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American Journal of Forensic Medicine & Pathology:
doi: 10.1097/PAF.0000000000000087
Case Reports

Fatal Gunshot Wound to the Head With Lack of Immediate Incapacitation

Aesch, Bruno MD*†; Lefrancq, Thierry MD; Destrieux, Christophe MD, PhD†§; Saint-Martin, Pauline MD*

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From the *CHRU de Tours, Institut Médico-Légal; and †CHRU de Tours, Service de Neurochirurgie, Tours; ‡Résidence Le Vauban, Nevers; and §Inserm U930, Université François Rabelais de Tours, Tours, France.

Manuscript received April 12, 2013; accepted October 27, 2013.

This study has no sources of funding.

The authors report no conflicts of interest.

Reprints: Pauline Saint-Martin, MD, Institut Médico-Légal, CHRU TOURS, 37044 TOURS Cedex 9, France. E-mail:

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Investigation of deaths caused by penetrating gunshot wounds to the head often raises the possibility of foul play. The forensic pathologist may be asked if the victim was able to perform certain acts after the gunshot, and how quickly this person might have become incapacitated. The possibility of a suicidal act can depend on these answers. We report the case of a 45-year-old woman whose body was found with a right temporal entrance wound. A shotgun was found 60 ft from the body location. The question of knowing if this woman had been able to shoot herself in the head and then walk a distance of 60 ft before dying was essential for the investigation, as suicide was the first hypothesis. The autopsy and a careful neuropathology investigation allowed to answer this question. In the literature, multiple publications report cases of victims who were able to act following penetrating ballistic head injury.

Gunshot wounds to the head are supposed to be rapidly fatal. More than 90% of penetrating craniocerebral gunshot wounds lead to death.1 However, despite this high mortality rate, numerous publications have reported delayed neurological deficit and unconsciousness following a gunshot wound to the head.2 During this interval between injury and death, the person may be able to perform certain functions, such as walking, or talking. The forensic pathologist needs to know the conditions necessary to support the hypothesis of absence of immediate incapacitation following a gunshot wound to the head, because determination of the homicidal or suicidal nature of the act might depend on its analysis. Neuropathology is particularly important, as it allows evaluating precisely the extent of the brain injury and the possibility of physical activity following the shot.3,4

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The body of a woman was found by a passerby lying on the ground near a car in a wooded area. She was identified as a 45-year-old woman, who had last been seen alive the day before by her estranged husband. In France, when a suspicious death is investigated, the police may call a medicolegal doctor to make a first examination of the body at the scene. In our case, no physician was called, as the policemen found a suicide note in the car and empty blisters of alprazolam near the body. The investigators made the hypothesis of drug intoxication, even if there were blood on the face and maggots covering some unusual parts such as the right temple. The body was taken to the forensic institute, and an autopsy was requested by the district attorney. Radioscopy of the body was performed and showed the presence of multiple pellets inside the skull. The policemen went back to the wooded area to search for a weapon. They found a 9-mm-caliber shotgun, a very small caliber that could be the European equivalence of a 410 shotgun, loaded with birdshot. In this type of ammunition, the shot is packed into a brass case backed with a cork wadding and powder. Pellets consist of lead spheres measuring 2 mm in diameter (approximately 0.08 inch). The shotgun was found 60 ft from the body location. They also found several pieces of paper tissue covered with blood, around 40 ft from the body location.

The external examination of the body showed an entrance wound on the right temple. The wound was covered with maggots. There was no exit wound. There were no other traumatic injuries. We noted blood spatter on the lower pant legs. Measurements of the right arm were consistent with the use of this shotgun by this woman who was right-handed, according to her husband. The entrance wound was difficult to interpret. It appeared to be seared, and there was a broad area with gunshot residue deposition (Fig. 1). Because of putrefaction and maggot feeding, the range of fire was hard to evaluate, but there was no stippling, and we believe this to be a contact or near-contact wound. The skull examination found a localized, round, irregular skull fracture of the right temporal bone without radiating fractures. The cranial defect was small, without separation of the pellets (Fig. 2). After removal of the skull, the cork wadding was found inside the cranium. There were a subdural hematoma and a diffuse subarachnoid hemorrhage of the right cerebral hemisphere, but no visible intracranial hemorrhage of the left cerebral hemisphere. The brain weighed 1400 g and was swollen. A large hematoma was seen by the right frontal lobe. The brain was fixed in formalin for further examination. The rest of the autopsy was normal.

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Neuropathology was requested. The brain was cut in horizontal sections (Fig. 3). A large defect could be seen on the right frontal lobe, showing the projectile path. The pellets reached the white matter of the right frontal lobe and spared the right basal ganglia, except the superior part of the pallidum. Several pellets were found in the cerebral tissue. A moderate bilateral intraventricular hemorrhage without dilatation was noted. The left cerebral hemisphere was intact. Slices of the brain stem revealed an area of bleeding in the median part of the pons, evoking Duret hemorrhage (Fig. 4).

