After a Gunshot Injury to the Brain, Keeping Hope Alive and Swelling at Bay

Astronaut Mark Kelly holds the left hand of his gravely injured wife, Rep. Gabrielle Giffords. Photo released to the public by Rep. Giffords’s office.

Lori Shutter, MD, Director of the Neurocritical Care Program at the UC Gardner Neuroscience Institute and Associate Professor of Neurosurgery and Neurology, was interviewed Monday on WLW-700 about neurotrauma and the kind of treatment that follows a gunshot injury to the brain.

Speaking with Scott Sloan and Tracy Jones, Dr. Shutter answered questions that many people have been asking in the wake of the tragic shooting of Rep. Gabrielle Giffords and 19 other individuals outside a Tucson supermarket on January 8. Six people were killed and 13 injured, including Ms. Giffords, who was shot in the head at point-blank range. Ms. Giffords has begun opening her eyes and moving her arms and legs, but she remained in critical condition on Friday.

Whether one survives a gunshot wound to the head, Dr. Shutter said, depends on the trajectory of the bullet as it enters the skull. “If the bullet stays on one side of the brain, then it might be a survivable injury,” Dr. Shutter told WLW.

People usually do not survive, she said, if the bullet involves both sides (hemispheres) of the brain, or if the bullet goes from the lower part of the brain to the top, or from the top down to the brainstem, which connects to the spinal cord and is involved in a multitude of vital functions, including breathing, alertness and heart rate.

As a neuro-intensivist, Dr. Shutter is devoted to the comprehensive care of critically ill patients who have suffered trauma to the brain from a gunshot, fall, car accident, hemorrhage or stroke. In University Hospital’s state-of-the-art Neuroscience Intensive Care Unit (NSICU), Dr. Shutter and her team provide care that is unique in its concern with the relationship between the brain and other organ systems in the setting of critical illness.

A primary objective for clinicians in the NSICU is to control brain swelling as much as possible following a traumatic brain injury.

When the brain suffers trauma, it automatically takes self-protective action. The brain cells release arachidonic acid, which triggers a series of events that draw additional cells and chemicals to the injured site. While some of these compounds appear to be protective to inhibit harmful inflammation, others are harmful if they remain in the area too long. Their fight to save the injured brain can spill over into nearby areas, damaging neighboring structures. Thus far doctors have been unable to prevent or manipulate these progressive changes that follow traumatic brain injury.

“Swelling tends to start reaching its peak three to five days after the injury,” Dr. Shutter told WLW. “Once you get someone through that first period of brain swelling and possible infections, only then can you start talking about what the long-term disability will be … Anybody who has had a severe head injury, whether it’s penetrating or non-penetrating, is critical for the first week.”

In Tucson, in a procedure called a decompressive hemicraniectomy, physicians removed nearly half of Rep. Giffords’s skull so that her swelling brain would not suffer additional trauma. Researchers are continually seeking ways to control brain swelling. In May 2010, UC researchers began enrolling patients in a randomized clinical trial to assess whether administering the hormone progesterone immediately after a moderate to severe traumatic brain injury will reduce brain damage and swelling and thereby improve the patients’ mental and physical outcomes. Progesterone occurs naturally in both men and women.

The Cincinnati portion of the study is being led by Dr. Shutter and Jay Johannigman, MD, Professor and Director of the Division of Trauma and Critical Care.

The $14.5 million progesterone study, funded by the National Institute of Neurological Disorders and Stroke and known as ProTECT III, will enroll 1,140 patients over a period of several years at more than 30 medical centers throughout the United States.

Researchers at UCNI are also studying “spreading depressions,” subtle disturbances in the brain following neurotrauma and are working to develop the next generation of brain monitoring so that they can more effectively manage patients in the critical hours and days following neurotrauma. Recovery from traumatic brain injury varies widely. Although brain tissue does not grow back, the brain retains “plasticity,” the ability to create new connections between brain cells and learn new ways of doing things. Age matters, as the potential for plasticity is greater in younger people. The language centers of young children who have suffered brain injury have been known to migrate to the side of the brain opposite the injury, notes Michael Privitera, MD, Director of the UC Epilepsy Center.

Dr. Giffords’s language recovery, Dr. Privitera said, will be influenced by whether the damaged hemisphere – the left — is dominant for language. “In most right-handers, the left hemisphere is dominant for language, so her language recovery might be better if she’s left-handed or has a strong family history of left-handedness.”

A gunshot wound to the head, Dr. Shutter told WLW, would almost always leave some time of long-term disability. What that would entail in Rep. Giffords’s case, she said, “is impossible to know right now.”

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