Original Article
Fatal Penetrating Head Injuries Caused by Projectile Tear Gas Canisters
Samer S. Hoz1, Zaid S. Aljuboori2, Ali A. Dolachee3, Zahraa F. Al-Sharshahi1, Mohammed A. Alrawi1,
Ammar M. Al-Smaysim1
- BACKGROUND: Since their advent in the 1920s, tear gas
canisters (TGCs) have been frequently used in crowd
control. Few reports have documented nonpenetrating in-
juries attributed directly to TGCs. In this study, we report a
case series of fatal penetrating head injuries caused by
TGCs.
- METHODS: We conducted a retrospective chart review
of all the patients who were admitted to the Neurosurgery
Teaching Hospital in Baghdad, Iraq, since the start of the
antigovernment protests (October 2019). All patients who
suffered penetrating head trauma caused by TGCs were
included in our study. We collected patient demographics,
wound location, neurologic examination, computed to-
mography (CT) scan findings, surgical management, and
clinical outcomes.
- RESULTS: We found 10 cases of penetrating head trauma
caused by TGCs. All victims were men, with a mean age of
16 years (range, 14e19 years). The mean Glasgow Coma
Scale score was 7 (range, 3e10). The neurologic exami-
nation revealed unilateral hemiplegia/hemiparesis and
pupillary abnormality in 40% (n [ 4) and 50% (n [ 5) of the
patients, respectively. CT scans revealed an extensive
pattern of brain damage. Surgical intervention was done in
80% of cases (n [ 8), which included removal of the TGC,
wound debridement, and hemostasis. The in-hospital mor-
tality rate was 100% (N [ 10), with all fatalities occurring
within 1e3 days of admission.
- CONCLUSIONS: TGCs have the potential to cause le-
thal penetrating head injuries, calling for a reevaluation
Key words
- Brain
- Canister
- Head
- Penetrating
- Tear gas
- Trauma
Abbreviations and Acronyms
CS: Chlorobenzalmalononitrile
CT: Computed tomography
GCS: Glasgow Coma Scale
ICP: Intracranial pressure
TGC: Tear gas canister
WORLD NEUROSURGERY 138: e119-e123, JUNE 2020
of their safety and methods of use in terms of human
health.
INTRODUCTION
T
ear gases are frequently used by law enforcement agencies
to disperse crowds or to force compliance. They were first
introduced in the 1920s, and many different agents have
been developed since then.1 The most commonly used chemical is
chlorobenzalmalononitrile (CS per military classification).2 These
chemicals can be delivered by a variety of means, including
canisters, grenades, munitions, among others. Importantly, the
delivery method plays a pivotal role in its terminal impact.1,2
They work by irritating the skin and the mucous membranes
and should result in no more harm than these intended short-
lived noxious effects.2 Although intended as nonlethal weapons,
there have been numerous incidents where the use and misuse
of these agents have resulted in serious injuries and even
death.3-6 A recent systematic review reported 2 fatalities and 48
permanent disabilities attributed to tear gas exposure.6
Additionally, numerous case reports have recorded serious
injuries caused by projectile tear gas ammunition, including
globe injuries, blindness, maxillofacial wounds, and closed
traumatic brain injuries.7-10 The first historical evidence of pene-
trating traumatic brain injury caused by tear gas canister (TGC)
was found in skull remains that belonged to one of the 54th
Massachusetts Volunteer Infantry members. The characteristics of
the skull defect led to the assumption that it was inflicted by a
metal TGC.11 However, case reports on TGC- related penetrating
traumatic brain injury are extremely rare in the literature. One
such case was reported by our institution in 2018.12
From the 1Department of Neurological Surgery, Neurosurgery Teaching Hospital, Baghdad,
Iraq; 2Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA;
and 3Department of Surgery, College of Medicine, University of Al-Qadisiyah, Diwaniyah,
Iraq
To whom correspondence should be addressed: Zaid S. Aljuboori, M.D.
[E-mail: zaid.aljuboori@yahoo.com]
Citation: World Neurosurg. (2020) 138:e119-e123.
https://doi.org/10.1016/j.wneu.2020.02.050
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All rights reserved.
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 ORIGINAL ARTICLE
SAMER S. HOZ ET AL. TEAR GAS CANISTERS RELATED HEAD INJURIES

Table 1. Patient Demographics, Neurologic Examination, Computed Tomography Scan Findings, Management, and Outcomes
Patient Age GCS Score Pupil Unilateral Wound Time Until
Number (years) Sex on Admission Reactivity Weakness (Entry Site) CT Scan Findings* Surgeryy Death (Days)

