Characteristics of civilian head gunshot injuries in a country with low firearm related violence

Abstract

Head gunshot injuries in civilian settings are severe traumas associated with high morbidity and mortality. Most studies focus on populations from regions with high firearm violence, limiting their applicability to low-violence settings. This study investigates the characteristics, management, and outcomes of head gunshot injuries in the Czech Republic, a country with low firearm-related violence and a unique injury profile dominated by suicides. We analyzed a prospectively collected cohort of 100 patients treated for head gunshot injuries at a single center between 2000 and 2024. Inclusion criteria included civilian head gunshot injuries in patients aged ≥ 18 years, admitted with signs of life. Data collected included demographic characteristics, context of injury (suicide, assault, accident, law enforcement), firearm types (conventional, less-lethal, captive bolt guns), Glasgow Coma Scale (GCS) scores, imaging findings, surgical interventions, and outcomes. Statistical analyses included Chi-square, Mann-Whitney tests, Kaplan-Meier survival analysis, and Cox regression modeling. Of 100 patients (94% male, mean age 50.0 years), 81% sustained injuries from suicide attempts. Conventional firearms caused 74% of injuries, while less-lethal guns (21%) and captive bolt guns (15%) contributed significantly. The mean GCS on admission was 6.35, with 65% of patients presenting with a GCS of 3. Penetrating injuries occurred in 58% of cases. Surgical intervention was performed in 27 patients (27%) and was associated with lower mortality (25.9% vs. 75.3%, p < 0.001). Overall survival varied significantly by firearm type, with less-lethal gun injuries showing improved outcomes (30-day mortality: 19.0%; mean survival: 2634 days). Suicidal injuries had worse outcomes compared to other contexts (30-day mortality: 70.4% vs. 26.3%, p < 0.001). In this low-violence setting, firearm-related suicides dominate head gunshot injuries, with a notable prevalence of less-lethal guns and captive bolt guns. The study highlights the importance of regional variations in injury patterns and outcomes, underscoring the need for tailored clinical guidelines and public health interventions to address specific demographic and cultural contexts.

Introduction

Head gunshot injuries in a civilian setting represent a severe form of trauma associated with high morbidity and mortality. However, existing research on civilian populations with head gunshot injuries often suffers from low quality and high risk of bias¹. The “Guidelines for the Management of Penetrating Brain Injury,” developed in 2001, largely extrapolate recommendations from studies on military populations and closed traumatic brain injury (TBI) data². This heavy reliance on military and closed TBI data limits the relevance and applicability of these guidelines to civilian populations with distinct injury profiles, particularly in countries with low firearm-related violence. Surprisingly, the 2001 guidelines remain the most recent, highlighting a significant gap in the field of penetrating brain injury, as no updated recommendations have been published in more than two decades³.

When analyzing published cohorts from civilian settings, most studies originate from countries with high rates of firearm violence, such as the United States, Latin America, South Africa, or the Middle East^4–9. Interestingly, in the United States, the firearm homicide rate is 25 times higher, the firearm suicide rate is 8 times higher, and the unintentional gun death rate is more than 6 times higher than those in other high-income countries¹⁰. These high rates contribute to the large volume of data available from such countries, creating a bias toward populations with high firearm-related violence. In contrast, the Czech Republic has a notably low rate of firearm-related deaths, with only 1.5 deaths per 100,000 people, less than half the global average of 3.4 per 100,000¹¹. This lower rate of firearm violence presents a unique demographic profile.

Another important aspect to consider is the relative proportion of homicides and suicides in firearm-related deaths across different regions. Globally, homicides are twice as common as suicides among firearm-related deaths (2.1 vs. 0.9 per 100,000)¹¹. Some studies report that in certain cohorts, the proportion of suicides is as low as 3–4%^12,13. However, in central and northern Europe, the percentage of suicides in firearm-related deaths can be substantially higher, reaching 67.1–79.7%^14–16.

This study aims to provide insights into a distinct population affected by head gunshot injuries, as exemplified by countries like the Czech Republic. In this specific demographic context, characterized by generally low firearm violence, suicides constitute the majority of firearm-related incidents—a pattern in stark contrast to regions where homicides predominate. By focusing on this underrepresented population in the literature, the study characterizes the injury patterns, management strategies, and outcomes of head gunshot injuries, offering valuable insights that may inform clinical practice and public health policy in similarly low-violence settings.

