SPECIAL ARTICLE

BALLISTICS FOR THE NEUROSURGEON

Rahul Jandial, M.D.
Department of Neurosurgery, University of California, San Diego, San Diego, California

Brett Reichwage, M.D.

Department of Neurosurgery, University of Florida, Gainesville, Florida

CRANIOCEREBRAL INJURIES FROM ballistic projectiles are qualitatively different from injuries in unconned soft tissue with similar impact. Penetrating and nonpenetrating ballistic injuries are inuenced not only by the physical properties of the projectile, but also by its ballistics. Ballistics provides information on the motion of projectiles while in the gun barrel, the trajectory of the projectile in air, and the behavior of the projectile on reaching its target. This basic knowledge can be applied to better understand the ultimate craniocerebral consequences of ballistic head injuries.
KEY WORDS: Ballistics, Brain, Gunshot, Injury, Projectile, Trauma
Neurosurgery 62:472480, 2008
DOI: 10.1227/01.NEU.0000297046.66788.89

Michael Levy, M.D., Ph.D.

Department of Neurosurgery, University of California, San Diego, San Diego, California

www.neurosurgery-online.com

Vincent Duenas, B.S.

University of San Diego College of Medicine San Diego, California

Larry Sturdivan, B.S., M.S.

LMS Scientic Models, Sante Fe, New Mexico Reprint requests: Brett Reichwage, M.D., 4343 NW 61st Terrace, Gainesville, FL 32606. Email: brett.reichwage@neurosurgery.u.edu Received, July 16, 2007. Accepted, September 28, 2007.

allistics has been identied as the science of the motion of a projectile through a gun barrel, subsequently through a medium such as air, and eventually into or through a target (33). However, ballistics is not only associated with bullets. The motion of any body in unpowered ight is that of a ballistic projectile. This category covers objects, from hand-thrown objects to intercontinental ballistic missiles, at a full range of masses and velocities. The science of ballistics is usually divided into three categories: interior ballistics, which is particular to rearms and deals with the motion of a bullet in the gun barrel; exterior ballistics, the study of the ight of a projectile through air; and terminal ballistics, which deals with the behavior of the ballistic projectile upon reaching its target. When the target is a person, the study is called wound ballistics (1, 4, 9, 34). In addition to penetrating injuries, wound ballistics covers blunt injury from nonpenetrating ballistic projectiles and multiple injuries by separate impacts from fragmenting munitions. Other types of injury, such as blast and incendiary effects, are not, strictly speaking, ballistic phenomena but are often studied as part of wound ballistics. Of particular importance for our purposes is to understand the projectile behavior that results in craniocerebral injuries. Before the 14th century AD, when gunpowder was introduced to Europe by the Mongols, the majority of head injuries were caused by low-velocity objects such as sabers, swords, lances, arrows, slingshots, and hand- or machine-thrown projectiles, usually stones. The introduction of gunpowder initiated the

evolution of relock, matchlock, intlock, and wheel lock muskets. There was a slow but consistent progression toward guns with faster and more accurate bullets. Initially, firearm projectiles were lead balls, handloaded through the muzzle. Muzzle-loading rearms were used for many years. Rifling, which allowed spin stabilization of nonspherical bullets, was invented in AD 1520. The elongated bullets, still made of solid lead, were much more accurate than the lead balls that prevailed at the time and were still used for centuries thereafter. Two hundred years passed before jacketing or plating of the lead bullets was devised to slow the build-up of lead in the gun barrel. Cleanerburning propellants gradually replaced the original black gunpowder, which dramatically slowed fouling of the gun barrel by burned gunpowder particles (21, 34). In 1847, Delvigne introduced elongated bullets with a hollow base. Pressure from the burning propellant expanded the base of the bullet into the rifling grooves in the barrel, which helped preserve the structural integrity of the grooves during acceleration of the bullet (Fig. 1). In 1847, Captain Minie inserted an iron cup into the hollow base to maintain symmetric expansion of the bullets. These new bullets, called minie balls, were muzzle loaded into percussion muskets. From 1850 until the turn of century, breech-loading ammunition gradually replaced the muzzle loaders. Bullets were jacketed with a hard-gilding metal, such as cupronickel, which lowered friction in the muzzle in addition to reducing fouling. Lowered friction and larger amounts

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FIGURE 1. Cross-sectional and oblique views of a rie bore. (Used with permission from www.huntered.com.)

of more efficiently burning propellant resulted in a substantial velocity increase to 2000 ft/s (615 m/s) or more (1, 22). After the Hague Convention of 1889, military bullets were required to be fully jacketed at the tip. For efficient, automated assembly, these are left open at the base. Much hunting ammunition continued to have open-tip jackets that are solid across the base of the bullet (closed base). The introduction of gunpowder around the world also gave rise to explosive, fragmenting munitions, such as grenades and artillery ammunition. The explosive element in such munitions soon evolved into a variety of higher-powered explosive compounds. As these made their way into industrial uses, the number of injuries from accidental industrial explosions soon outpaced military action and hunting accidents as a cause of the injuries with which we are concerned. From the beginning, however, the contribution of military-based scientific studies into the causes and treatment of craniocerebral injuries was disproportionate to the proportion incurred as casualties of war.

