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Habte YW, Shao B, Pajer HB, Ma KL, Abicho TB, Feleke Y, Bizuneh YA, Laeke T, Tirsit A, Spader HS. Profile of Patients Receiving Computed Tomography Scans for Mild Traumatic Brain Injury in a Tertiary Care Hospital in Ethiopia. World Neurosurg 2024:S1878-8750(24)00591-6. [PMID: 38608809 DOI: 10.1016/j.wneu.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading contributor to emergency department (ED) mortalities in Ethiopia. Mild TBI patients comprise half of all TBI patients presenting for care in Ethiopia and have a high potential for recovery. As such, context-specific care-improving strategies may be highly impactful for this group of patients. OBJECTIVE This study examines the presentation and disposition of mTBI patients who received a computed tomography scan of the head upon arrival at the largest teaching hospital in Ethiopia. METHODS A retrospective cohort study was conducted from 2018 to2021 including patients >13 years old with a head injury and a Glasgow Coma Score of 13-15 who obtained a computed tomography scan of the head. Variables were collected from medical charts and single and multivariable analyses assessed outcomes of clinically important TBI (ciTBI) requiring a neurosurgical procedure or admission. RESULTS A total of 193 patients were included. They were predominantly young men with no comorbidities, injured in road traffic accidents or by assault, had stable vital signs and were treated in lower-acuity ED areas. A minority demonstrated focal deficits, and 29.5% of patients had ciTBI. Most patients were discharged from the ED, but 13% were taken for operative neurosurgical procedures and 10.4% were admitted to the neurosurgery ward for observation. ED stays ranged from 8 hours to 10 days, as patients waited for CT availability, neurosurgical decision, or transportation. Female sex was independently protective of ciTBI. Self-referral status was independently protective against operative intervention. Female sex and self-referral status were independently protective of a disposition of admission and/or going to the operating room. CONCLUSIONS This study characterizes the mTBI subgroup of head injury patients in Ethiopia's busiest ED: predominantly healthy young men with low-acuity presentations and only a fraction with abnormal neurological examinations. Nonetheless, about one-third had ciTBI and a minority were taken for neurosurgical procedures or admission, with female sex and self-referral identified as protective factors. Meanwhile, many patients stayed in the ED for days due to social or other nonmedical reasons. As TBI care in Ethiopia continues to improve, optimizing care for the mTBI subgroup is tantamount given their high recovery potential. This care will benefit from efficiently identifying those who need intervention or hospital level of care, and discharging those who do not.
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Affiliation(s)
| | - Belinda Shao
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
| | - Hengameh B Pajer
- Department of Emergency Medicine, HCA Houston Kingwood, Houston, Texas, USA
| | - Kevin L Ma
- Department of Neurosurgery, Brown University, Providence, Rhode Island, USA
| | | | | | | | - Tsegazeab Laeke
- Addis Ababa University, College of Health Sciences, Black Lion Specialized Hospital, Addis Ababa, Ethiopia
| | - Abenezer Tirsit
- Addis Ababa University, College of Health Sciences, Black Lion Specialized Hospital, Addis Ababa, Ethiopia
| | - Heather S Spader
- Department of Neurosurgery, University of Virginia, Charlottesville Virginia, USA.
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Teshita G, Wondafrash M, G/Egziabher B, Getachew B, Bergene E. Clinical characteristics and functional outcome of surgically treated adult head trauma patients with acute subdural hematoma: Ethiopian tertiary hospitals experience. World Neurosurg X 2024; 21:100264. [PMID: 38260115 PMCID: PMC10801322 DOI: 10.1016/j.wnsx.2023.100264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/29/2023] [Accepted: 11/28/2023] [Indexed: 01/24/2024] Open
Abstract
Background Acute subdural hematoma (ASDH) is one of the most common and devastating lesions in traumatic brain injury with a mortality rate upto 60 % especially in low-income countries. The present study aimed to determine the clinical characteristics and functional outcomes and the associated factors of surgically treated head trauma patients with ASDH. Methods Between January 2018 and January 2021 we identified 140 head trauma patients with ASDH who underwent surgical evacuation in three tertiary hospitals. Epidemiological data were collected; the six-month functional outcome was studied using an extended Glasgow outcome score (EGOS) and associated factors were also studied. Univariate analysis was performed at first, and variables with a P-value of <0.05 were entered into the multivariable logistic regression model. Results Male predominance was seen accounting for 87 % and assault was the most common mechanism of injury (35.7 %). Sixty-five (56.5 %) of patients achieved favorable functional recovery (EGOS of 5-8) and 50 (43.5 %) of patients had unfavorable recovery (EGOS of 1-4) after 6 months of follow-up. In multivariate logistic regression models, GCS <5, Pupillary abnormality, hypotension, oxygen saturation <90 at presentation, and hospital-acquired pneumonia were the independent factors associated with unfavorable functional outcomes. Conclusion In our setup, most of the patients are male from assault injuries. There is still a high rate of unfavorable outcomes in patients with acute subdural hematoma. GCS <5, pupillary abnormality, hypotension and desaturation at presentation, and postoperative hospital-acquired infection are predictors for unfavorable functional outcomes.
