Gunshot head injuries in Dhaka amid the violent crackdown in July 2024

Penetrating gunshot injuries to the brain are among the most severe types of traumatic brain injury, often linked with high mortality rates and long-term disability. These injuries, frequently seen in military conflicts and areas affected by urban violence, cause significant tissue destruction due to the high kinetic energy transferred to intracranial structures [1]. Despite advances in neurosurgical techniques and critical care, the prognosis for gunshot-related brain trauma remains poor, with global survival rates below 10% and only a minority of cases achieving functional recovery [2].

In 2024, Bangladesh experienced one of its most significant civil movements, which met with violent suppression by state forces [3, 4]. During this time, over 30,000 people were injured, many of whom suffered gunshot wounds, especially to the head [5]. Public and private hospitals in Dhaka became overwhelmed with critical trauma cases, many involving complex skull injuries that required urgent neurosurgical treatment [6, 7].

Reports from human rights organisations indicated that of the 1,581 reported deaths, 77% resulted from gunshot wounds, with over 60% involving military-grade firearms [8]. Such ballistic trauma generally involves high-velocity projectiles, which cause both direct tissue laceration and secondary damage from shockwave propagation, bone fragmentation, and cavitation effects. These injuries are often complicated by haemorrhage, cerebral oedema, infection, and herniation syndromes [9].

Despite the rising incidence of civilian cranial gunshot injuries in politically unstable regions, literature from low-resource settings remains scarce. Prognostic factors such as the initial Glasgow Coma Scale (GCS) score, bullet trajectory, injury location, and complications, such as abscess or hematoma, are vital for predicting outcomes but are understudied in these environments [10]. The aim of the study was to evaluate the clinical management and outcomes of gunshot brain injuries sustained during the civil unrest in 2024

Study design and setting

This study was conducted at BSMMU, which has since been renamed Bangladesh Medical University (BMU), National Institute of Neurosciences, Islami Bank Central Hospital, Aurora Specialised Hospital in Dhaka, which played an important role in delivering neurosurgical care to trauma patients due to violent crackdowns during the civil unrest from 16 July to 9 September 2024.

Patient selection and data collection

A total of 217 inpatients were included in the study sample based on available medical records during the study period who sustained gunshot-related head injuries, including pellets in the orbits. Those who survived the first post-operative day were followed up for two months. The exclusion criteria comprised patients with non-penetrating head injuries, injuries resulting from mechanisms such as blunt force trauma, and individuals with incomplete medical records.

Classification of the firearm identified

Gunshot injuries were classified based on the bullet’s velocity. The injuries were categorised as follows: Low velocity: e.g., handguns or small-calibre bullets (e.g., 1.27 mm, 2.3 mm). Medium velocity: e.g., submachine guns (9.02 mm), High velocity: e.g., assault rifles such as AK-47 (9.07 mm).

Injury location

Parietal, frontal-temporal, occipital, and parasellar regions were identified as the primary injury locations. The site of injury was recorded for each patient, and the associated clinical presentation was noted.

Surgical approach

The choice of surgical approach was influenced by the injury's location and severity, as well as the patient’s condition upon admission. Most patients underwent standard craniotomy, decompressive craniectomy, and surgical toileting. Almost all bullets in the brain were removed by keyhole craniotomy. Some pellets in the scalp were removed under local anaesthesia those who were symptomatic. A significant number of patients did not require any surgery and were treated conservatively, especially, patients diagnosed with multiple pellets in the scalp and deep brain who were asymptomatic needed no surgery. However, a patient presenting with a deep brain injury and a brain abscess required a more comprehensive surgical procedure. One major surgery was performed under local anaesthesia due to the nature of the injury and the patient’s clinical condition.

Functional outcome

The patients' functional outcomes were assessed using GOS at 2-month follow-up, and the following categories were used: GOS 1 (Death), GOS 2 (Persistent vegetative state), GOS 3 (Severe disability), GOS 4 (Moderate disability), and GOS 5 (No disability).

Ethical concern

Each treatment and procedure was performed after proper counselling regarding the possible outcome and risk of the procedure. Consent was obtained from the patient and legal guardian, along with assent from the minors, as applicable. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Retrospective ethical approval was obtained from the Institutional Review Board at BMU, given the emergency nature and the life-threatening injuries sustained by the patients. The patient's treatment was prioritised over obtaining ethical approval beforehand.