FIGURE 2. Comparative photograph showing the size differentials of commonly used calibers. (Kalkomey Enterprises, Inc., 2006. Used with permission from www.hunter-ed.com.)

FIREARMS AND AMMUNITION

Firearms
Firearms that can be wielded by a single person include handguns, rifles, and shotguns. Firearms can be subclassified based on their type of action, defined as the way a cartridge is loaded, fired, and expelled from the firing chamber, and may incorporate a bolt, pump, lever, revolving cylinder, semiautomatic, or fully automatic action. Firearms and ammunition also come in different calibers. Caliber is the diameter of the firearm bore (inside of the barrel), measured from land to land (a land is the interior metal surface of the bore between the rifling grooves) and expressed in fractions of an inch or millimeters (Fig. 2). Caliber is a nominal term, however, as some do not correspond to the actual bore or bullet diameter. Ammunition is constructed to fit into a specific firearm.

Common firearm and ammunition calibers include .17, .22, .25, .223, .30, .38, .44, .45 (calibers in inches) and 5.56, 7.62, and 9 mm. Weapons are made in other calibers, but these are less common in the United States. Handguns include revolvers and semiautomatic pistols. Revolvers are usually cheaper, more reliable, more accurate, and easier to master than their semiautomatic counterparts. However, whereas a semiautomatic can hold up to 19 rounds, a revolver usually has a six-round capacity. Semiautomatics use the recoil produced from a red round to eject the spent cartridge case, load the next cartridge, and cock the hammer, whereas revolvers depend on the shooter to advance and re the next round. In addition to using a more complicated mechanism for firing and reloading, semiautomatics often use smaller propellant charges and drain some energy from the propellant to operate the mechanism, which lessens their power relative to a revolver (14). Although longer and heavier than handguns, and more difficult for a criminal to conceal, rifles offer greatly increased accuracy and power and are easier to use and more accurate than handguns. Semiautomatic rifles and handguns have a similar mechanism of action, but the rie has a much stronger ring chamber to withstand the greater pressure that accompanies a larger propellant charge and a longer barrel. Lever action, bolt action, and single-shot action are generally found in more powerful hunting ries.

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Shotguns also have long barrel lengths but almost universally lack riing. Thus, the shotgun is known as a smoothbore. Although the weapon is also known as a scattergun, the presence of riing in a shotgun would impart a spin that would exaggerate the scatter of the shot to near uselessness. Gauge is the term used for the diameter of the shotgun barrel; the larger the gauge, the smaller the bore diameter. They re a number of (usually) spherical shots from a single cartridge. The number of shots is determined by the cartridge, not the weapon. Shotguns are available in single shot, double barrel, pump, or semiautomatic actions (14). The most popular shotgun is the 12 gauge, but 410, 20, 28, and 10 gauges are also common.

Center-re Rie Ammunition

The range of sizes and powers of rifle cartridges is even wider than that of handgun rounds. They range from .17 to .700 caliber, and the most common calibers are .223 (Fig. 3) and .30. Big-game rounds, ranging up to .70 caliber and 1000 grains mass, are rare and should seldom be encountered. In fact, high-energy rifle bullets are so lethal that the neurosurgeon will see few brain injuries caused by them. If they are seen, most will be acciFIGURE 3. The shape and size of dental hits from very distant .223 caliber ammunition. (Used ranges or ricochets striking at by permission of Corbin Manuequally low velocities. facturing.)

Ammunition
Jacketed bullets have a lead core with a metal covering that is usually a copper alloy but may also be mild steel or aluminum. The lead core may include a steel insert to give the bullet better hard-target penetration. Open-tip bullets may have either a soft point or a hollow point. The typical soft point is a rounded lead tip, whereas the hollow point lives up to its name, having a small conical hole in the bare lead. Jacketed bullets are reputed to be more likely to ricochet than their unjacketed counterparts (29).

Shot Shells
Shotgun ammunition varies widely, depending on the purpose for which the gun is to be used (Figs. 46) (30). The spherical shot cannot be packed to provide a seal for the propellant gases in the chamber and muzzle, so a seal is provided by wadding, consisting of a plastic seal that contains most of the propellant gases behind the shot to maximize the muzzle velocity (Fig. 4). The wadding is expelled with the shot and, at short range, is a ballistic projectile in its own right. In addition to shot pellets, there is also slug ammunition, which is generally a solid core of lead encapsulated in radiolucent plastic with riing integrated into the plastic to spin the round to give the slug ight stability. Shot shells are constructed for each gauge, and shells of each size can be lled with different-diameter shot (33).

Small Rounds and Rimre Cartridges

The smallest projectile is the copper-plated steel BB, which would not penetrate the cranium of any but the smallest infant. Slightly more powerful lead pellets in the same .177 caliber are only slightly more hazardous, mostly to the eye. Neither contains metals different from those found in other ammunition. Rimre cartridges are used in handguns, primarily target pistols, and light ries. Rimre cartridges contain primer within the rim. The .22-caliber rimre bullet is .22-inch in diameter and weighs from 28 to 40 grains or 3.25 g. The rounds are unjacketed and usually have a hollow point, and the muzzle velocity of the long rie cartridge, when red from ries, is about 1000 ft/s. The lower-power rimre rounds have lower velocity. All sizes have a much smaller muzzle velocity when red from handguns.