Methods

We analyzed a prospectively collected cohort of patients with head gunshot injuries treated in Military University Hospital between 2000 and 2024. This study was reviewed and approved by the the Ethics Committee of the Military University Hospital with approval number 108/19–65/2024. All research was performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. As this study is observational in nature, the need for informed consent to participate was waived by the Ethics Committee of the Military University Hospital.

Inclusion criteria

• Patients aged 18 years and older.

• Patients admitted to the emergency department with signs of life.

• Head injury specifically caused by a firearm.

• Injury sustained in a civilian setting.

Exclusion criteria

• Injuries related to combat or military conflict.

• Cases with insufficient patient data for analysis.

Demographic variables such as age, sex, and contexts of injury (categorized as suicide attempt, assault, accident, or law enforcement incident) were recorded. Upon admission, all patients underwent evaluation using the Glasgow Coma Scale (GCS) to assess their neurological status.

Injury characterization involved detailed documentation of gunshot wound types, with firearms categorized as conventional, less-lethal, or captive bolt guns. Conventional firearms are designed to fire bullets at high velocity and are primarily intended for military, law enforcement, hunting, or self-defense purposes. Less-lethal guns were defined to include gas pistols, Flaubert rifles, air rifles, small-bore rifles, flare guns, crossbows, and other low-velocity firearms, highlighting their reduced lethality compared to conventional firearms. In this manuscript, the term “less-lethal” follows the commonly accepted nomenclature used in policing, forensic, and medical literature, which describes weapons designed to minimize but not eliminate the risk of fatal injury^17–19. Captive bolt guns, typically used in livestock slaughter, function by deploying a retractable bolt that penetrates the skull, causing instantaneous unconsciousness or death in animals. These devices can be misused in humans, most commonly in suicide attempts. CT imaging was utilized to assess the extent of intracranial injury, recording the number of lobes affected by the projectile trajectory and the specific planes of the skull involved (sagittal, coronal, or both). Surgical intervention was defined as any procedure beyond simple suturing of entry or exit wounds, and patients were categorized based on whether they received surgical treatment. Overall survival (OS) data were obtained from health insurance records.

The primary outcomes of this study included the extended Glasgow Outcome Scale (GOSE), evaluated both at discharge and during follow-up visits, along with the overall survival rates of injured patients, categorized by the context of injury and the type of firearm used.

Sample size calculation

The sample size was set to achieve adequate precision for the primary descriptive endpoint (30-day mortality) and sufficient events for multivariable survival modeling. Assuming a 30-day mortality of ~ 60% based on prior reports, a minimum of 92 patients would yield a two-sided 95% CI with a half-width of ± 10% for the mortality proportion (n = z²·p(1 − p)/d² = 1.96²·0.6·0.4/0.10² ≈ 92). We therefore rounded up to 100 to allow for attrition/missing data and to ensure approximately ≥ 60 events, providing ≥ 10 events per parameter for a Cox model including our main predictors (context of injury and firearm type) and key covariates. Accrual was stopped when the 100th consecutive patient meeting inclusion criteria was enrolled (2000–2024).

A total of 17 patients were excluded from the analysis, including 12 with combat- or military-related injuries and 5 with insufficient clinical data for evaluation.

Statistical analysis

Descriptive statistics, including measures of central tendency and variability, were used to summarize baseline characteristics. Chi-square and Mann-Whitney tests (depending on the variable type) were employed to examine group differences based on the context of injury (suicidal vs. other) and gun type (conventional firearms vs. less-lethal guns vs. captive bolt gun). Survival was analyzed using the Kaplan–Meier (KM) method, with the log-rank test applied to compare survival distributions by context of injury and gunshot type. Overall survival (OS) was defined as the time from admission to death or the last follow-up (up to 10 years). Following the KM analysis, a multivariate Cox regression model was conducted to assess the main and interaction effects of the context of injury and gunshot type on OS. Statistical significance was set at the conventional level of α = 0.05, and all analyses were performed using IBM SPSS version 25.0 (SPSS Inc., Chicago, IL).

