What question did this study set out to answer?

The aim is to determine if combining clinical findings and CT-derived scores provides better predictions of mortality in patients with penetrating cranial gunshot injuries.

April 23, 2026Open Access

From Neurological Severity to Anatomical Burden: An Integrated Clinical–CT Model for Predicting In-Hospital Mortality in Adults with Penetrating Cranial Gunshot Injuries

Key Points

The aim is to determine if combining clinical findings and CT-derived scores provides better predictions of mortality in patients with penetrating cranial gunshot injuries.
Retrospective analysis of adult patients with penetrating cranial gunshot injuries treated at a tertiary referral centre.
Evaluation of clinical variables and CT scores using multivariable logistic regression with in-hospital mortality as the primary outcome.
Performance assessment through ROC analysis and internal validation methods.
The in-hospital mortality rate observed was 56.6%, with early mortality noted in 33.6% of patients.
Low GCS scores, non-reactive pupils, increased anatomical burden scores, and midline shift were independently linked to higher mortality risk.
The integrated model achieved an AUC of 0.87, indicating good prediction performance, which remained at 0.86 after internal validation.

Abstract

Background/Objectives: Cranial gunshot injuries represent severe traumatic brain injuries associated with high mortality rates. This study investigated whether integrating clinical findings at admission, including GCS score and pupillary response, with a CT-derived anatomical burden score and midline shift improves the prediction of in-hospital mortality. Methods: Adult patients aged 18 years and older with penetrating cranial gunshot injuries (n = 143) treated at a tertiary referral centre between 1 January 2005 and 31 December 2025 were retrospectively analysed using a single-centre cohort design. All included patients completed in-hospital follow-up, defined as hospital discharge or in-hospital death. Clinical variables, the anatomical burden score, and midline shift were evaluated using a multivariable logistic regression model where the primary outcome was in-hospital mortality. Model performance was assessed using ROC analysis, calibration measures, and bootstrap internal validation. Results: The in-hospital mortality rate was 56.6%, with early mortality occurring in 33.6% of patients. In the multivariable analysis, a low admission GCS score (≤8), bilateral non-reactive pupils, an increased anatomical burden score, and midline shift were independently associated with a higher risk of mortality. The model demonstrated good discrimination (AUC = 0.87; 95% CI 0.81–0.93), and similar performance was maintained following internal validation (optimism-corrected AUC = 0.86). The addition of radiological parameters to clinical variables improved model discrimination (ΔAUC = 0.07; 95% CI 0.02–0.11). Conclusions: The combined evaluation of admission clinical findings and CT-based anatomical parameters may support a more structured early estimation of in-hospital mortality risk in adult patients with penetrating cranial gunshot injuries.

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