Center-re Handgun Ammunition

A center-fire cartridge is one in which the primer is located in the center of the cartridge case head. These cartridges, used in semiautomatic pistols and revolvers, fire bullets that range from .25 to .45 caliber (nominal diameter in inches) with a variety of bullet weights and nose configurations in each size. The most popular sizes were once divided according to the group that used them. United States law enforcement carried the .38 revolver, the United States military preferred the .45 automatic, and Europeans used 9-mm pistols. This has now changed, although these are still among the most common calibers found in the United States. Other common ammunition includes .25- and .32-caliber cartridges. Several other calibers are less commonly encountered. Some, such as .40 caliber and 10 mm, are virtually the same size, but neither round will fit weapons made for the other.

FIGURE 4. Shotgun ammunition schematic showing the relationships between the primer, gunpowder, wad, casing, shell, and both shot- and slug-type projectiles. (Kalkomey Enterprises, Inc., 2006. Used with permission from www.hunter-ed.com.)

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FIGURE 5. Examples of the various shapes of shotgun slugs. (Used by permission of Corbin Manufacturing.)

Other Exotic Ammunition

Explosive bullets are designed to explode on impact. This effect is achieved by adding an agent such as lead azide at the front of the cartridge. Swan and Swan (33) point out that these bullets often fail to explode and may pose a threat either to the surgeon during dbridement or to the pathologist during autopsy. It would be difcult, however, to distinguish, on the usual hospital x-ray, between the explosive round that did not detonate and the hollow-point bullet that did not deform. Rubber and plastic less-than-lethal ammunition is often used in the United States by Special Weapons and Tactic teams and for riot control to decrease the risk of injury (Fig. 7). However, neither rubber nor plastic ammunition is radiopaque, and therefore, neither can be seen on most diagnostic imaging in the unlikely event that they penetrate (26, 33).

FIGURE 7. Less-than-lethal bean-bag ammunition. (Used by permission of Corbin Manufacturing.)

Projectiles from Explosive Munitions and Accidental Explosions

Explosive bullets, such as the devastator round, are designed to detonate on impact and, thus, will produce extensive tissue injury with the additional risk of a contaminated wound. Bullets are not the only missiles that can cause a penetrating craniocerebral injury. For example, fragments from explosive munitions weighing only 1 to 2 g caused most fatal brain injuries in Vietnam (M.E. Carey, unpublished data from analysis of casualties surveyed by the Wound Data and Munitions Effectiveness Team, in Vietnam). Despite their potentially devastating effects, individual shell and grenade fragments are usually not as damaging as a bullet. For small pieces of shrapnel to cause death or serious injury, the casualty must be relatively close to the source of the explosion. This is because the fragments are irregularly shaped, usually have small mass, and have high aerodynamic drag, so they tend to lose velocity and kinetic energy quickly in air. Over the years, however, the vast majority of nonfirearm ballistic injury to civilian populations has not been from either truck bombs or fragmenting munitions, whether military or improvised, but rather from accidental explosions. These FIGURE 6. This diagram shows the diameters of the various shot and buckshot ammunition available. (Kalkomey range from domestic and Enterprises, Inc., 2006. Used with permission from www.hunter-ed.com.) public building explosions

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caused by gas leaks to detonations in grain elevators, reneries, mines, port facilities, and other environments in which explosive mixtures can accumulate.

INTERIOR AND EXTERIOR BALLISTICS

When dealing with bullet wounds, the surgeon will not generally be able to reconstruct the details of the bullets interior and exterior ballistic behavior before impact from the appearance of the wound and projectile. For the reader who wishes to gain a more thorough background on these topics than is presented in an article such as this, there are many good books and articles to be found in the technical library or on the Internet (for instance, see references 17, 19, 20, 28). When a bullet is red from a rearm, it is accelerated to a nal muzzle velocity by the very rapid burning of a propellant. Ballisticians have long noted that the travel down the barrel of the weapon is the nal stage in the manufacture of the bullet. Normal engraving from the riing and minor changes in the configuration of the projectile from the accelerating force (termed setback deformation) will have little effect on the wound ballistic behavior of the bullet. Occasionally, major setback deformation will signicantly affect accuracy and terminal performance, degrading the former and enhancing the latter. It would be difcult, however, if not impossible, for the treating physician (or the ballistic expert) to distinguish deformation at launch from deformation at impact. Riing was most likely invented to allow elongated bullets to present a smaller presented area and correspondingly lower drag. The spin allowed the bullet to be stabilized in ight, like the spinning toy top, which kept the bullet oriented point-rst in ight. As ried rearms gained in popularity, however, it was soon determined that they had a dramatically increased accuracy over smoothbores, which red spherical projectiles. This was because not only did the radial spin of the rie bullet impart no lift, but any aerodynamic lift due to asymmetric nose shape was also turned into a tight spiral by the rapid spin. The effective diameter of this spiral is typically less than the diameter of the bullet and, thus, has no effect on accuracy. Besides mass, velocity, and shape, there is another characteristic of the bullet that has a signicant inuence on its terminal behavior. It is the angle that the bullets long axis makes with its direction of ight. This angle is termed yaw. Bullets usually y at relatively low yaw. Excessive yaw increases drag, causing the bullet to slow faster, and decreases accuracy by increasing the aerodynamic lift. The effects of yaw in terminal behavior are considered in the next section.