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The investigation showed that the shotgun belonged to the father of the victim. The decedent had a history of severe depression and was treated with alprazolam. Despite our advice, the district attorney refused to order a toxicological analysis. In France, it is up to them to decide, as they pay the bill for complementary analysis. They often refuse to perform them for cost-related reasons. The investigators ruled the death as a suicide.

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Incapacitation has been defined by Karger1 in 1995 as “a physiologically based inability to perform complex and longer-lasting movements independent of consciousness and intention.” This definition excludes reflexes or automatisms. In criminal cases, the question of the potential for physical activity, as well as the survival time, following a penetrating gunshot wound to the head can arise and is often difficult to evaluate. Voluntary physical activity implies a functioning brain stem to control breathing and heartbeat, intact motor paths of conduction, and intact motor areas. In our case, brain examination found injuries of the right frontal lobe with a short path and a very minimal injury of the basal ganglia. The right temporal, parietal, and occipital lobes, as well as the left cerebral hemisphere, were intact.

A literature review highlights numerous publications in the forensic literature reporting lack of incapacitation following penetrating gunshots to the head,2 including cases of multiple gunshot wounds in suicidal acts.5,6 In this exhaustive review, Karger2 studied the location of cerebral wounding in such cases of sustained functional capability to act following a gunshot wound to the head and found that the largest group was formed by injuries to 1 or both frontal lobes. He had 2 reasons for this logical finding: first, the absence of vital and motor areas and then the location of the frontal brain in the skull and the base of the anterior cranial fossa acting like a barrier against the tissue disruption and displacement caused by the missile-tissue interaction. Other cases reported injuries of 1 temporal lobe, but never wounding both temporal lobes, the brain stem, the diencephalons, major paths of conduction, or the cerebellum.2

Three conditions seem to be necessary to support the hypothesis of delayed incapacitation: (1) the use of a slow and lightweight projectile with low velocity, (2) absence of injuries of vital and motor areas, and (3) absence of evidence of overpressure injuries. These injuries include skull fractures separated from primary fractures or secondary wound fractures; remote brain contusions caused by impact of the tissue against the skull; and intracerebral petechial hemorrhages, separated from the direct gunshot wound path by intact brain tissue.7,8 Intraparenchymal hemorrhages and herniation syndrome are due to the secondary brain swelling and therefore are not included in this category.

In conclusion, we were confident saying this woman was able to walk a certain distance before dying (1) because of the use of a small cartridge with small gunpowder load and low kinetic energy that explains the irregular fracture limited to the right temple without associated extensive fractures, (2) because of the site of injury: the frontal lobe is not involved in vital functions, (3) because the pellets are ballistically weak and did not penetrate very deep in the brain, and (4) because the brain swelling was the cause of a Duret hemorrhage, which implies that the victim lived for a while. This case underlines the importance of the scene examination, as the shotgun was not immediately found, and the importance of neuropathology.

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The authors thank Dr Jonathan Hayes for his helpful advice.

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1. Karger B. Penetrating gunshots to the head and lack of immediate incapacitation. I. Wound ballistics and mechanisms of incapacitation. Int J Legal Med. 1995; 108: 53–61.

2. Karger B. Penetrating gunshots to the head and lack of immediate incapacitation. II. Review of case reports. Int J Legal Med. 1995; 108: 117–126.

3. Oehmichen M, Meissner C. Routine techniques in forensic neuropathology as demonstrated by gunshot injury to the head. Legal Med. 2009; 11: S50–S53.

4. Oehmichen M, Meissner C, König HG, et al. Gunshot injuries to the head and brain caused by low-velocity handguns and rifles. A review. Forensic Sci Int. 2004; 146: 111–120.

5. Hejna P, Miroslav S, Zatopkova L. The ability to act—multiple gunshot wounds. J Forensic Legal Med. 2012; 19: 1–6.

6. Karger B, Brinkmann B. Multiple gunshot suicides: potential for physical activity and medico-legal aspects. Int J Legal Med. 1997; 110: 188–192.

7. Itabashi HH. Injuries due to firearms and other missile-launching devices. In: Itabashi HH, Andrew JM, Tomiyasu U, et al. Forensic Neuropathology—A Practical Review of the Fundamentals. Amsterdam; London: Elsevier Academic Press; 2004; 232–237.

8. Thiex R, Thron A, Uhl E. Delayed oedema in the pyramidal tracts remote from intracerebral missile path following gunshot injury. Neuroradiology. 2004; 46: 140–143.


forensic science; forensic pathology; incapacitation; ballistic head injury; neuropathology; suicide

Copyright © 2014 by Lippincott Williams & Wilkins


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