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Affiliation(s)
- Gemechu Teshita
- Department of Neurosurgery, Minilik Referral Hospital, Addis Ababa, Ethiopia
| | - Mulualem Wondafrash
- Department of Neurosurgery, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Biniam G/Egziabher
- Department of Neurosurgery, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Biruk Getachew
- Department of Neurosurgery, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Eyerusalem Bergene
- Department of Neurosurgery, Saint Paul's Millennium Medical College, Addis Ababa, Ethiopia
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Shakir M, Altaf A, Irshad HA, Hussain N, Pirzada S, Tariq M, Trillo-Ordonez Y, Enam SA. Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review. World Neurosurg 2023; 180:169-193.e3. [PMID: 37689356 DOI: 10.1016/j.wneu.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs. METHODS A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively. RESULTS A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified. CONCLUSIONS Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.
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Affiliation(s)
- Muhammad Shakir
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.
| | - Ahmed Altaf
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Nowal Hussain
- Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Sonia Pirzada
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Mahnoor Tariq
- Department of Community Health Sciences, Aga Khan University Hospital, Karachi, Pakistan
| | - Yesel Trillo-Ordonez
- Duke University Division of Global Neurosurgery and Neurology, Durham, North Carolina, USA
| | - Syed Ather Enam
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Demlie TA, Alemu MT, Messelu MA, Wagnew F, Mekonen EG. Incidence and predictors of mortality among traumatic brain injury patients admitted to Amhara region Comprehensive Specialized Hospitals, northwest Ethiopia, 2022. BMC Emerg Med 2023; 23:55. [PMID: 37226098 DOI: 10.1186/s12873-023-00823-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Traumatic brain injury is a substantial cause of mortality and morbidity with a higher burden in low and middle-income countries due to healthcare systems that are unable to deliver effectively the acute and long-term care the patients require. Besides its burden, there is little information on traumatic brain injury-related mortality in Ethiopia, especially in the region. Therefore, this study aimed to assess the incidence and predictors of mortality among traumatic brain injury patients admitted to comprehensive specialized hospitals in the Amhara region, northwest Ethiopia, 2022. METHODS An institution-based retrospective follow-up study was conducted among 544 traumatic brain injury patients admitted from January 1, 2021, to December 31, 2021. A simple random sampling method was used. Data were extracted using a pre-tested and structured data abstraction sheet. Data were entered, coded, and cleaned into EPi-info version 7.2.0.1 software and exported to STATA version 14.1 for analysis. The Weibull regression model was fitted to determine the association between time to death and covariates. Variables with a P-value < 0.05 were declared statistically significant. RESULTS The overall incidence of mortality among traumatic brain injury patients was 1.23 per 100 person-day observation [95% (CI: 1.0, 1.5)] with a median survival time of 106 (95% CI: 60, 121) days. Age [AHR: 1.08 (95% CI; 1.06, 1.1)], severe traumatic brain injury [AHR: 10 (95% CI; 3.55, 28.2)], moderate traumatic brain injury [AHR: 9.2 (95% CI 2.97, 29)], hypotension [AHR: 6.9 (95% CI; 2.8, 17.1)], coagulopathy [AHR: 2.55 (95% CI: 1.27, 5.1)], hyperthermia [AHR: 2.79 (95% CI; 1.4, 5.5)], and hyperglycemia [AHR: 2.28 (95% CI; 1.13, 4.6)] were positively associated with mortality while undergoing neurosurgery were negatively associated with mortality [AHR: 0.47 (95% CI; 0.27-0 0.82)]. CONCLUSION The overall incidence of mortality was found to be high. Age, severe and moderate traumatic brain injury, hypotension at admission, coagulopathy, presence of associated aspiration pneumonia, undergoing a neurosurgical procedure, episode of hyperthermia, and hyperglycemia during hospitalization were the independent predictors of time to death. Therefore, interventions to reduce mortality should focus on the prevention of primary injury and secondary brain injury.