TERMINAL (WOUND) BALLISTICS

Penetrating Projectiles
The study of wound ballistics has a long and varied history. For centuries, experimenters, mostly hunters, soldiers, and surgeons, have developed myriad explanations for the causes of observed injuries, from the frictional heat of penetration to rel-

atively recent myths such as hydrostatic shock. Since the beginning of the 20th century, different experimental methods were used to demonstrate the destructive power of bullets on tissues. In 1915, Sir Victor Horsley observed a temporary cavity in clay 30 to 40 times the diameter of the missile. In 1941, Black et al. (2) used 20% gelatin to study temporary cavity formation in gelatin by high-speed photography. The modern era of serious physical modeling began with the Department of Defense contract with Princeton University during World War II. A summary of their modeling results is published in Chapter III of reference 100, along with a number of contemporary wound ballistics articles. Beginning in the late 1940s, this research was continued at the Armys Biophysics Division, Edgewood Arsenal, MD. In the 1950s, Biophysics Laboratory Director A.J. Dziemian used a polynomial in velocity to model retardation in tissue and a 20% gelatin tissue simulation (10). This model was updated for chunky grenade and shell fragments in the 1970s (31) and nondeforming bullets in the 1990s (23, 24). It can be shown that the quantity of tissue damage would be proportional to the kinetic energy deposited in the tissue by the penetrating projectile if it were not for the well-known rate dependence of tissue damage. This rate dependence is best illustrated by silicone putty. Stretch it slowly and it will distend indenitely, but stretch it very rapidly and it will snap. Tissue, of course, is much less rate-dependent than silicone putty, but Peters (23) and Peters et al. (24) have shown that this rate effect gives rise to a tissue damage measure that is dependent on the size of the projectile. All projectiles leave a (nearly vacuous) temporary cavity in their wake, some large and some virtually the size of the penetrating missile. The cavity is present behind all projectiles in all media. In air, the collapse of the cavity is seen on spark shadowgraphs as a turbulent wake. The tissue damage is not, as sometimes stated, caused by the temporary cavity. Both damage and the cavity are caused by the outward movement of the tissue, which stretches and tears the tissue. The vacuous cavity will stay open long enough for the atmospheric pressure to push air inside. The inward rush of air can sweep in debris, usually parts of the clothing and dirt that were dislodged by the projectiles impact. Of course, whatever bacteria are on this debris will also enter. The temporary cavity collapses and reopens in a pulsatile fashion for a few cycles within a few milliseconds. At points near the tip of the advancing bullet, the pressure is very high, measuring in thousands of atmospheres. It is this pressure that Carey (5) calls juxtamissile pressure. The tissue, which has acquired enormous radial velocity, separates from the projectile surface, creating the temporary cavity. It is important to note that regardless of the size of the maximum temporary cavity envelope, all the energy lost by the penetrating projectile is deposited in tissue at very high strain rates. After separation (cavitation), the tissue no longer interacts with the bullet. Thereafter, all damage in the expanding tissue is caused by the radially directed kinetic energy of the tissue itself. The amount of tissue injured beyond its ability to recover depends on the strength of the tissue, the amount of prompt

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damage (a function of the size of the missile), the size of the temporary cavity, and, to a lesser extent, the presence of bone or air-lled cavities nearby. Both leakage of intracellular uid from injured cells and blood from ruptured capillaries will infuse the intercellular space, causing swelling. In addition, torn connective tissue and cell membranes will lessen the elasticity of the injured tissue. These effects combine to create a temporarily deformed quantity of tissue around the wound track. This swollen tissue pushes outward against the elastic tension of undamaged tissue, opening up a permanent cavity and creating a back-pressure that further compromises the blood ow to injured tissue. Compromised circulation can lead to further cell death in tissue that was not ruptured by the initial insult. Clinically and in animal experiments, the permanent cavity is seen to be lled with blood, dead tissue, and sometimes the debris mentioned above, such as skin, dirt, or pieces of clothing. Primary or secondary fragments may also be contained therein. As the bullet yaws, the increase in presented area and the increase in drag coefcient result in a dramatic increase in the drag force on the bullet. The force retarding the bullet is also a force on the tissue. Increased retardation leads to an increased rate of energy transfer to tissue, thereby increasing the severity of the injury. Almost all bullets will be recovered either noseforward or base-forward, however, as they will be turned to align with the wound track as the temporary cavity collapses. One thing that they will not do is to tumble rapidly endover-end, as stated in some of the literature (16). This is the unfortunate expectation created by the use of the word tumble to describe yaw growth. The growth of yaw in tissue explains why an entry wound (at small yaw) may be quite small while the exit wound is gaping and large (21). The large exit wound is caused by the missile exiting at high yaw. One benet attributed to a hollow- or soft-point bullet is that it is less likely to exit the target with signicant residual kinetic energy, thereby posing a smaller risk to bystanders (18, 33). However, the damage to the primary target is larger at the same striking energy because the expanded bullet transfers most or all of its kinetic energy to the tissue and usually stops within the body (Fig. 8). Unfortunately, when an injured patient appears for treatment, neither the physician nor the law enforcement personnel will be able to determine the exact circumstances under which the injury took place, so the information in the last few sections is of little immediate use to the neurosurgeon. Striking velocity, for instance, is a function of the condition of the weapon and ammunition (or the explosive device), the distance from the weapon (or detonation) to the victim, yaw or orientation of the projectile as it travels through the air, and other unknown or poorly determined factors. Similar lack of information limits the knowledge of mass, striking yaw, and thickness of any barriers penetrated before striking the person (including clothing).