Results

The cohort consists of a total of 100 patients, with 94 males and 6 females. The mean age at diagnosis is 50.0 years (range 18–83 years). The majority of injuries were related to suicide attempts (81.0%), followed by 11.0% due to violent assaults, 4.0% from accidents, and 4.0% from law enforcement incidents. Penetrating gunshot wounds were the most common, occurring in 58.0% of cases. Perforating injuries, where the bullet exited the body, were observed in 41.0% of patients. One case involved a grazing injury, where the bullet made superficial contact with the body without penetrating deeply. In 21% of cases, the injuries were caused by less-lethal guns, including gas pistols, Flaubert rifles, air rifles, small-bore rifles, flare guns, crossbow and imitations of historical percussion firearms. In 15% of cases, the injury was caused by a captive bolt gun, a device typically used in livestock slaughter that fires a retractable bolt into the skull to induce immediate unconsciousness or death.

The mean GCS on admission was 6.35 (range 3–15). Notably, 65% of patients had an initial GCS score of 3.

Assessing the projectile trajectory, CT scans showed involvement of 0 to 3 lobes. Two lobes were affected in 39% of patients, while 29% had one lobe affected. A total of 16% had three lobes involved, and another 16% had no lobes affected. In 37% of patients, the projectile did not cross any major skull planes. The sagittal plane alone was crossed in 23 patients, while 2 patients showed involvement of only the coronal plane. Both sagittal and coronal planes were crossed in 38 patients.

Out of the 100 patients, 27 underwent surgical intervention, defined as any procedure beyond a simple suture of the entry or exit wounds. The remaining 73 patients did not receive surgical treatment.

The mean GOSE at discharge was 2.93 (range 1–8). During follow-up, the best-recorded GOSE had a mean of 3.02 (range 1–8). Out of the 100 patients, only 7 patients (7%) showed improvement in their GOSE scores during the follow-up. The mean GOSE improvement for these patients was 2.14 points (range 1–5). Mortality rate (GOSE = 1) at discharge was 61.0%.

The 30-day mortality rate was 62.0%, with a mean overall survival (OS) of 1 024.6 days for the entire cohort. Patient cohort information is summarized in Table 1.

Table 1.

Descriptive characteristics of the patient sample: continuous variables are presented as mean (range), and categorical variables are presented as count (percentage).

Patients	n = 100
Sex
Male	94 (94.0%)
Female	6 (6.0%)
Age (years)	50.0 (18–83)
Context of injury
Suicide attempt	81 (81.0%)
Violent assault	11 (11.0%)
Accident	4 (4.0%)
Law enforcement incident	4 (4.0%)
Type of injury
Penetrating	58 (58.0%)
Perforating	41 (41.0%)
Grazing	1 (1.0%)
Type of gun
Conventional firearms	74 (74.0%)
Less-lethal guns	21 (21.0%)
Captive bolt gun	15 (15.0%)
GCS on admission	7.16 (3–15)
Lobes affected by projectile
0 Lobes	16 (16.0%)
1 Lobe	29 (29.0%)
2 Lobes	39 (39.0%)
3 Lobes	16 (16.0%)
Skull plane crossed by projectile
None	37 (37.0%)
Sagittal only	23 (23.0%)
Coronal only	2 (2.0%)
Sagittal and Coronal	38 (38.0%)
Surgical intervention
Yes	27 (27.0%)
No	73 (73.0%)
GOSE at discharge	3.07 (1–8)
Best recorded GOSE	3.50 (1–8)
30-day mortality	62 (62.0%)

Suicide

Among the cases analyzed, 81 patients (81.0%) sustained injuries as a result of suicide attempts. The subgroup demonstrated statistically significant differences in multiple variables compared to the non-suicidal group. The mean age in the suicide group was higher at 52.5 years versus 39.1 years in the non-suicidal group (p = 0.006). Initial GCS scores were lower in the suicide subgroup (mean GCS = 5.63) compared to the non-suicidal group (mean GCS = 9.42, p = 0.003).

Further, the involvement of brain lobes was more extensive in the suicide subgroup, with a mean of 1.53 affected lobes compared to 1.00 in the non-suicidal group (p = 0.032). Injury of deep brain structures observed was also more frequent in the suicide group (61.7%) compared to the non-suicidal group (31.6%, p = 0.018). The rate of neurosurgical intervention was lower in the suicide group (mean = 0.23) versus the non-suicidal group (mean = 0.42), though this difference was not statistically significant (p = 0.101).

