- Department of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria
- Neurosurgery Unit, University of Nigeria Teaching Hospital, Enugu, Nigeria
Samuel C. Ohaegbulam
Department of Neurosurgery, Memfys Hospital for Neurosurgery, Enugu, Nigeria
DOI:10.4103/2152-7806.91137Copyright: © 2011 Ohaegbulam SC. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: 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 26-Dec-2011;2:182
How to cite this URL: 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 26-Dec-2011;2:182. Available from: http://sni.wpengine.com/surgicalint_articles/cranial-computed-tomography-scan-findings-in-head-trauma-patients-in-enugu-nigeria/
Background:The choice of radiological investigations in head trauma in Africa is influenced by factors such as cost. Some patients who require computed tomography (CT) scan elsewhere are either managed blindly or do not present for it at the appropriate time. This paper evaluates the CT scan findings as they are obtained in cases of head trauma in a region of Nigeria.
Methods:Prospectively recorded data of all head injury patients who presented for CT scan between January 2009 and April 2010 at Memfys Hospital for Neurosurgery (MHN), Enugu, Nigeria, were analyzed. Mobile CereTom 8-Slice CT was used in all cases. New and follow-up cases were included.
Results:There were 204 CT scans for head trauma (171 new, 33 follow-up), accounting for about 34% of all head CT scans performed with this unit. The male to female ratio was 3.5:1. About 33.9% of the patients were in the third and fourth decades of life. In 19.9% cases, CT was unremarkable, while 80.1% cases had abnormal CT findings. The CT diagnosis was not in keeping with the indication of head trauma in 7%, and 13% had more than one finding. The most common CT findings were: subdural hematoma 30%, cerebral contusions and edema 30.7%, skull fractures 23.4% and extradural hematoma 8.0%. About 64% of the CT findings required surgical interventions. The overall mortality was 11.1%, but amongst the 137 patients who had abnormal CT findings, it was 13.9%.
Conclusion:The high yield and diversity of CT scan findings in head trauma patients support the indication for the appropriate use of CT in diagnosis and management of head trauma even in developing countries.
Keywords: CT scan, geographical neurosurgery, head injury, mobile CereTom CT
Head injury is a major health problem worldwide. In developing countries, the management is further worsened by factors like poverty, lack of medical insurance cover, availability and affordability of investigative and treatment modalities. The hospital where this study was carried out is located in Enugu with a population of about 723,000 (2006 National Census).[
A compounding factor for scarce resource allocation is that the young and the low income earners are more likely to engage in occupational and social risks that predispose to head injury.[
The early detection of extra-axial hematomas made possible by CT results in early surgical intervention with marked improvement in morbidity and mortality in head trauma patients. A previous study in Nigeria had observed that the lack of CT scan facilities in a center contributed a great deal to a high mortality rate of 19.8% in head trauma.[
In this local environment, the prevalence of head injuries had consistently risen over the decades.[
Various factors are responsible for this failure. There are few CT scan centers and they are not easily accessible to many of the referring doctors. Most of the doctors in Nigeria are trained in centers without CT scan facilities, and therefore lack adequate knowledge about the value of CT scanning in the management of head trauma. Some doctors are unwilling to refer their patients to other colleagues for fear of losing the patients. There is also the false impression that because CT scan is expensive, it is an avoidable financial burden to poor families. The pitiable transport facilities and unavailability of ambulance services make the transfer of ill patients to other hospitals particularly challenging.
Against this socioeconomic background, the aim of this study was to evaluate CT scan findings in head injury patients in Enugu, Nigeria.
MATERIALS AND METHODS
This is an analysis of prospectively recorded data of all head injury patients who presented for CT scanning between January 2009 and April 2010 at MHN. The initial clinical examination was performed by a neurosurgical resident. The Glasgow Coma Score (GCS) used for the analysis was recorded by a senior neurosurgical resident after resuscitation and stabilization of the patient. CT scan was recommended for all patients with moderate and severe head injury (GCS 3–12). Patients who were graded GCS 13–15 were recommended for CT scan if there was clinical suspicion of intracranial complications such as focal neurological deficit, seizures and skull fractures or if the patients were intoxicated. Most patients seen at MHN had been evaluated in other hospitals before referral.