FIGURE 8. Hollow-point ammunition before and after impact. (Used by permission of Corbin Manufacturing.)

Generally, they cause tissue damage immediately below the site of the impact. However, blunt impacts to the head can result in injuries that do not resemble injuries to other areas. These are discussed in the next section.

CEREBROCRANIAL INJURY FROM BALLISTIC PROJECTILES

Combat wounds and civilian gunshot wounds involving head injury will be predominantly penetrating injuries. These involve small, dense, penetrating projectiles, such as bullets, shotgun pellets, and fragments from munitions or improvised explosive devices. In accidental explosions or large-scale terrorist bombings, penetrating injuries are only part of the spectrum. Blunt impact to the head can cause lethal injuries to the brain and upper cord without penetrating the cranium. Between these extremes lies a continuous spectrum of intermediate projectiles impacting at a variety of velocities, producing a mix of blunt and penetrating injuries. It might be difcult to tell whether the particular intracranial lesion is due to penetration or rotation. As the cranial contents are much less mobile than other parts of the body, one should expect that the wound track(s) would still be in the shape of a gentle curve.

Penetrating Ballistic Injuries to the Head

Although most penetrating injuries to the head involve bone, the ones of interest at present are those that penetrate the cranial cavity after perforating the overlying soft tissue. The primary factors that determine whether the projectile will penetrate the cranium are the energy at impact on bone, the contact area between the projectile and bone, and the thickness of bone at the area of impact. As indicated above, the penetration of bone is a fracture event. In the case of small, dense projectiles, such as bullets or metallic fragments, penetration is caused by a punch-out fracture, leaving a crater on the inner table of the cranium. For the larger, slower projectile, the fracture event is more likely to be a cantilever fracture of roughly wedge-shaped pieces of cranium, somewhat like the fracture pattern in a crust of ice atop liquid water when a weight is dropped on it or a person steps on it. Predictive models of the probability of penetration of both types have been formulated (32).

Nonpenetrating (Blunt) Projectiles

Injuries caused by the blunt impact of a large projectile moving at low speed are different for different body locations.

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The bullet that fails to penetrate the cranium is almost always a low-velocity impact. This may be due to extreme range, penetration of a substantial barrier before hitting the victim (including helmets in a military setting), an old, deteriorated propellant charge, or a defective weapon. For most firearm projectiles that are capable of penetrating the cranium, the remaining velocity after cranial penetration will be substantial. Unless fragmented, the projectile will usually either perforate, exiting the opposite table of the cranium, or be stopped on the opposite side without exiting. The bullet will have taken a slightly curved path between the entry point and final location. For the fragmented projectile, each fragment will have described a curved path, independent of the paths of other fragments, which will usually have curvature in different directions. The temporary cavity that is created in unconned soft tissue is greatly modied by the containment of the cranium. The limited elasticity of the cranium allows little outward movement of the contents that would ordinarily create a large temporary cavity. Instead, the tissue is forced to close in behind the projectile. This not only creates a large, complex pressure environment within the cranium but also replaces the usual radial motion of the tissue with a curvilinear motion. The rule of thumb is that tissue will move away from locations at high pressure toward locations at lower pressure. Flow patterns are inuenced by the irregular shape of the container, the path of the projectile, and the presence of tough connective tissue barriers, such as the tentorium cerebelli and the falx cerebri. If the projectile is a bullet from a moderate- to high-power rie, at any reasonable range, the internal pressure generated by the passage of the bullet will produce an explosive rupture to the cranium at a nearby point on the cranium, lateral to the trajectory of the bullet. The pressure on the cranium is highest at the location closest to the point at which the bullet has deposited energy at the maximum rate. The past tense is used because the explosion will happen shortly after the bullet has already exited. This injury is not usually survivable. Brain is not a particularly strong or elastic tissue. The damage caused by a penetrating projectile would be expected to be as great or greater than penetrating wounds of other soft tissues. The suppression of damage by the restriction of outward movement would likely be more than offset by the added curvilinear movement of tissue, with the rupturing strains it causes. The major differences between bullet penetration injury and injuries from irregular fragments from explosions or shotgun pellets are the smaller mass and impact velocity of these projectiles and the higher probability of multiple penetrations. The fragments from munitions tend to separate more rapidly than shotgun pellets do. The fragment injuries will almost always be separate penetrations with little or no interaction between separate wounding events. Conversely, with a shotgun, a close-up shot will produce a mass of projectiles that tends to penetrate as a single object, producing much greater penetration than a single pellet could at the same impact velocity. This is particularly true of head injuries. The leading pellets would penetrate