Regarding functional outcomes, the GOSE at discharge and best recorded GOSE were significantly lower in the suicide subgroup (mean GOSE at discharge = 2.44; best GOSE = 2.46) than in the non-suicidal group (mean GOSE at discharge = 5.00; best GOSE = 5.42, p < 0.001 for both measures). Survival duration in days was also significantly shorter in the suicide subgroup (mean = 712.12 days) compared to the non-suicidal group (mean = 2360.53 days, p < 0.001, see Fig. 1). 30-day mortality was higher in the suicide group (70.4%) than in the non-suicidal group (26.3%, p < 0.001).

Fig. 1.

Kaplan-Meier survival analysis comparing survival between individuals with suicide as the context of injury (purple) and others (yellow).

Less-lethal guns

The subgroup of patients who sustained head injuries from less-lethal guns comprised 21 cases, with a mean age of 51.7 years (range: 18–77 years). The mean GCS score was 10.7, significantly higher compared to the rest of the cohort (p < 0.001). Neurosurgical intervention was performed in 11 cases (52.4%), which was also significantly higher than in the conventional firearm group (p < 0.001). The injuries were caused by small-bore rifles (n = 6) and gas guns (n = 6), followed by Flaubert guns (n = 3), percussion revolver replicas (n = 2), air rifles (n = 2), and single cases involving a crossbow and a flare gun. Clinical outcomes, measured by the GOSE at discharge and the best recorded GOSE, were significantly better in the less-lethal gun subgroup (p < 0.001). The mean GOSE at discharge was 5.86, and the best GOSE recorded was 5.95, both outperforming the rest of the cohort. Additionally, when comparing overall survival, patients in the less-lethal gun subgroup demonstrated significantly longer survival than those injured by conventional firearms (p < 0.001) or captive bolt guns (p = 0.002, see Fig. 2; Table 2). 30-day mortality was 19.0%, which was significantly lower than in conventional group (78.1%, p < 0.001) and captive bolt gun group (53.3%, p = 0.031).

Fig. 2.

Kaplan-Meier survival analysis comparing survival between groups categorized by type of firearm: conventional firearms (red), captive bolt guns (blue), and less-lethal guns (green).

Table 2.

Comparative analysis of patient outcomes stratified by firearm type: statistical evaluation includes group-specific values for clinical and survival metrics across three firearm categories, with intergroup comparisons (I vs. II, I vs. III, II vs. III) provided as p-values in the lower section.

	Age (years)	GCS	Surgical intervention	GOSE at discharge	Best GOSE	Survival (days)	30-day mortality
I. Conventional (n = 64)	47.02	4.83	12.50%	1.97	2.06	485.33	78.1%
II. Captive bolt (n = 15)	60.40	6.73	53.33%	2.93	3.00	1072.27	53.3%
III. Less-lethal (n = 21)	51.71	10.71	52.38%	5.86	5.95	2633.86	19.0%
Comparison (p value)
I. vs. II.	0.017	0.097	0.001	0.018	0.011	0.053	0,061
I. vs. III.	0.363	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001	< 0.001
II. vs. III.	0.195	0.010	1.000	< 0.001	< 0.001	0.002	0,031

The patient who sustained the flare gun injury attempted suicide by discharging the device intraorally, resulting in extensive oropharyngeal trauma, a clival fracture, and brainstem hypodensity on CT imaging. An intracranial pressure monitor was inserted for observation; the patient remained unconscious and died 10 days after the injury.

Captive bolt gun

The subgroup of patients who sustained head injuries from captive bolt guns comprised 15 cases, with a mean age of 60.4 years (range: 29–77 years). The mean GCS score was 6.73, significantly higher compared to the conventional firearm cohort (p < 0.001). Neurosurgical intervention was performed in 8 cases (53.3%), which was significantly higher than in the conventional firearm group (p < 0.001). GOSE at discharge and the best recorded GOSE, were significantly higher in the captive bolt gun subgroup than in the conventional firearm subgroup, but lower than in the less-lethal gun subgroup (p < 0.001). The mean GOSE at discharge was 2.93, and the best GOSE recorded was 3.00, both outperforming the rest of the cohort. The overall survival of patients with injuries caused by captive bolt guns was significantly worse than that of those injured by less-lethal guns (p = 0.002), while it was slightly better than the survival of patients injured by conventional firearms, though this difference did not reach statistical significance (p = 0.053, see Fig. 2; Table 2). 30-day mortality was 53.3% in this group.

