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Jan. 27, 2011 -- Arizona Rep. Gabrielle Giffords has survived a point-blank gunshot wound to the head.
How is this possible? What can surgeons do? What are Giffords' chances of recovery -- and what will recovery mean?
To answer these and other questions, WebMD consulted prominent medical experts with experience in dealing with brain injuries, including gunshot wounds. We also consulted experts in assessment and rehabilitation of patients with brain injuries. None of these experts is treating Giffords, and none has access to her medical records.
These experts include:
- Eugene S. Flamm, MD, professor and chairman of the department of neurological surgery at Albert Einstein College of Medicine/Montefiore Medical Center in New York.
- Keith L. Black, MD, professor and chairman of the department of neurosurgery and director of the Maxine Dunitz Neurosurgical Institute at Cedars-Sinai Medical Center in Los Angeles.
- Nina Zeldis, PhD, a specialist in rehabilitation medicine, formerly of Tel Aviv University in Israel, now in private practice.
- Mark Brooks, PhD, a neuropsychologist at Glancy Rehabilitation Hospital in Duluth, Ga.
- David Langer, the director of cerebrovascular research at Cushing Neuroscience Institute in Great Neck, N.Y.
- Alan Manevitz, MD, a family psychiatrist at Lenox Hill Hospital in New York. He has worked with many disaster victims, including those involved in Hurricane Katrina and the 9/11 terrorist attacks.
What part of Gabrielle Giffords' brain was injured?
The precise nature of Giffords' wound -- exactly which brain structures were destroyed -- has not been made public. What is known is that a 9 mm bullet fired point-blank at the left rear of her head passed through the brain and exited the left front of her head near her left eye.
That part of the brain controls vision, language, and the ability to move the right side of the body. All of these functions are at risk, notes Keith L. Black, MD.
"The physicians in Arizona indicated that the wound was away from these critical structures," Black says. "Based on those comments, that is a positive side for the congresswoman."
The bullet did not pass from the left side of the brain to the right side of the brain. That almost certainly would have done far more damage, Black notes.
How bad is Giffords' brain injury?
It's a very, very serious wound. About 90% of people shot in the head do not survive, David Langer says.
But there is much reason for hope in Giffords' case.
Giffords' neurosurgeon, Michael Lemole, MD, says his patient is able to understand simple commands -- such as "Show me two fingers," and "Wiggle your toes" -- and to perform these tasks.
This is heartening news, says Eugene S. Flamm, MD.
"The fact that she is being described as able to follow commands, when they lighten up on her medications, that is encouraging," Flamm says. "But I don't know whether this injury means she is paralyzed on the right side: That is a very important issue. If she is not moving her right side, that makes it hard to imagine good recovery."
It now appears that Giffords can indeed move the right side of her body, although the extent to which she is able to do this remains unclear.
The biggest issue facing Giffords is that she has suffered what Flamm calls "sort of the ultimate traumatic brain injury."
Brain tissues bruised by the force of the bullet continue to swell for days after the original injury. Such swelling can kill even more brain cells than those destroyed by the original injury.
"The problem with swelling in the brain is it is inside the skull, a closed cavity. If the pressure from the swelling reaches the arterial blood pressure, you no longer get blood flow to the brain and the brain is starved of blood," Black says. "Then you get collateral death of tissues surrounding the bullet wound itself."
This swelling, Flamm says, continues for about five days -- and usually is worst on the third day after the injury.
To reduce the swelling:
- Giffords' doctors removed a section of her skull.
- Giffords' doctors put her into a medically induced coma.
- Steroids can be given to reduce swelling.
- A concentrated sugar solution can be given to draw fluid out of the brain.
- Hyperventilation via a respirator can keep brain cells from starving of oxygen.
These efforts appear to have been extremely successful. Giffords is no longer in critical condition and has survived the critical period for brain swelling.
Why was part of Giffords' skull removed?
After removing bone fragments from Giffords' brain, her doctors also removed a large section of her skull. This was done to give her bruised brain some room to swell.
If the bone had not been removed, the pressure inside her head might have built up to the point where it starved the brain of blood.
"You take the skull up, but you still have the scalp covering the brain," Black says. "Then once the swelling goes down you can go back and put in an artificial skull plate or even the skull piece itself. But most of the time in a head injury you don't keep the bone, because it is contaminated with hair and bullet. So you come back about four weeks later and replace it with acrylic bone plates."