the cranium before the trailing projectiles would enter at nearly undiminished velocity. The neurosurgeon will see very few close-range direct cranial hits from shotguns. The vast majority will go directly to the medical examiner. Writers speak of wadding as being a possible penetrating projectile at very close range (3, 30). If this were to occur with a cranial shot, however, the probability of survival to reach a medical facility is vanishingly low. Near misses, giving rise to a few pellet hits, will behave much the same as any group of independent, penetrating projectiles. If the wadding were to hit the cranium without interacting pellets to augment penetration, it would almost certainly be stopped before penetrating the cranium. Even though it is radiolucent, one should find it hard to miss the wadding embedded in the scalp. Depending on the size of the weapon, the amount of choke to restrict spread, and the size of shot, a shotgun blast from a range of a few to several meters will scatter the pellets sufficiently that they will behave as individual low-velocity projectiles. As is the usual case with natural phenomena, these two cases are at the ends of what is a continuous spectrum. At intermediate ranges, the outer pellets might act as independent projectiles, while the mass toward the center exhibited significant interaction. Again, most of these injuries would not be survivable. The cases actually encountered in surgery are most likely from shots at an appreciable distance or near misses at closer range where only the outer few pellets hit the cranium. The phenomena of tumbling and yaw are, of course, irrelevant to wounding by spherical shotgun pellets and irregular fragments (33). This does not mean, however, that these projectiles will penetrate in perfectly straight lines. The fragments, in particular, will develop lift that curves the trajectory. Under the right conditions, the curvature can be dramatic. Projectiles with high kinetic energy are likely to transfer enough energy to the cranium to transform bone fragments into secondary missiles. This is particularly true of tangential hits that travel through the periphery of the cranium. As bone is twice as dense as soft tissue, the retarding force is also twice as large at the same velocity and yaw. Thus, the bone and bone fragments acquire more kinetic energy than a comparable length of soft tissue. The secondary missiles from these hits can be just as lethal as through-and-through hits by the same projectile, despite the fact that the primary missile never enters the cranial cavity. The lower energy .22 long rie bullet and fragments with comparable energy are not as likely to create bone fragments with sufcient velocity to act as secondary missiles (33), whether from direct or tangential hits. As mentioned in the last section, the connement of the cranium minimizes the formation of the temporary cavity, so that the pulsatile nature of the cavity is minimal or nonexistent. However, the pressure that would create the cavity is diverted into shearing forces that may injure as much tissue or more than the temporary cavity would. This rapid tissue damage quickly results in contusion and necrosis (15, 27). In the absence of signicant mass effect, small-entrance bullet wounds to the

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head should be treated with local wound care and more extensive wounds with nonviable scalp, bone, or dura should be dbrided before closure. In the presence of mass effect, necrotic brain tissue may be resected, but surgical dbridement of the missile tract has not been shown to improve outcomes (25). The internal pressure in the brain that would create a large temporary cavity in unconned tissue can result in stellate fractures of the cranium. Carey (5) has reported on an in vivo feline model in which the animals were wounded intracranially with missiles of varying velocity. He observed that even missiles with low energy provoked respiratory effects in the animals despite the fact that the missile came no closer than 2 cm to the brainstem. It is likely the shearing motion of the tissue that ows from high pressure near the projectile toward the near-zero pressure behind the missile that propagates to some distance from the path of the projectile. He concludes that if a missile enters the brain without severely disrupting the brain or harming an eloquent structure, it is most likely ordinary pressure that affects the respiratory centers in the brainstem, potentially causing death. Even if a missile enters the brain without severely disrupting the brain (and without signicant mass effect) or harming an eloquent structure, respiratory arrest may still occur from brainstem dysfunction. He distinguishes between this kind of immediate threat to life and the problem of longerterm neurological deficits (5). Thus, the management of patients after intracranial gunshot wounds can be split into two injury phases: injury of the brainstem and injury of the cerebral cortex. Immediately after penetrating injuries, treatment should be directed at the maintenance of respiration and blood pressure, given injury to the brainstem with resultant respiratory and cardiac compromise. Delayed or secondary cortical injury can occur from days to weeks after the injury and needs to be addressed through long-term treatment options including cerebral protective agents (5). Given the widespread movement associated with the high pressure gradient, brain tissue other than the brainstem can be damaged. Damage has been found to occur in the form of frontal, supraorbital, and lobular contusions. In some cases, the transfer of cavitating energy is strong enough to result in fractures of the orbital roof (15, 27). Remote contusions involving the mamillary bodies, uncal gyri, cerebellar tonsils, and adjacent medulla oblongata associated with supratentorial wounds have been reported (27). Signs of tonsillar and transtentorial herniation can result from brain structure displacement through or against their respective dural compartments and foramina (27). If the projectile is large (massive) and traveling at low velocities, it is not likely to penetrate the cranium. However, it can still cause intercranial injury, often referred to as the boxers blow or whiplash injury. This injury results from rapid rotation of the head relative to its support at the top of the neck. Think of holding a bucket of water, then rapidly twisting the bucket by the bail. The bucket will rotate, but the water within lags in rotation. Rapid rotation of the head results in a similar lag of the contents inside the rigid cranium that rotates as a unit. This lagging produces shear on the brain tissue and may

