|Year : 2015 | Volume
| Issue : 1 | Page : 27-30
Cranial computed tomography utilization in head trauma in a Southern Nigerian tertiary hospital
Ehimwenma Ogbeide1, Alphonsus R Isara2
1 Department of Radiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
2 Department of Community Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Web Publication||26-Feb-2015|
Department of Radiology, University of Benin Teaching Hospital, P. M. B. 1111, Benin City, Edo State
Background: Computed tomography (CT) is the imaging modality of choice in evaluating patients with acute head trauma. Objective: The objective of this study is to assess CT utilization in head trauma in University of Benin Teaching Hospital (UBTH) with reference to sociodemographic characteristics and cause of injury. Materials and Methods: A retrospective study of patients who had CT scanning done for head trauma in the UBTH, from 2011 to 2013 was undertaken. Medical Records of patients with special emphasis on the patient's demographic characteristics and detailed information about the cause of injury of the patients were obtained from the accident and emergency department of the hospital. Data were analyzed using SPSS version 17. Results: A total of 1387 patients with male: female ratio of 3.7:1 were studied. The mean age of the patients was 33.2 ± 18.8 years. Road traffic accidents (RTA) were the predominant cause of injury among the patients accounting for 62.6% of the cases. Gunshot injury (GSI) and patients struck by objects accounted for only 2.7% and 1.3% of the cases, respectively. The Glasgow coma score (GCS) of the patients revealed that 42.0%, 26.1%, and 31.9% of patients had severe head injury, moderate injury, and mild injury, respectively. Conclusion: Road traffic accidents involving young adult males constituted the predominant cause of injury in patients that had brain CT in UBTH. There is an urgent need for improvement in the condition of roads and enforcement of the use of protective devices by road users to curb the epidemic of head injury resulting from RTAs.
Keywords: Computed tomography, Southern Nigeria, traumatic brain injury
|How to cite this article:|
Ogbeide E, Isara AR. Cranial computed tomography utilization in head trauma in a Southern Nigerian tertiary hospital. Sahel Med J 2015;18:27-30
|How to cite this URL:|
Ogbeide E, Isara AR. Cranial computed tomography utilization in head trauma in a Southern Nigerian tertiary hospital. Sahel Med J [serial online] 2015 [cited 2019 Oct 15];18:27-30. Available from: http://www.smjonline.org/text.asp?2015/18/1/27/152155
| Introduction|| |
Head injury is a major public health problem in Nigeria and indeed worldwide. Traumatic brain injury (TBI) impacts the daily lives of disabled survivors, their families, caregivers, and communities as a whole. A considerable proportion of trauma-related deaths are due to head injuries. TBI is referred to as a "silent epidemic" because the problems that result from it are often not visible. 
Head injury management requires a multidisciplinary approach. In the emergency setting, computed tomography (CT) is an established and very useful imaging modality in the evaluation of head trauma because of the information provided and relatively fast image acquisition time. CT is the imaging modality of choice in the triage of acute head injured patients, the main objective being to detect clinically important traumatic brain injury where emergent intervention is required. There is a paucity of data in our environment on the pattern of utilization of CT in patients with suspected TBI. The primary etiologic factors of TBI vary according to age, socioeconomic factors and geographical region and any planned intervention must be tailored accordingly.  This study, a part of a larger study on various aspects of neurotrauma in our institution, was aimed at describing in particular, socio-demographic characteristics and other features such as cause of injury in patients referred for CT scans following head trauma.
| Materials and methods|| |
A retrospective study of patients who presented for CT scans over a 30-month period from February 2011 to July 2013, following head trauma was undertaken. The study setting was the Radiology Department of the University of Benin Teaching Hospital (UBTH). The UBTH is located in Benin City, Edo State, Nigeria. The hospital is a level I urban trauma center, which serves as a referral center for the people of Edo and other States in Southern part of Nigeria. Data reviewed were from the request forms, and included age, sex, and indication for the CT scan. In addition, data obtained from the Accident and Emergency Department included admission Glasgow coma score (GCS) and detailed description of cause of injury where available. Data were analyzed with the use of SPSS version 17.0 Chicago: SPSS Inc. Statistical test of association was carried out using the Chi-square test.
| Results|| |
A total of 1387 patients who presented for CT scan in UBTH following head trauma during the 30-month period under review had sufficient information to be enrolled into the study. [Table 1] shows the age distribution of the patients. The mean age of the patients was 33.2 ± 18.8 years (age range <1-90 years). A higher proportion of the patients were in the age group 26-45 years. There were 1089 (78.5%) males and 298 (21.5%) females giving a male: female ratio of 3.7:1.