Statistical analysis

Quantitative variables, such as age, GCS scores, and surgical duration, are presented as means and standard deviations. Categorical variables, including sex, bullet type, injury location, surgical procedure, and GOS, are expressed as frequencies and percentages. The GOS (five categories) was used to assess patients' functional recovery at 2-month follow-up. All data analyses were conducted using SPSS version 27.

This study provides valuable insights into the clinical management, surgical interventions, and functional outcomes of patients with gunshot head injuries. The study’s findings offer a broader understanding of gunshot head injury management and outcomes in a civilian setting, with a particular focus on the importance of early surgical intervention, injury characteristics, and post-operative recovery.

Most patients (89.9%) in this study sustained injuries from low-velocity (e.g., handgun, shotgun), which is not similar to cases reported in conflict zones [11]. The rate of scalp injuries (76.5%) matches findings in civilian populations, where gunshot head injuries often affect superficial skull areas [12]. This high rate of scalp injuries may stem from the typical bullet trajectory that impacts the outer regions of the head. High-velocity projectiles, such as those from AK-47 rifles, tend to cause more severe neurological damage, including brain haemorrhages and foreign body retention [13]. The scalp involvement, brain oedema, hemorrhagic contusion and depressed skull fractures were consistent with reports on civilian gunshot injuries where low-velocity projectiles commonly result in less severe intracranial penetration [14, 15].

On arrival, most patients presented with mild traumatic brain injuries and maintained consciousness; there is a need for rapid assessment and intervention [16, 17]. Surgical management was tailored based on the location and severity of the injury. Conservative treatment of asymptomatic pellets was used in about 45% of patients, while the rest underwent surgery. Among the 119 operated patients, the use of local anaesthesia in nearly half reflects a pragmatic approach adapted to patient condition and resource availability, consistent with best practices in civilian neurosurgical trauma [18, 19]. It underscores the inherent flexibility in surgical techniques, contingent upon the severity of the injury and the patient's condition. This methodology is corroborated by prior studies in which local anaesthesia is employed for less complex or critical conditions [20]. On the other hand, general anaesthesia was used in more than half of the surgeries to ensure optimal patient comfort and effective control during the critical intervention phase [21].

The post-operative complications in our study were similar to those in other studies on traumatic brain injuries, especially the penetrating brain injuries [22, 23]. The infection rate in our study is relatively low compared to military settings with a higher occurrence of gunshot wounds [24]. The incidence of brain oedema is a significant complication, as cerebral oedema often develops after brain injuries, particularly in high-velocity trauma [11]. Similarly, the occurrence of seizures in one patient matches reported rates of post-traumatic epilepsy following penetrating brain injuries [25].

We could achieve good functional outcomes for patients, as measured by GOS, which were higher than those reported in other studies, possibly due to delayed or insufficient medical care [26]. These findings align with research on military and civilian brain injuries, where many patients with penetrating brain injuries may experience long-term functional impairments [20]. The low mortality rate observed is encouraging despite having high-velocity gunshot wounds that usually lead to high mortality [14, 19]. This positive result may be attributed to rapid intervention and early surgical management, as well as the rapid deployment of intensive care at the participating hospitals.

In contrast to military environments where gunshot-related brain injuries are frequently observed, our research indicates more favourable outcomes within a civilian context. Military trauma management often entails delayed or intricate injuries, commonly impacting multiple body systems and constrained by resource limitations [27]. Nonetheless, analogous findings regarding the significance of early surgical intervention and immediate medical treatment have been reported in both civilian and military settings, underscoring the importance of multidisciplinary approaches to improving survival rates and recovery outcomes [16, 22]. The environment during the crackdown compelled emergency medical teams to limit patients' civil identity and to seek ethical approval before surgical interventions, because saving lives was prioritised over strict research ethics.

Conclusion

This study shows that gunshot brain injuries caused by the violent crackdown during civil unrest in Bangladesh mainly affected young male civilians, with low-velocity firearms being the most common cause. While brain oedema, haemorrhagic contusions, and skull fractures were frequent, personalised surgical management—including conservative care for asymptomatic cases, keyhole craniotomy, and extensive craniotomy—resulted in favourable outcomes. Early intervention, prompt use of intensive care, and adaptable surgical strategies contributed to a high rate of good functional recovery and relatively low mortality