cause shear injury to small blood vessels and nerves that pass into the cranium. Another complicating factor is the compartmentalization of the cerebral contents by the tentorium and the falx. The shear pattern inside these nonspherical compartments is different with every different direction of rotation. Each rotation is a combination of front to back (nodding), side to side (tilt toward shoulder), and rotation about the spine (shaking ones head), in different proportions depending on the orientation of the body and the trajectory of the projectile. These shear forces can cause injury in unexpected sites far from the point of impact. This injury can be caused by thrown bricks, large debris from explosions, or close-range impact of blunt weapons, such as rubber bullets. As is often the case, the rotation injury may be produced in combination with cranial fracture and partial penetration. This makes the injury easy to miss as one concentrates on the obvious cranial fracture and local injury to the brain. A patient with a gunshot wound to the head will tend to present in the emergency department with signs and symptoms of brainstem compression and tonsillar herniation, which include apnea and bradycardia. The computed tomographic scan may be only mildly abnormal and show no signs of expanding mass, midline shift, or edema (6, 27). It is the sudden increase in intracranial pressure caused by the temporary cavitation that can result in coma or death, even if eloquent structures are not directly affected by the bullet (68, 1113, 27).

CONCLUSION
Craniocerebral injuries from ballistic projectiles are qualitatively different from injuries in unconned soft tissue with similar impact. Penetrating and nonpenetrating ballistic injuries are inuenced not only by the physical properties of the projectile, but also by its ballistics. Ballistics provides information on the motion of bullets while in the gun barrel, the trajectory of the projectile in air, and the behavior of the projectile on reaching its target. This basic knowledge can be applied to better understand the ultimate craniocereberal consequences of ballistic injuries of the head.

REFERENCES
1. Belkin M: Wound ballistics. Prog Surg 16:724, 1979. 2. Black AN, Burns BD, Zuckerman S: An experimental study of the wounding mechanism of high velocity missiles. Br Med J 2:872874, 1941. 3. Calhoun KH, Li S, Clark WD, Stiernberg CM, Quinn FB: Surgical care of submental gunshot wounds. Arch Otolaryngol Head Neck Surg 114:513519, 1988. 4. Callender GR: Wound ballistics: Mechanism of production of wounds by small arms bullets and shell fragments. War Med 3:337350, 1943. 5. Carey ME: Experimental missile wounding of the brain. Neurosurg Clin N Am 6:629642, 1995. 6. Cooper PR: Gunshot wounds of the brain, in Head Injury. Baltimore, Williams & Wilkins, 1982, pp 257274. 7. Crockard HA: Bullet injuries of the brain. Ann R Coll Surg Engl 55:111123, 1974. 8. Crockard HA, Brown FD, Johns LM, Mullan S: An experimental cerebral missile injury model in primates. J Neurosurg 46:776783, 1977.