The cause of injury of the patients is shown in [Table 2]. Road traffic accident (RTA) was the major cause of injury among the patients accounting for 62.6% of the cases. It was not possible to ascertain the exact cause of injury in 300 (21.6%) patients. Gunshot injury (GSI) and patients struck by objects accounted for only 2.7% and 1.3% of the cases, respectively. Falls and unspecified cause of injury were higher among the female patients while, there were a higher proportion of males who were involved in RTAs, assault, GSIs and struck by objects [Table 3]. The recorded GCS of the patients showed that 42.0% of the patients had severe head injury (GCS <9), 26.1% had moderate head injury (GCS 9-12) while 31.9% had mild head injury (GCS 13-15) [Figure 1].
Of the 868 patients who had RTAs, data on the particular type of RTA were available for only 466 (53.7%) of the patients. This revealed that 129 (27.7%) were involved in vehicular accidents, 236 (50.6%) were involved in motorbike accidents while 101 (21.7%) were pedestrians. A cross-tabulation of some characteristics of the patients and the type of RTA is shown in [Table 4]. The association between the age group of the patient and the type of RTA was statistically significant (P < 0.0001). Furthermore, a significant association was seen between the sex of the patient and the type of RTA (P < 0.0001). However, there was no statistically significant association between the degree of injury of the patients and the type of RTA (P = 0.638).
|Table 4: Some characteristics of the patients and the type of road traffic accidents (n=466) |
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| Discussion|| |
Head injury is a global health problem and a significant cause of morbidity and mortality in Nigeria. A wide variation exists in the etiology of head trauma in different parts of the world although the most common causes include RTAs, falls, and assault.  The world is facing a silent epidemic of RTAs in developing countries: By 2020 road traffic crashes will have moved from ninth to third place in the world ranking of the burden of disease and will be in second place in developing countries.  Every day about 3000 people die and 30,000 people are seriously injured on the world's roads, nearly half of them with head injuries.  Most of the victims are from the low- or middle-income countries with pedestrians, cyclists and bus passengers bearing most of the burden.  Fatality rates are 6 times greater in developing countries than in high-income countries and furthermore, this appears to be on the rise.  RTA was the predominant cause of trauma in our study, as documented in other studies from within Nigeria. ,,, Child-centered series from some African countries have also found RTAs as a major cause of head trauma. ,, On the contrary, time trend data from many developed countries for road deaths indicate a decrease for some years. Attributed to this are preventive measures such as use of seat belts, motorcycle helmets, and enforcing laws on alcohol limits for drivers. 
In this study, males were more affected than females, accounting for 78.5% and 21.5%, respectively, with majority resulting from RTA, as has been documented in other head trauma series. ,, In particular, with respect to motorcycle-related head trauma, the proportion was much higher in the males compared to their female counterparts (male: female ratio of 15.9:1). Commercial motorcycle riders in Nigeria are almost exclusively males. Persons involved in motorcycle-related traffic accidents constitute a high-risk group because of disregard for traffic rules, lack of adherence to safety precautions such as the use of appropriate helmets for riders and passengers. In this study, motorcyclists had the highest number of severely head injured patients compared to vehicle occupants and pedestrians. There is a recent ban on the use of motorcycles as a means of commercial transportation within the Benin metropolis. This may lead to a reduction in RTA-related head trauma resulting from motorcycle accidents in the metropolis.
Rapid motorization of major cities in Nigeria has brought about a higher incidence of pedestrian injury in addition to that of motorcyclists and vehicle occupants. Pedestrian head injured patients form a category that deserves special consideration as they constitute a high-risk group with high-mortality expected to occur following high-speed collisions. Pedestrians are more likely to be severely injured than vehicle occupants with pedestrian injuries being particularly common in children and the elderly.  This is consistent with our findings in the younger age group between 2 and 15 years with pedestrian injuries occurring in 79.6% of documented RTA-related head injuries. However, in those aged 65 and above, more cases of head trauma occurred in motorcycle accidents (50.0%), while 33.0% were pedestrians, although the percentage in elderly pedestrians was somewhat higher than was obtained for other adult subgroups, which ranged between 12% and 17.0%.
Other causes of head trauma in our study population included falls 92 (6.6%), assault 72 (5.2%) GSI 37 (2.7%) and struck by an object 18 (1.3%). Gunshot injuries are on the increase in contemporary Nigeria, although the extremities may be the more commonly targeted site. ,,, Males in our study were much more commonly affected in cases of GSI and in cases of assault which may be attributed to younger males being generally more aggressive and adventurous. The male: female ratio of patients who required cranial CT scan following falls was 2-1, much closer than other specified causes of injury.