What would be the signs that Giffords' condition is getting worse?
In the short term, brain swelling was Giffords' most serious threat. That threat now is greatly reduced.
Her doctors have replaced her respirator with a tube that goes directly into her windpipe. This helps protect the airway, but would make it difficult for her to speak.
There was also a risk of brain infection, but as time goes by this becomes less likely. And because Giffords suffered a very severe brain injury, seizure remains a serious risk.
Overall, Giffords is making a remarkable recovery. It now seems certain that she will leave the hospital -- possibly in a matter of days -- and begin her rehabilitation.
Once Giffords enters a rehab facility, a team of professionals will take over her care. That team will perform a thorough evaluation, and then begin her rehab regimen as soon as possible, says Mark A. Brooks, PhD, a neuropsychologist at Glancy Rehabilitation Hospital, Duluth, Ga.
"They will establish treatment goals and execute them the following day," Brooks tells WebMD. "You can't postpone treatment. The window of recovery is greatest early on. The more aggressive you are in the beginning, the better the outcome."
Will Giffords survive?
"Survival? We are beyond that phase," Flamm says. "What is of greater concern is the quality of survival."
Black says he's seen patients who have been shot in the head make amazing recoveries.
"We have had patients who have been shot in the head and were able to return to their previous occupations and are functioning near normal," he says. "This may have to occur on a gradual basis. ... The brain will continue to recover for six to 18 months."
The parts of the brain destroyed by the bullet are gone forever. But other injured areas may recover.
"Some brain cells now in shock are still alive and those cells will go ahead and recover once the initial trauma is resolved," Black says. "The cells that were destroyed and died, the surrounding areas will try to take over those functions by making new connections. And there are stem cells in the brain that can come out and regenerate some of the tissue."
Brooks notes that while the brain cells destroyed during Giffords' injury are gone, the damage may be limited.
"A bullet wound is more like a stroke than a blow to the head from a car wreck, because the tissue damage is so circumscribed," he says. "The potential for recovery is greater for the tissue that didn't get taken out."
Will Giffords recover?
As Flamm notes, survival is one thing and recovery is another. It's very rare for a person with extensive brain damage -- such as that caused by a bullet -- to regain all of the abilities and functions he or she had before the injury.
So far, the news from Giffords' bedside is good. But until she is formally evaluated by a team of rehabilitation specialists, the extent of her disabilities remains unclear.
Nina Zeldis, PhD, taught rehabilitation medicine at Israel's Tel Aviv University for more than 20 years. She notes that people who, like Giffords, have suffered damage to the left side of the brain tend to have:
- difficulty speaking and understanding speech
- difficulty reading
- increased impulsivity
- lack of emotional control
- decreased problem-solving ability
- diminished long-term planning
- problems with hand/eye coordination
"The things we do every day and don't think about, all these things we think of as little become enormous and difficult to do," Zeldis says.
During rehabilitation, Zeldis says, many patients are able to compensate for these problems. But many others -- even though they work every bit as hard -- do not.
"It is beautiful when a person makes a little bit of progress, and terrible if you don't see any," she says.
Emotional issues are every bit as difficult as physical issues for a person recovering from trauma, says Alan Manevitz, MD, a psychiatrist who has helped many people cope with disasters such as Hurricane Katrina and the 9/11 terrorist attacks.
"Survivors have to challenge themselves with rational thoughts, to remind themselves who really is to blame -- not themselves -- and to restore their sense of safety," he says. "They have to talk with others so they don't isolate themselves, and to concentrate on the strengths that have made them resilient in the past. That is a strategy of how to cope with the feelings."
What challenges will Giffords face during rehab?
As soon as it's safe for her to leave the acute-care hospital, Giffords will enter a rehabilitation facility.
A team of professionals will oversee her care. At a minimum, this team will include:
- A physiatrist. Physiatrists are rehabilitation experts who treat injuries or illnesses that affect how a person moves.
- A neuropsychologist. Neuropsychologists are experts in how brain injuries affect behavior.
- A speech therapist.
- A physical therapist.
- An occupational therapist.
Each member of the team will evaluate Giffords. Then the team will meet and come up with a treatment plan. Treatment will begin immediately.
Assessment will include an evaluation of Giffords' language skills and on what she is and isn't able to do physically. Until this is done, Brooks says, there really is no way to know what the congresswoman can and cannot yet do.
And given her remarkable, against-all-odds recovery so far, there's no way to say what she won't be able to accomplish.