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9. DeMuth WE Jr: Bullet velocity as applied to military rie wounding capacity. J Trauma 9:2738, 1969. 10. Dziemian AJ: The penetration of steel spheres into tissue models. Technical Report CWLR 2226, Edgewood Arsenal, MD, August 1958. 11. Freytag E: Autopsy ndings in head injuries from rearms. Statistical evaluation of 254 cases. Arch Pathol 76:215-225, 1963. 12. Holt GR, Kostohryz G Jr: Wound ballistics of gunshot injuries to the head and neck. Arch Otolaryngol 109:313318, 1983. 13. Kirkpatrick JB, Di Maio V: Civilian gunshot wounds of the brain. J Neurosurg 49:185198, 1978. 14. Klatt EC: Firearms tutorial. WebPath: The internet pathology laboratory for medical education. 19942006. 15. Lindenberg R: Mechanical injuries of brain and meninges, in Spitz WV, Fisher RS (eds): Medicolegal Investigation of Death. Springeld, IL, Charles C Thomas, 1973, pp 435439. 16. Lowry LD: Trauma, in Schuller DE (ed): Otolaryngology-Head and Neck Surgery. St Louis, Mosby-Year Book, 1986, pp 16211630. 17. McCoy R: Modern Exterior Ballistics. Atglen, Schiffer Publishing, Ltd., 1999. 18. Menzus RC, Anderson LE: The Glaser safety slug and the Velex/Velet exploding bullet. J Forensic Sci 25:44, 1980. 19. No Author. Ballistics. ES310: Introduction to Naval Weapons Engineering. Federation of American Scientists. January 20, 1998. http://www.fas.org/ man/dod-101/navy/docs/es310/ballstic/Ballstic.htm. Accessed April 13, 2006. 20. No Author. Chronograph. Online Encyclopedia Britannica. No date. http://encyclopedia.jrank.org/CHR_CLI/CHRONOGRAPH.html. Accessed April 13, 2006. 21. Ordog GJ: Wound ballistics, in Ordog GJ (ed): Management of Gunshot Wounds. New York, Elsevier Science Publishing Co., 1988, pp 2560. 22. Owen-Smith MS: High-velocity and military gunshot wounds, in Ordog GJ (ed): Management of Gunshot Wounds. New York, Elsevier Science Publishing Co., 1988, pp 6177. 23. Peters CE: A mathematical-physical model of wound ballistics. J Trauma (China) 6 [Suppl]:S303S318, 1990 24. Peters CE, Sebourn CL, Crowder HL: Wound ballistics of unstable projectiles. Part I: Projectile yaw growth and retardation. J Trauma 40 [Suppl]:S10S15, 1996. 25. Pruitt BA: The management and prognosis of penetrating brain injury. J Trauma 51 [Suppl 2]:S1S86, 2001. 26. Redgrave AP: Plastic bullets in riot control. Lancet 1:1224, 1983. 27. Selden BS: Craniocerebral wound ballistics. Indiana Med 80:150152, 1987. 28. Settles GS: High-speed imaging of shock waves, explosions and gunshots. Am Sci 1:2231, 2006. 29. Spitz WU: Injury by Gunre: Part I. Gunshot Wounds, in Spitz WU, Fisher RS (eds): Medicolegal Investigation of Death. Springeld, Charles C Thomas, 1993, pp 311381. 30. Stiernberg CM, Jahrsdoerfer RA, Gillenwater A, Joe SA, Alcalen SV: Gunshot wounds to the head and neck. Arch Otolaryngol Head Neck Surg 118:592 597, 1992. 31. Sturdivan LM: A Mathematical Model of Penetration of Chunky Projectiles in a Gelatin Tissue Simulant, ARCSL-TR-78055, Chemical Systems Laboratory, Aberdeen Proving Ground, MD, August 1978. 32. Sturdivan LM, Bexon R: A Mathematical Model of the Probability of Perforation of the Human Skull by a Ballistic Projectile, Technical Report ARCSL-TR-81001. Chemical Systems Laboratory, Aberdeen Proving Ground, MD, April 1981. 33. Swan KG, Swan RC: Wound ballistics for the civilian surgeon. Surg Annu 17:163187, 1985. 34. Wilson LB: Dispersion of bullet energy in relation to wound effects. Milit Surg 49:241251, 1921.

strikes the head. The authors succeed in using plain English to explain some very complex concepts. I learned a lot from reading this article, and the authors could no doubt enjoy successful careers as physics teachers if they ever decide to give up neurosurgery. This article will serve as the definitive reference work on ballistics in neurosurgery for many years to come. Alex B. Valadka Houston, Texas

andial et al. have presented a nice overview of ballistic principles and how they relate to injuries we encounter in neurosurgery. Through an appreciation of the projectile-tissue interactions and resulting tissue stresses and strains that occur during penetrating brain injuries, we can better understand the resulting clinical manifestations and pathophysiological changes with these injuries. One of our current challenges is dening how the physical forces discussed here in the terminal ballistic section are modied when combined with a blast wave or other energies. An improved understanding of these mechanisms can help spawn innovative improvements in our care and outcome of patients with these tragic injuries. James Ecklund Washington, DC

he authors present a very detailed and coherent summary of the history, basic physics, nomenclature, and neurosurgical implications of rearm ballistics. Although this is a subject that can ll many volumes, they have been able to create a product of reasonable length that is of value to audiences of widely varying familiarity with rearms and ballistics. This primer may encourage further study but can easily stand alone and in doing so provides a practicing neurosurgeon with a reference for basic information relevant to discussions with families, law enforcement personnel, and colleagues. Leon E. Moores Washington, DC

andial et al. have written a very succinct and well-organized overview of penetrating head injuries and ballistics. They nicely review the history of gunpowder and rearms and clearly describe the differences between civilian and military penetrating injuries. They conclude with a clear summary of evidence-based recommendations for the treatment of penetrating brain injuries, emphasizing gunshot wounds. This article is timely, given the increasing number of soldiers returning from Iraq with head injuries. The majority of neurological injuries in Iraq veterans are closed head injuries and neuropsychological problems. In fact, approximately 20% of Iraq war veterans will have prolonged depression, severe anxiety, or posttraumatic stress disorder upon discharge according to Hoge et al. (1). But, a thorough understanding of the ballistics of penetrating injuries is essential for optimal treatment of those injuries, and good outcomes can result if critical deep structures (basal ganglia and brainstem) have not been damaged. Donald W. Marion Boston, Massachusetts

COMMENTS

andial et al. have provided us with a very thorough review of exactly what happens when a bullet is red and when a projectile

1. Hoge CW, Auchterlonie JL, Milliken CS: Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 295:10231032, 2006.

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