1 14 Male 10 Normal No Right frontal Canister in R frontal lobe across the Yes 1
midline
2 17 Male 9 Normal No Right frontal Canister in R frontal lobe across the Yes 1
midline
3 15 Male 9 Normal No Right frontal Canister in R frontal lobe Yes 3
4 18 Male 8 Normal Right Left occipital Canister in L occipital lobe and basal Yes 3
ganglia region
5 19 Male 8 Normal No Midline occipital Canister in both occipital lobes across the Yesz 1
midline
6 16 Male 6 DNRP (R) Left Right parietal Canister in R parietal and frontal lobes Yes 2
7 17 Male 3 DNRP (bilateral) NA Left parietal Canister in bilateral parietal lobes across Nox 1
the midline
8 15 Male 3 DNRP (bilateral) NA Right parietal Canister in R parietal and frontal lobes Nox 1
9 16 Male 7 DNRP (L) Right Left parietal Canister in L parietal and occipital lobes Yes 3
10 16 Male 7 DNRP (R) Left Right parietal Canister in R parietal lobe Yes 2

All patients had a combination of the following: skull fractures, intraparenchymal bone fragments, multiple brain contusions, brain edema, pneumocephalus, intraventricular hemorrhage, tract
hemorrhage, and subarachnoid hemorrhage. Notably, all patients had brain tissue through the scalp wound.
GCS, Glasgow Coma Scale; CT, computed tomography; R, right; L, left; DNRP, dilated nonreacting pupil, NA, not applicable.
*Indicates unique CT scan findings.
ySurgery included canister removal with wound debridement and closure.
zIn this patient the canister could not be removed because of profuse bleeding from the straight venous sinus.
xCases were not treated with surgery, only a simple wound closure was done.

We hereby report a series of cases of fatal penetrating head
injuries caused by TGCs during the recent antigovernment pro-
tests in Baghdad, Iraq. To our knowledge, this is the first case
series of its kind. The objective of this study is to share our
experience and to illustrate the fatality of these weapons.
METHODS
Data Collection
We conducted a retrospective medical chart review of all patients
admitted to the Neurosurgery Teaching Hospital in Baghdad since
the start of the protests in October 2019. All patients who sus-
tained a penetrating head injury by TGC were included in the
study. The data we collected included patient demographics,
admission Glasgow Coma Scale (GCS) score, pupillary reactivity,
neurologic examination, wound description, initial computed to-
mography (CT) head scan findings, surgical management, and
clinical outcomes.
failure of improvement, mannitol boluses (every 4 or 6 hours) were
used empirically. A target of systolic blood pressure
100 mm Hg
was achieved using normal saline and blood transfusion for he-
matocrit values <30. Patients with GCS scores of 8 were sedated,
intubated, and mechanically ventilated. Ceftriaxone was used for
postoperative antibiotic prophylaxis. Seizure control was achieved
using phenytoin as first-line treatment and phenobarbital as
second-line treatment.
Operative Management
The surgical intervention included an extension of the existing
scalp wound in lieu of the traditional trauma flap with a large
craniectomy centered around the canister entry site followed by
canister removal. Also, we debrided any devitalized brain and skin
followed by hemostasis and antibiotics irrigation. The dura was
closed with pericranial patch. An external ventricular drain was
only used for significant intraventricular hemorrhage with dilated
ventricles. For nonsurgical candidates, simple wound closure was
done.

Medical Management RESULTS

The patients were transferred by a 3-wheeled motorized vehicle
tuk-tuk, which is used as a low-cost taxi. After admission to the
emergency department, patients were stabilized and triaged based
on the severity of their injuries. No intracranial pressure (ICP)
monitoring devices are available at our facility, therefore, ICP
monitoring was not part of the management. On deterioration or
A total of 41 patients were admitted to our institution because of
TGC-related head injuries. We documented 10 cases of pene-
trating head injuries caused by TGC (Table 1). All the victims were
men, with a mean age of 16 years (range, 14e19 years). The mean
GCS score was 7 (range, 3e10). Notably, all patients had brain
tissue outside the scalp wound. On examination, motor