Surgical group

Among the 27 surgically treated patients, the most common procedure was debridement of the wound canal with duroplasty (16 cases), followed by decompressive craniectomy combined with debridement of the wound canal and duroplasty (nine cases), intracranial pressure monitor insertion (one case), and external ventricular drain placement (one case). Injuries were caused by less-lethal guns in 11 of these cases (40.7%). The mean survival time within this subgroup was 2184.21 days. The mortality rate was 25.9% in the surgical group, significantly lower than the 75.3% observed in the non-surgical group (p < 0.001).

Comparing effects of context of injury and type of firearm on survival

The use of less-lethal guns was more common in the non-suicidal group (mean = 0.37) compared to the suicide subgroup (mean = 0.17); however, this difference did not reach statistical significance (p = 0.061). The multivariate Cox regression model revealed a nonsignificant interaction effect between contex of injury and type of firearm (p = 0.954), suggesting that these variables exert independent effects on OS. When the multivariate Cox model was adjusted to include only main effects, both context of injury (HR = 3.2, p = 0.004) and type of firearm (HR = 5.1, p < 0.001) demonstrated significant impacts on OS, even after accounting for the effects of the other predictor.

Complications

Infectious complications were observed in five cases. Cerebrospinal fluid leakage through the exit projectile wound was documented in one patient, which resolved without progression to meningitis or the need for surgical intervention. Two cases of early meningitis were identified: one in a surgically managed patient and the other in a conservatively treated individual. Both were successfully treated with antibiotic therapy. A single case of brain abscess was reported in a patient who initially sustained a captive bolt gun injury, underwent decompressive craniectomy, and subsequently developed an abscess requiring stereotactic puncture and drainage. Additionally, one case of late meningitis was reported, presenting 12 years post-injury, attributed to a cranial base defect. Notably, no hemorrhagic complications were recorded in this series.

Discussion

The present study provides unique insights into head gunshot injuries in the Czech Republic, a country characterized by a low incidence of firearm-related violence. Patterns of firearm-related head injuries are known to vary regionally, influenced by sociocultural and legal factors such as firearm accessibility and the prevailing context of injury. Previous research has demonstrated strong associations between firearm ownership rates and suicide incidence, highlighting the relevance of local context when interpreting injury patterns and outcomes^18,19.

Within this framework, our data highlight a distinct epidemiologic profile compared with reports from high-violence regions. Suicidal injuries represented 81% of all cases—an exceptionally high proportion even among European cohorts—and injuries from less-lethal and captive-bolt firearms formed a notable share of incidents (21% and 15%, respectively)^20–22.

In the following discussion, we primarily focus on the unique characteristics of our cohort in comparison to other reports, particularly the high rate of suicides and the use of specific firearms, including less-lethal guns and captive bolt guns.

Suicides

Self-inflicted injuries resulting from suicide attempts were observed in 81.0% patients in our cohort (see Fig. 3). The proportion of suicides resulting from head gunshot injuries is a complex issue influenced by multiple factors, including the overall homicide and suicide rate, prevalence of psychiatric disorders, firearm accessibility, and sociodemographic characteristics.

Fig. 3.

A 3D CT reconstruction demonstrating a typical penetrating craniocerebral gunshot injury sustained during a suicide attempt. (a) Entrance wound characterized by a small, circular defect in the right temporal region, accompanied by a displaced skull fracture. (b) Exit wound in the left temporoparietal region, surrounded by comminuted fractures with radiating fracture lines. (c) Axial CT slice showing the wound track of a 9 mm projectile crossing the midline, with extensive hemorrhage involving critical deep structures and extending into the occipital horns of the lateral ventricles. (We express our gratitude to the Editor-in-Chief of Czech and Slovak Neurology and Neurosurgery for kindly granting permission to include Fig. 3 in this manuscript, which was previously published in their journal⁵⁸.