The National Institute for Health and Clinical Excellence offers advice for the care of all patients who present with suspected or confirmed head injury with or without other major trauma and the GCS is one of several parameters taken into consideration.  GCS is the most commonly utilized means of defining severity of head injury serving as an objective assessment of the level of consciousness.  Various studies have evaluated CT scan use in minor head trauma. ,,,, Haydel et al. suggested that minor head injured patients who should undergo CT can be identified by the presence of one or more of seven clinical findings.  A study found that current protocols based on clinical findings may miss 30% of elderly intracranial injury patients and recommended head CT scans on all elderly patients with minor head trauma.  The available data on GCS in our study shows that the severely head injured patient group that had CT evaluation was the largest. This is not unexpected as the probability that head injured patients with lower GCS are harboring a surgically remediable intracranial insult may be higher than those with higher scores. Head trauma patients with low admission GCS have a poor prognosis with a score of 3 being the lowest possible and associated with high-mortality rate.  It is important to note that other variables such as age, pupil size and reactivity, CT findings, abnormal motor responses, etc., play a very significant role as predictors of outcome after head trauma. However, our study has the following limitations: First, our study cohort consisted solely of a head trauma population that had CT evaluation. Thus, our findings may not be viewed as representative of the larger head trauma population in our environment. Secondly, it was not possible to obtain complete data for all the patients who had CT scan following head trauma.
| Conclusion|| |
Road traffic accidents constituted the predominant cause of injury in patients who had CT evaluation in UBTH following head trauma and amongst them young adult males were most commonly involved. Patients with severe head injury were more likely to have CT evaluation. We recommend improved road infrastructure, enforcement of traffic laws and use of protective devices including seat belts and helmets by motorcyclists to reduce the epidemic of head injury.
| References|| |
National Centre for Injury Prevention and Control. Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Atlanta, GA: Centre for Disease Control and Prevention; 2003.
Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: A review. Epilepsia 2003;44 Suppl 10:2-10.
Jennett B. Epidemiology of head injury. J Neurol Neurosurg Psychiatry 1996;60:362-9.
World Health Organization. Neurological Disorders: Public Health Challenges. WHO; Geneva. 2006. p. 164-73.
Akang EE, Kuti MA, Osunkoya AO, Komolafe EO, Malomo AO, Shokunbi MT, et al
. Pattern of fatal head injuries in Ibadan: A 10 year review. Med Sci Law 2002;42:160-6.
Emejulu JK. Epidemiological patterns of head injury in a newly established neurosurgical service: One-year prospective study. Afr J Med Med Sci 2008;37:383-8.
Elesha SO, Daramola AO. Fatal head injuries: The Lagos University Teaching Hospital experience (1993-1997). Niger Postgrad Med J 2002;9:38-42.
Ohaegbulam SC, Mezue WC, Ndubuisi CA, Erechukwu UA, Ani CO. Cranial computed tomography scan findings in head trauma patients in Enugu, Nigeria. Surg Neurol Int 2011;2:182.
Ogbeide E, Isara AR, Akhigbe AO, Ighodaro EO. Computerized tomographic findings in children with head trauma in a Nigerian tertiary hospital. J Coll Med 2010;15:46-52.
Obajimi MO, Jumah KB, Brakohuapa WO, Idrissu W. Computed tomography features of head injury in Ghanaian children. Niger J Surg Res 2002;4:84-8.
Bahloul M, Chelly H, Gargouri R, Dammak H, Kallel H, Ben Hamida C, et al
. Traumatic head injury in children in South Tunisia epidemiology, clinical manifestations and evolution. 454 cases. Tunis Med 2009;87:28-37.
Agrawal A, Galwankar S, Kapil V, Coronado V, Basavaraju SV, McGuire LC, et al
. Epidemiology and clinical characteristics of traumatic brain injuries in a rural setting in Maharashtra, India. 2007-2009. Int J Crit Illn Inj Sci 2012;2:167-71.
Uduma FU, Mathieu M. An accounting of pathology found on head computed tomography. Glob J Health Sci 2011;3:171-80.
Solagberu BA. Epidemiology and outcome of gunshot injuries in a civilian population in West Africa. Eur J Trauma 2003;29:92-6.
Yinusa W, Ogirima MO. Extremity gunshot injuries in civilian practice: The National Orthopaedic Hospital Igbobi experience. West Afr J Med 2000;19:312-6.
Obajimi MO, Shokunbi MT, Malomo AA, Agunloye AM. Computed tomography (CT) in civilian gunshot head injuries in Ibadan. West Afr J Med 2004;23:58-61.
Onuminya JE, Ohwowhiagbese E. Pattern of civilian gunshot injuries in Irrua, Nigeria. S Afr J Surg 2005;43:170-2.
National Institute for Health and Clinical Excellence. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. London, UK: National Collaborating Centre for Acute Care; 2007.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med 2000;343:100-5.
Miller EC, Holmes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997;15:453-7.
Jeret JS, Mandell M, Anziska B, Lipitz M, Vilceus AP, Ware JA, et al
. Clinical predictors of abnormality disclosed by computed tomography after mild head trauma. Neurosurgery 1993;32:9-15.
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al
. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1391-6.
Mack LR, Chan SB, Silva JC, Hogan TM. The use of head computed tomography in elderly patients sustaining minor head trauma. J Emerg Med 2003;24:157-62.
Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg 2004;139:1066-8.
[Table 1], [Table 2], [Table 3], [Table 4]