues were closed, carefully excising only clearly necrotic skin and mucosa. Soft tissue deficits were evident in the frontal and frontonasal areas. The ophthalmologists were called for an opinion as soon as the extent of the left eye injury was apparent, and were called in again after the craniofacial reconstruction was performed. They performed an evisceration with placement of silicone implant and temporary tarsorrhaphy.

Postoperatively, the patient showed a persistent leak of cerebrospinal fluid from the frontal soft tissue deficit, and three days later, at the request of neurosurgeons, coverage of the residual dural and frontonasal skin defect was performed by using a radial forearm free flap. Further reconstructive procedures are planned as soon as the patient’s condition, both physically and mentally, has stabilised.

Discussion

Recent literature reports that the mortality rate for a suicide attempt ranges from 7.7% to 93% [2-14]. In our case, the patient survived extensive injuries after an emergency operation by an interdisciplinary team. Between 1990 and 2008, Loyola V. Gressot et al. reported that 199 suicide patients were admitted to Ben Taub General Hospital in Houston, Texas, a Level 1 trauma centre. After surviving initial resuscitation, 19% of all admittees and 40% of those who survived ultimately had a favourable functional outcome at 6-month follow-up of moderate disability or good recovery. Loyola V. Gressot et al. suggest a scoring system for the rapid assessment of patients with a GSWH at the time of the first CT scan.

GCS Score

Our patient had an initial GCS of 12 and increased in the shock room to 13, which indicated a favourable prognosis. A lower GCS score upon presentation is associated with higher mortality and worse functional outcomes[4, 5, 7-9, 11, 13, 15, 16]. It should always be kept in mind that in case of organic damage of the eyes, injuries of the tongue or damage of nerves or muscles affecting the motor function, adequate application of the GCS is limited. Grahm et al. and Martins et al. showed that an aggressive surgical intervention should only be performed in a patient with a GCS score of at least 3–5[17].

Age and Sex

Our patient was a 57 years old male. Loyola V. Gressot et al. showed that most of the suicide patients are between 20 to 40 years old[8]. In accordance with other studies, they found that older patients had worse outcomes than young patients[13, 15].

Pupils

Bilaterally nonreactive pupils are a negative prognostic indicator[14, 15, 18]. In our patient the left pupil was destroyed completely by the bullet and the right pupil was 3 mm and slightly oval in shape without any pupillary reaction to light. Some authors argue that pupillary response is an equivocal finding because most patients with a low GCS score will have nonreactive pupils[4].The response of the pupils appears to be most enlightening in patients with GCS scores of 3–5 at presentation as an indicator of possible survivability[19]. Despite swelling and bleeding, in our opinion, it is important to attempt a best possible basic ophthalmological examination in these difficult circumstances.

Bullet Trajectory

The bullet trajectory in this patient destroyed the frontal area with frontal lobe injury. Bullet trajectory has been shown to impact both mortality and morbidity from penetrating brain injuries, with bi-hemispheric and posterior fossa injuries demonstrating worse outcomes[4, 5, 7-9, 11-13, 15, 16, 18]. A 96.2% mortality rate for bihemispheric injuries and a 100% mortality rate for posterior fossa injuries are reported by Martins et al.[8]. A much lower mortality rate of 19.2% for patients with GSWHs involving the posterior fossa was shown by Nathoo et al.[10]. This series had a relatively high mean GCS score of 11, and did not include any patients with a GCS score lower than 6[6]. It has been reported that transventricular injuries have high rates of mortality[9, 11, 15,19]. Grahm et al. advocated nonoperative management of patients with bihemispheric or multilobar involvement of the dominant hemisphere if they have a GCS score of 6–8 upon presentation, unless a significant hematoma is also present[4]. Improved outcomes in patients with a pure bifrontal injury, like our case, were also observed by Stone et al. in a relatively small cohort of eight patients with bifrontal injuries. While it is widely accepted that bihemispheric injuries are ominous, the outcomes of patients with purely bifrontal injuries is probably equal to those of patients with unihemispheric injuries[14].

Other Factors

Associated injury, respiratory arrest upon arrival, and hypotension upon arrival have been associated with higher mortality in other series[5, 15, 20]. The patient in our case had a blood pressure of 70 to 30 mmHg, a pulse of 161 per minute, an oxygen situation of 83%, respiratory rate of 12 and a body temperature of 35.4 degrees at initial presentation. Loyola V. Gressot et al. showed in their study that surgical intervention was associated with improved mortality and morbidity. Levy et al. showed that craniotomy for patients with a GCS score of 3–5 improved with regard to mortality but not morbidity[19]. Due to the relatively good general condition of the patient, the craniotomy was performed as an emergency procedure. In a later paper selecting patients presenting with a GCS score of 6–15, Levy showed that operative intervention was only significantly associated with morbidity in patients with an initial GCS score of 12–15, though operative intervention was associated with decreased mortality for all patients[18].

All of these studies have a selection bias, in that patients who underwent surgery were those who were thought to be able to survive the surgery. In previously published studies, many patients with less favourable clinical status did not undergo surgery. Several authors have developed treatment algorithms based upon their findings [4, 8,14]. Turina et al. proposed the War Head Injury Score for predicting mortality in military penetrating craniocerebral trauma based upon GCS score and Injury Severity Score[21]. This case, in particular, clearly illustrates the aspect of giving priority to survival when a reasonable chance of survival and quality of life is present, compared to the self-determination of a suicide attempt.

Conclusion

Patients with a gunshot wound to the brain continue to present a challenge to the treating physician. Patients suffering this type of injury continue to be plagued by high mortality rates and poor neurological outcomes. In this case, we reported on a patient’s suicidal shot injury in relation to GCS score, age, pupils, bullet trajectory, and other factors. In our view, although many of these patients have poor neurological outcomes and commonly have long, complex clinical courses, every patient should receive the best possible medical care regardless of a rating on a scale.

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