CT scan was performed within 1 hour of arrival to the facility, but generally patients presented from 3 hours to 40 days post trauma. All scans were performed with 8-slice mobile CT scanner (CereTom CT by NeuroLogica Corporation, Danvers, MA, USA). The protocol used contiguous axial 5-mm sections without contrast from about the level of C3 vertebra to the vertex. Without further radiation given to the patient, the software was used to reformat the scan in thinner slices of 2.5 mm. The images were then viewed in brain and bone windows with multiplanar reconstructions (MPR) in coronal and sagittal planes and reported by a Consultant Radiologist as well as by a Neurosurgeon. The findings were carefully recorded. Additional information documented included age, gender, time of injury, cause of injury, clinical classification of injury into mild, moderate and severe, GCS, CT findings, source of referral and whether first or follow-up CT scan.
Follow-up CT was not routinely performed, but when clinically indicated, was done only for patients who could afford the additional cost, between days 4 and 7. Urgent follow-up CT scan was done whenever unexplained clinical or neurological deterioration occurred. MHN has CT angiography (CTA), magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) facilities and these were subsequently used whenever clinically indicated, provided the additional cost was acceptable to the family of the patient. The treatment and outcome were included in this study. Glasgow Outcome Scale (GOS) was used to assess clinical outcome at the time of discharge or death and at 1 month from injury. The GOS was obtained by a senior neurosurgical resident.
A total of 603 cranial CT scans were performed in the period under investigation and 204 (33.8%) including 33 follow-up cases were done for trauma. The male to female ratio was 3.5:1. In this study, about 33.9% of the patients were in the third and fourth decades of life [
In this series, 19.9% of patients had a normal CT finding while 80.1% had abnormal CT findings. About 7% had findings not in keeping with traumatic lesions and 3.5% were found to have suspiciously atypical hemorrhage, which was subsequently confirmed to be a preceding aneurismal hemorrhage or non-traumatic cerebrovascular accident. About 13% had more than one finding in their CT scan, but 4% yielded results related to trauma.
The most common CT findings due to head injury were: cerebral contusions and edema in 30.7%, subdural hematoma in 27%, skull fractures in 23.4% and extradural hematoma in 8.0% [
In this study, only 33 patients had a follow-up CT scan and 6 of them were satisfactory. However, the rest had the following findings: intracerebral hemorrhage (ICH) in 3 patients, re-bleeding in 4 patients, new complications like edema, pneumocephalus or hydrocephalus in 7 patients, and residual hematoma in 13 patients.
Head injury is a major health problem and a frequent cause of death and disability. In developing countries, the incidence of traumatic brain injury is increasing as traffic increases, besides other confounding factors such as industrialization, falls and ballistic trauma.[
The majority of our patients were found to be in the third, fourth and second decades of life. This age group is the most active and productive group of our society and are more likely to be exposed to both occupational and social risks. The male:female ratio in our study was 3.5:1. This demographic pattern is similar to other data from our region.[
The mobile CT scanner used in this study has been shown to be easy to use, safe and provides adequate radiological quality for diagnosis.[
In this study, 80.1% had a pathological CT scan finding while 19.9% revealed a “normal” CT scan finding. The subgroup of patients with apparently normal CT scan finding and clinical evidence of severe head trauma often has diffuse axonal injury. This is frequently not easily diagnosed with CT scan.[
In a recent epidemiological study in Germany, the time elapsing between the accident and initial hospital assessment was less than 1 hour in 63%, and about 19.3% of patients received CT.[
In developed countries, a CT scan is even recommended for patients with mild head injury because one in five patients will have an acute lesion detectable by CT scanning.[
In this study, 7% of patients had a diagnosis that was not in keeping with head trauma. About 3.5% of the patients referred to this center as head injury were found to have atypical features and subsequent CTA confirmed that they have had a preceding ruptured intracranial arterial aneurysm or non-traumatic cerebrovascular accident. In these cases, the ictus preceded the accident and the head injury was spurious. Obviously, the management of such conditions differs from that of head injury. This finding buttresses the importance of early CT scan in the planning of treatment for suspected head injury patients.