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SAMER S. HOZ ET AL.
Figure 1. Computed tomography scan of the brain axial view shows a
tear gas canister lodged in the right frontal lobe.
weakness in the form of hemiplegia/hemiparesis was noted in
40% of the patients (n ¼ 4). The presence of dilated nonreactive
pupil was recorded in 50% of the patients (n ¼ 5). The
anatomic distribution of the canister entry wound was as
Figure 2. Computed tomography scan of the brain axial view shows a
tear gas canister lodged in the left occipital lobe with extensive skull
fracture.
WORLD NEUROSURGERY 138: e119-e123, JUNE 2020
ORIGINAL ARTICLE
TEAR GAS CANISTERS RELATED HEAD INJURIES
Figure 3. Computed tomography scan of the brain midsagittal view
shows a tear gas canister lodged in the midline affecting both occipital
lobes.
follows: parietal 50% (n ¼ 5), frontal 30% (n ¼ 3), and occipital
20% (n ¼ 2). The canisters crossed midline in 40% (n ¼ 4) and
assumed a complete intracranial location in 20% (n ¼ 2) of
cases. The head CT scans revealed extensive injuries which
included multiple skull fractures, in-driven bone fragments,
multiple brain contusions, diffuse brain edema, pneumocephalus,
intraventricular hemorrhage, tract hemorrhage, and subarachnoid
hemorrhage (Figures 1e7). Operative intervention was performed
in 80% of the cases (n ¼ 8) because of salvageable neurologic
examinations, whereas conservative management was used in the
remaining 2 victims (20%) because they had a nonsurvivable brain
injury. The canisters were successfully removed in 7 patients
(70%). In 1 case, the canister obstructed and injured the straight
sinus, and was left in place because of the risk of uncontrollable
bleeding. The in-hospital mortality rate was 100% (N ¼ 10), with
all fatalities occurring within 1e3 days of admission because of
uncontrollable ICP and brain edema.
DISCUSSION
TGCs are usually used by government agencies for crowd control
and compliance. These weapons are increasingly used worldwide.6
With this widespread use grows the need for a heightened
understanding of the impact of these weapons on human
health. A standard TGC is usually composed of a host of
chemicals, including orthochlorobenzalmalononitrile (CS), the
tear gas, and methylene chloride, the dispersal agent. The
canister also contains a denotator and a propellant to fire the
projectile. The deployment velocity, and hence the damage
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 ORIGINAL ARTICLE
SAMER S. HOZ ET AL. TEAR GAS CANISTERS RELATED HEAD INJURIES

Figure 4. Computed tomography scan of the brain 3-dimensional Figure 6. Computed tomography scan of the brain 3-dimensional
reconstruction shows a tear gas canister lodged in the right parietal reconstruction shows a tear gas canister lodged in the left frontal
region. region.

caused by the cartridge are determined by both the firing device factors include the ammunition type, firing angle, concentration
and the distance from the target, with shorter distances having of the chemicals, and the surrounding environmental
the propensity to cause severe penetrating injuries.1 Additional conditions, specifically heat and humidity.6 All victims in this
series sustained serious head injuries because of a combination

Figure 5. Computed tomography scan of the brain 3-dimensional

reconstruction shows a tear gas canister lodged in the right occipital Figure 7. Computed tomography scan of the brain 3-dimensional
region. reconstruction shows a tear gas canister lodged in the left parietal region.

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 ORIGINAL ARTICLE
SAMER S. HOZ ET AL. TEAR GAS CANISTERS RELATED HEAD INJURIES

of thermal, mechanical, and chemical insults caused by the tear
gas cartridge.13 We used the internationally accepted
management algorithms for penetrating head trauma.14
However, we maintained a lower threshold for intervening
surgically, considering the large size of the foreign body (the
canister) relative to the size of the cranium.
Importantly, the gravity of the injuries and the high fatality rate
reported in our study warrant a serious action plan to limit similar
future incidents. Also, we suggest that the use of such weapons
should be subject to strict regulations, including governmental
policies mandating indirect firing. Besides, there should be
internationally defined standards governing the design, synthesis,
and trade of these devices. Amnesty International has investigated
the use of these weapons and concluded that the culprit canisters
were a variant of the standard TGCs being used internationally.
They specifically pointed out the differences in their weight,
design, and manufacturing. The report concluded that these
canisters were intended for military use.15
The manufacturers should oblige to preset standards of safety
features. For example, they could add a manual setting option to
the gun design to control the projectile range. Additionally,
antiriot police personnel should be made aware of the lethal po-
tential of these weapons and might be enrolled in specialized
training programs aimed at the safe handling of these weapons.
Moreover, further research is needed to understand the short- and
long-term consequences of repeated exposure to tear gas. Some
have reported that the long-term health effects of tear gases
include posttraumatic stress disorder, major depressive disorder,
and chronic respiratory disease (e.g., asthma).16,17
Limitations in this study may stem from several factors. First, our
small cohort size significantly impacts the statistical power of the
study. Second, there were no eyewitness accounts; hence, we could
not understand the injury mechanics, such as the projectile firing
range and angle. Nevertheless, it can be inferred that most shoot-
ings occurred at a close distance given the severity of the injuries.
Finally, anecdotal evidence including numerous media reports ac-
counting for hundreds of other tear gaserelated fatalities was not
included in our study. Therefore, the number of fatalities reported
in our case series is an underestimation of the real-world figures.
CONCLUSIONS
Our findings demonstrate that, when fired directly at the head, tear
gas weapons have the potential to inflict serious injuries and death.
For penetrating head injuries related to TGCs, the mortality rate can
be extremely high. Consequently, strict international guidelines are
required before the use of these weapons can be condoned again.

8. Corbacioglu SK, Guler S, Er E, Seviner M, Aslan S, latest/news/2019/10/iraq-gruesome-string-of-fatalities-

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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 7 January 2020; accepted 7 February 2020
Citation: World Neurosurg. (2020) 138:e119-e123.
https://doi.org/10.1016/j.wneu.2020.02.050
Journal homepage: www.journals.elsevier.com/world-
neurosurgery
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
rights reserved.

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