Can Giffords Recover From Point-Blank Gunshot to Head?
By Daniel J. DeNoon
WebMD Health News
Reviewed by Laura J. Martin, MD
Jan. 10, 2011 -- Although Arizona Rep. Gabrielle Giffords remains in critical condition, it appears she may survive a point-blank gunshot wound to the head.
How is this possible? What can surgeons do? What are Giffords' chances of recovery -- and what will recovery mean?
To answer these and other questions, WebMD consulted prominent medical experts with experience in dealing with brain injuries, including gunshot wounds. None of these experts is treating Giffords, and none has access to her medical records.
These experts include:
- Eugene S. Flamm, MD, professor and chairman of the department of neurological surgery at Albert Einstein College of Medicine/Montefiore Medical Center in New York.
- Keith L. Black, MD, professor and chairman of the department of neurosurgery and director of the Maxine Dunitz Neurosurgical Institute at Cedars-Sinai Medical Center in Los Angeles.
- Nina Zeldis, PhD, a specialist in rehabilitation medicine, formerly of Tel Aviv University in Israel, now in private practice.
- David Langer, director of cerebrovascular research at Cushing Neuroscience Institute in Great Neck, N.Y.
- Alan Manevitz, MD, a family psychiatrist at Lenox Hill Hospital in New York. He has worked with many disaster victims, including those involved in Hurricane Katrina and the 9/11 terrorist attacks.
What part of Gabrielle Giffords' brain was injured?
The precise nature of Giffords' wound has not been made public. What is known is that a 9 mm bullet fired point-blank at the left rear of her head passed directly through the brain and exited the left front of her head.
That part of the brain controls vision, language, and the ability to move the right side of the body. All of these functions are at risk, notes Keith L. Black, MD.
"The physicians in Arizona indicated that the wound was away from these critical structures," Black says. "Based on those comments, that is a positive side for the congresswoman."
The bullet did not pass from the left side of the brain to the right side of the brain. That almost certainly would have done far more damage, Black notes.
How bad is Giffords' brain injury?
It's a very, very serious wound. About 90% of people shot in the head do not survive, David Langer says.
But there is much reason for hope in Giffords' case.
Giffords' neurosurgeon, Michael Lemole, MD, says his patient is able to understand simple commands -- such as "Show me two fingers," and "Wiggle your toes" -- and to perform these tasks.
This is heartening news, says Eugene S. Flamm, MD.
"The fact that she is being described as able to follow commands, when they lighten up on her medications, that is encouraging," Flamm says. "But I don't know whether this injury means she is paralyzed on the right side: That is a very important issue. If she is not moving her right side, that makes it hard to imagine good recovery."
The biggest issue facing Giffords is that she has suffered what Flamm calls "sort of the ultimate traumatic brain injury."
Brain tissues bruised by the force of the bullet continue to swell for days after the original injury. Such swelling can kill even more brain cells than those destroyed by the original injury.
"The problem with swelling in the brain is it is inside the skull, a closed cavity. If the pressure from the swelling reaches the arterial blood pressure, you no longer get blood flow to the brain and the brain is starved of blood," Black says. "Then you get collateral death of tissues surrounding the bullet wound itself."
This swelling, Flamm says, continues for about five days -- and usually is worst on the third day after the injury.
To reduce the swelling:
- Giffords' doctors removed a section of her skull.
- Giffords' doctors put her into a medically induced coma.
- Steroids can be given to reduce swelling.
- A concentrated sugar solution can be given to draw fluid out of the brain.
- Hyperventilation via a respirator can keep brain cells from starving of oxygen.
Why was part of Giffords' skull removed?
After removing bone fragments from Giffords' brain, her doctors also removed a large section of her skull. This was done to give her bruised brain some room to swell.
If the bone had not been removed, the pressure inside her head might have built up to the point where it starved the brain of blood.
"You take the skull up, but you still have the scalp covering the brain," Black says. "Then once the swelling goes down you can go back and put in an artificial skull plate or even the skull piece itself. But most of the time in a head injury you don't keep the bone, because it is contaminated with hair and bullet. So you come back about four weeks later and replace it with acrylic bone plates."
What is a medically induced coma?
"Medically induced coma" is not a specific term. It can mean anything from sedation with relatively mild medications to full unconsciousness induced by powerful drugs such as barbiturates or propofol.
"Probably [Giffords' doctors] are using medications that slow down the metabolic requirements of the brain," Flamm says. "It is putting the brain to sleep at a level where the patient is in a coma. The advantages are that the requirements on the brain are reduced, and this lowers pressure in the brain."
What would be the signs that Giffords' condition is getting worse?
In the short term, brain swelling is Giffords' most serious threat. Her doctors will work hard to get her off the respirator to reduce the risk of lung infection. There's also a risk of brain infection and of further bleeding. And because Giffords has suffered a very severe brain injury, seizure remains a serious risk.
Will Giffords survive?
Giffords remains in critical condition.
"Survival? We are beyond that phase," Flamm says. "What is of greater concern is the quality of survival."
Black says he's seen patients who have been shot in the head make amazing recoveries.
"We have had patients who have been shot in the head and were able to return to their previous occupations and are functioning near normal," he says. "This may have to occur on a gradual basis. ... The brain will continue to recover for six to 18 months."
The parts of the brain destroyed by the bullet are gone forever. But other injured areas may recover.
"Some brain cells now in shock are still alive and those cells will go ahead and recover once the initial trauma is resolved," Black says. "The cells that were destroyed and died, the surrounding areas will try to take over those functions by making new connections. And there are stem cells in the brain that can come out and regenerate some of the tissue."
Will Giffords recover?
As Flamm notes, survival is one thing and recovery is another. It's very rare for a person with extensive brain damage -- such as that caused by a bullet -- to regain all of the abilities and functions he or she had before the injury.
Nina Zeldis, PhD, taught rehabilitation medicine at Israel's Tel Aviv University for more than 20 years. She notes that people who, like Giffords, have suffered damage to the left side of the brain tend to have:
- difficulty speaking and understanding speech
- difficulty reading
- increased impulsivity
- lack of emotional control
- decreased problem-solving ability
- diminished long-term planning
- problems with hand/eye coordination
"The things we do every day and don't think about, all these things we think of as little become enormous and difficult to do," Zeldis says.
During rehabilitation, Zeldis says, many patients are able to compensate for these problems. But many others -- even though they work every bit as hard -- do not.
"It is beautiful when a person makes a little bit of progress, and terrible if you don't see any," she says.
Emotional issues are every bit as difficult as physical issues for a person recovering from trauma, says Alan Manevitz, MD, a psychiatrist who has helped many people cope with disasters such as Hurricane Katrina and the 9/11 terrorist attacks.
"Survivors have to challenge themselves with rational thoughts, to remind themselves who really is to blame -- not themselves -- and to restore their sense of safety," he says. "They have to talk with others so they don't isolate themselves, and to concentrate on the strengths that have made them resilient in the past. That is a strategy of how to cope with the feelings."
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SOURCES: Eugene S. Flamm, MD, professor and chairman, department of neurological surgery, Albert Einstein College of Medicine/Montefiore Medical Center, New York.Keith L. Black, MD, professor and chairman, department of neurosurgery and director, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, Los Angeles.Nina Zeldis, PhD, specialist in rehabilitation medicine.David Langer, director of cerebrovascular research, Cushing Neuroscience Institute, Great Neck, N.Y.Alan Manevitz, MD, family psychiatrist, Lenox Hill Hospital, N.Y. New York Times web site.
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