The proportion of suicides among firearm-related head injuries in countries with high firearm violence ranges from 3.3% to 48.8%^{5,12,13,20,23}. Higher proportions of firearm-related suicides have been reported across Europe, particularly in Central European countries such as Germany (56.6%), Switzerland (64.7%), Austria (67.1–72.1%), and the Czech Republic (72.8%)^14,24,25. This trend is primarily attributed to the notably low rates of firearm-related homicides in these countries, which results in suicides accounting for a larger proportion of firearm-related deaths¹¹. The highest proportion reported in the literature to date is 79.7%, as observed in a Finnish study¹⁵. It is noteworthy that, during the period of this study, Finland faced a significantly high prevalence of suicide and depression²⁶. However, in the years that followed, the suicide rate in Finland has seen a substantial decline, reflecting the impact of targeted mental health interventions and preventive measures²⁷.

30-day mortality in our cohort was significantly higher in the suicide group (70.4%) than in the non-suicidal group (26.3%, p < 0.001). Firearm-related suicides involving head injuries are consistently associated with exceptionally high mortality rates^4,23,28. This is due to a combination of factors, including the nature of contact gunshot wounds—where the firearm muzzle is positioned close to the skin—resulting in severe intracranial trauma, the involvement of elderly or critically ill individuals, and delays in receiving medical attention.

Less-lethal guns

In our cohort, less-lethal guns accounted for 21.0% of cases, which is markedly more than in other case series²⁹. These firearms are classified as “less-lethal” due to their low velocity and limited kinetic energy compared to conventional firearms. For example, air rifles discharge pellets at low velocities, typically less than 120 m per second, reducing the potential for deep penetration. Similarly, gas pistols fire rubber bullets, coated pellets with dispersal effects, or even blank rounds, while small-bore rifles use light, small-caliber bullets (e.g., 0.22 or less) that impart limited kinetic energy and further minimize the likelihood of deep penetration. They are primarily designed for purposes other than causing harm, such as sport shooting, training, historical reenactments, self-defense or riot control. However, our findings, consistent with other literature, underscore that these weapons can still inflict significant cranial and cerebral injuries, especially in cases of close-range discharge, where the likelihood of penetrating cranial structures is markedly increased^30–32​​.

The survival outcomes in our less-lethal gun cases were significantly better than the rest of the cases (p = < 0.001). In our cohort, 11 patients (52.4%) underwent a surgical treatment, and 30-day mortality was 19.0%. Comparatively Cook et al. reviewed 96 cases of low-velocity penetrating head injury and reported a mortality rate of 13.5%³³​​. Despite lower mortality rates than high-velocity firearm injuries, these injuries are associated with significant morbidity. Survivors of less-lethal gun injuries often face substantial long-term psychological and social challenges. Studies have shown that many experience chronic neurological impairments, cognitive dysfunction, and a decreased quality of life. Even when injuries are non-fatal, survivors frequently struggle with conditions such as post-traumatic stress disorder (PTSD), depression, and anxiety, which impact their daily functioning and overall mental health³⁴.

Captive bolt gun

Overall, a total of 15 patients (15.0%) sustained head injuries caused by a captive bolt gun. Of these, 14 patients (93.3%) suffered self-inflicted suicidal injuries, while one patient (6.7%) was injured during an assault. Overall, 6 patients (40.0%) injured by a captive bolt gun required surgical intervention, and 1 patient (6.7%) required placement of an intracranial pressure monitor. In terms of outcomes, 6 patients (40.0%) died from their injuries during hospitalization.

The captive bolt gun, originally developed as an economical tool for livestock slaughter, is occasionally used as a method of suicide, particularly in regions with strict firearm regulations³⁵. Its use in suicidal acts is particularly prevalent in Central and Southeastern Europe, where traditional rural livestock slaughtering practices have significantly contributed to the widespread availability of this device^35–38.

The captive bolt gun operates by rapidly extending a steel bolt from the device’s body, typically to a distance of 8–15 cm, instead of firing a projectile³⁶. This low-velocity mechanism, with speeds under 50 m/s, remains highly lethal. Despite its lower velocity compared to firearms, the combined kinetic energy of the bolt and bone fragments often results in severe or fatal injuries, with reported mortality rates exceeding 60%^35,39. These injuries typically present as sharp, circular entry wounds accompanied by characteristic soot deposits and a blind gunshot channel within the brain tissue. The wounding effect is somewhat less destructive than that of conventional firearms due to the shorter channel length and lower velocity³⁵. Our findings suggest that the overall survival of patients with injuries caused by captive bolt guns is significantly lower than that of those injured by less-lethal guns (p = 0.002) but slightly higher than that of patients injured by conventional firearms. However, thise difference did not reach statistical significance (p = 0.053)(see Fig. 2).

