頭部銃創例の臨床病理学的研究

Clinicopathological studies of craniocerebral gunshot injuries

I．はじめに

　頭部銃創例は，本邦においてもここ数年増加し，最近は特に一般市民が巻き込まれることも多く見られ深刻な社会問題となっている^14,19）．そこで脳外科医も救急医療の現場で本症の治療に遭遇することもありその病態の把握が救命の鍵になることも少なくないものと思われる．著者らは，9例の頭部銃創例を経験したので銃弾による脳損傷の形成のメカニズムについてCT scanと剖検所見との相関を中心に臨床病理学的検討を行ったので文献的考察を加え報告する．

Gunshot wounds are rare in Japan because of few regulatory laws against the possession of guns. Never-theless such wounds are increasing in prevalence these days. Reports on the microscopic findings concerning these intracerebral lesions are fewer than those on the macroscopic findings in the scalp, the skull and the in-tracranial cavity. In this study we evaluated computed tomographical and histopathological findings in cra-niocerebral gunshot injuies.

Cases: Nine patients with gunshot wounds to the head were presented. All were male and the age ranged from 17 to 66 years. Four were suicides and four were attempted murders and the last one was of unknown etiology. Morphological examination was performed on 5 autopsy cases. The distance of the bullet from the cranial cavity was as follows: long distance, 4 cases; close contiguity, 5 cases. The calibers of the weapons were as follows: 38mm in 6 cases, 45mm in 1 case and unknown in 2 cases.

Results: CT scans were examined in six cases, which revealed a missile track, hemorrhagic contusion, traumatic subarachnoid hemorrhage and marked ten-sion pneumocephalus. In some cases, CT scan also re-vealed bony and metallic fragments, some deep within the cranial cavity. In the histopathological study, we found marked swollen brain (brain weight over 1500mg) and hemorrhagic contusion in the vicinity of the missile track and interhemispheric fissure, and widespread traumatic subarachnoid hemorrhage and in-traventricular hematoma. We would like to emphasize especially the remote contusion seen in the distant part of the missile track as well as massive exsudation and hemorrhage around the nerve fiber bundles.

Remote contusion was observed in the inferior sur-face of the fronto-temporal lobes, and bilateral hemor-rhagic contusion was seen in the vicinity of the supe-rior longitudinal fissure on CT scans and autopsy find-ings. In one case, the bullet rotated within the intracra-nial cavity.

In conclusion, nine cases of craniocerebral gunshot injuries were examined, while we also reviewed the medical literature concerning the shearing injury pro-duced by gunshot brain wounds. The head injuries were further delineated by the correlation between autopsy and computerized tomography findings.