This study reveals that 13% of patients had more than one finding on CT. These findings may all be related to trauma as was the case for the 4% with a combination of intracerebral hematoma, contusion and acute subdural hematoma. In others, traumatic lesions occur in association with a potentially primary event such as cerebrovascular accidents and it becomes difficult to determine the primary pathology. A high index of suspicion, a good history and follow-up imaging with MRI if possible will often resolve this.
The early detection of extra-axial hematomas, as made possible by CT scan, results in early surgical intervention with marked improvement in morbidity and mortality in head trauma patients.[
CSH (27%) was the second most common abnormal finding in this study and contributed to the high rate of surgical intervention (63.5%) in the series. This is another pointer to late presentation for CT scanning. CSH is more common in the older age group and often follows minor head trauma. These patients will benefit from early diagnosis and prompt evacuation of any significant accumulation before neurologic and metabolic consequences set in. This was not the case in this study and the five deaths from CSH as well as the two deaths from epidural hematoma may have been prevented had the patients presented earlier for CT.
There is very limited utilization of CT scanning in the management of head trauma in Nigeria. The number of CT scan centers is small; they are widely apart and therefore not easily accessible for emergencies. The cost of installation and running a CT scan service is high. For prospective investors in CT scanning facilities as a business, bank loans are difficult to secure and remain unattractive because of very high interest rates that exceed 20% per year. These factors contribute to the high cost of obtaining a CT scan in Nigeria. Additionally, most doctors are trained in centers without CT facilities and are therefore not well informed about the utility of CT. Ignorance about CT technology in the setting of head injury is widespread in Nigeria and public awareness campaigns are slowly developing. There is also the tendency for some private medical practitioners to selfishly deny their patients the benefit of better care in a superior medical facility. The Nigerian Medical Council is confronting these challenges and Continuing Medical Education Certification Programs are being introduced and hopefully will make a difference. International Organizations could help by donating CT scanners to hospitals so as to increase the CT availability. The private sector and non-governmental organizations (NGOs) have an important role to play by supplementing government efforts as exemplified by MHN. Private/public sector initiatives are now being encouraged by the Nigerian government and have already materialized in some hospitals across the country. Furthermore, NGOs could assist indigent patients to pay for their CT and subsequent treatment. These measures might increase the volume of CT scans performed, and therefore contribute to a reduction in the cost of scanning.
Unfortunately, these measures would also increase the burden of providing neurosurgical treatment to the increased number of patients with positive CT scan findings. Patients who cannot afford the cost of CT scan obviously cannot afford the cost of the follow-up treatment, especially if surgery is indicated. From our experience, families and friends, when confronted with life-threatening CT scan findings, are more motivated to give financial assistance. Indeed, it is easier to convince families to pay for treatment than to pay for CT scan. Moreover, MHN in such situations would provide the emergency care and then appeal to the families to pay later. Most of them would ultimately honor their obligations, especially in cases with a satisfactory outcome.
The findings of cerebral contusions and edema in 30.7%, skull fractures in 16.8% and extradural hematoma in 8.0% are consistent with those from other studies.[
The high yield and diversity of CT scan findings in head trauma patients justifies the appropriate use of CT in diagnosis and management of suspected head trauma patients even in a developing country such as Nigeria. Although cost considerations are important, the patient should be given the chance of an appropriate work up early rather than later and this should not be prevented by the assumption that CT scanning is unaffordable. In our experience, when given the choice, patients and their families will likely opt for life and a good outcome. To achieve this, the patient may get financial assistance from the traditional extended family, friends, government agencies, churches and charitable organizations for the CT and any subsequent treatment. Ultimately, the answer to the cost problem may be in the universal health insurance scheme that is currently evolving over many years.
More research is needed to determine the causes of delayed referrals of head-injured patients for work up via CT, the consequences of this delay and what can be done to shorten the delay, to ultimately yield better therapeutic outcomes.
The authors gratefully acknowledge Neshmet Ohaegbulam, Ashraf Adel Fouad and Chidi Mbah for their technical help in the CT service.
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