The demographics of individuals employing captive bolt guns for suicide share common characteristics. They are often middle-aged men from rural areas with limited educational attainment and a history of psychiatric conditions³⁵. Some regional studies report a remarkably high prevalence of injuries caused by captive bolt guns. For instance, Sova et al. documented such injuries in 50.0% of their cohort (n = 10), while Gajdoš et al. reported an even higher prevalence, with 64.0% of their cases (n = 16) involving injuries from a captive bolt gun^40,41. In contrast, foreign literature outside Central and Southeastern Europe mainly reports isolated case studies of injuries caused by these devices^42–44.

Surgical intervention

In present cohort, 27% of patients underwent surgical intervention, yet these patients showed marginal improvements in survival and functional outcomes. Mortality rates were 25.9% in the surgical group compared to 75.3% in the non-surgical group (p < 0.001).

The literature reports a relatively wide range of the percentage of operated patients, ranging from 7.2% to 67.2% in civilian settings^45–50. Most authors agree that patients with a Glasgow Coma Scale (GCS) score of 3 and non-reactive mydriasis are not suitable candidates for surgery^46,51–53. For other patients, active resuscitative treatment is recommended, and early surgery is advised in the presence of significant intracranial hematomas or elevated intracranial pressure (ICP)^52,54–56. Patients with favorable prognostic factors, such as a Glasgow Coma Scale (GCS) score greater than 8 and limited lobar involvement, are particularly likely to benefit from such interventions⁷. Mortality rates in surgical cohorts range from 13% to 33%, compared to 66% to 83% in non-surgical cohorts. This survival benefit persists even after adjusting for GCS^1,57.

Limitations

This study has several limitations that should be acknowledged. First, the relatively small cohort of 100 patients reduces the statistical power of subgroup analyses and may limit the identification of broader trends. Additionally, the single-center study design is inherently less robust than a multicenter approach, as it may not adequately reflect the variability and diversity of patient populations or clinical practices. While the study’s focus on a population characterized by firearm-related suicides and less-lethal gun injuries is a notable strength, it also presents a limitation, as these findings may have limited applicability to settings where firearm homicides or injuries from conventional firearms are more common.

Conclusion

This study provides a unique perspective on head gunshot injuries in a country with low firearm-related homicide rates, highlighting important differences in injury patterns, management strategies, and outcomes compared to regions with higher firearm violence. The cohort consisted of 100 patients, which represents a relatively large sample size in the context of similar studies, particularly in low-violence settings. Our findings demonstrate that firearm-related suicides account for the vast majority of cases (81%), significantly exceeding the proportions reported in high-violence regions. Additionally, less-lethal guns and captive bolt guns were responsible for a notable proportion of injuries (21% and 15%, respectively), further reflecting the distinct demographic and cultural context of the Czech Republic. Despite the high mortality rates observed in the overall cohort, the study revealed improved overall survival in patients injured by less-lethal guns compared to those with injuries caused by conventional firearms or captive bolt guns. However, given the limited number of patients in these subgroups, these results should be interpreted with caution and viewed as exploratory rather than definitive. Nevertheless, these findings emphasize the importance of accounting for regional variations in injury profiles when developing management strategies and preventive measures.

Abbreviations

CT

Computed tomography

GCS

Glasgow coma scale

GOSE

Glasgow outcome scale extended

ICP

Intracranial pressure

KM

Kaplan-Meier

OS

Overall survival

TBI

Traumatic brain injury

Author contributions

MM was the main author and was involved in all stages of the study, including conceptualization, methodology, data curation; formal analysis, project administration and drafting the manuscript. TP was responsible for patient data extraction. NS contributed to the conceptualization of the study and participated in writing the discussion section. DH also contributed to the discussion section writing. VM and DN provided supervision. MK performed statistical analysis. All authors were involved in the final manuscript revision and approval.

Funding

This research was supported by Institutional support MO1012 by Ministry of Defence of the Czech Republic and Cooperatio Neuroscience by Charles University. The funders of the study had no role in the study design nor the collection, analysis, and interpretation of data, writing of the report, or decision to submit the manuscript for publication.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.

Ethics approval

This study was reviewed and approved by The Ethics Committee of the Military University Hospital with approval number 108/19–65/2024.