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Affiliation(s)
- Tiruye Azene Demlie
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mahlet Temesgen Alemu
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mengistu Abebe Messelu
- Department of Nursing, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Fasil Wagnew
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- National Center for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Enyew Getaneh Mekonen
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Tegegne NG, Fentie DY, Tegegne BA, Admassie BM. Incidence and Predictors of Mortality Among Patients with Traumatic Brain Injury at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. Patient Relat Outcome Meas 2023; 14:73-85. [PMID: 37051137 PMCID: PMC10083132 DOI: 10.2147/prom.s399603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
Background Traumatic brain injury is a major list of health and socioeconomic problems especially in low- and middle-income countries which influences productive age groups. Differences in patient characteristics, socioeconomic status, intensive care unit admission thresholds, health-care systems, and the availability of varying numbers of intensive care unit (ICU) beds among hospitals had shown to be the causes for the variation on the incidence in mortality following traumatic brain injury across different continents. The aim of this study was to assess the incidence and predictors of mortality among patients with traumatic brain injury at University of Gondar Comprehensive Specialized Hospital. Methods A retrospective follow-up study was conducted based on chart review and selected patient charts admitted from January, 2017 to January, 2022. Participants in the study were chosen using a simple random sample procedure that was computer generated. Data was entered with epi-data version 4.6 and analyzed using SPSS version 26. Both bivariate and multivariate logistic regression analyses were used, and in multivariate logistic regression analysis, P-value <0.05 with 95% CI was considered statistically significant. Results The magnitude of mortality was 28.8%. Most of the injuries were caused by assault followed by road traffic accident (RTA). About 30% of the subjects presented with severe head injuries and epidural hematoma (EDH) followed by skull fracture were the most common diagnoses on admission. The independent predictors of mortality were male sex (AOR: 6.12, CI: 1.82, 20.5), severe class injury with Glasco coma scale (GCS <9) (AOR: 5.96, CI: 2.07, 17.12), intraoperative hypoxia episode (AOR: 10.5, CI: 2.6-42.1), hyperthermia (AOR: 25, CI: 5.54, 115.16), lack of pre-hospital care (AOR: 2.64 CI: 1.6-4.2), abnormal appearance on both eyes (AOR: 13.4, CI: 5.1-34.6), in-hospital hypoxia episode and having extra-cranial concomitant injury were positively associated with mortality, while on admission, systolic blood pressure (SBP) of 100-149 (AOR: 0.086, CI: 0.016-0.46) was negatively associated with mortality. Conclusion The overall mortality rate was considerably high. As a result, traumatic brain injury management should be focused on modifiable factors that increase patient mortality, such as on-admission hypotension, a lack of pre-hospital care, post-operative complications, an intraoperative hypoxia episode, and hyperthermia.
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Affiliation(s)
- Nega Getachew Tegegne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Yilkal Fentie
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Correspondence: Biresaw Ayen Tegegne, Tel +251-9-27-60-14-27, Email
| | - Belete Muluadam Admassie
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Allen BC, Cummer E, Sarma AK. Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature. J Neurotrauma 2023; 40:602-619. [PMID: 36424896 DOI: 10.1089/neu.2022.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.
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Affiliation(s)
- Beddome C Allen
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elaina Cummer
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anand K Sarma
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Neurology, Division of Neurocritical Care, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
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Laeke T, Kalleklev L, Tirsit A, Moen BE, Lund-Johansen M, Sundstrøm T. Surgical treatment and outcome of chronic subdural hematoma: a comparative study between Ethiopia and Norway. Acta Neurochir (Wien) 2023; 165:49-59. [PMID: 36495322 DOI: 10.1007/s00701-022-05435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Here, we studied differences in demographics, treatment, and outcome for CSDH patients in low-income (Ethiopia) and high-income (Norway) countries and assessed potential outcome determinants. METHODS We included patients from Addis Ababa University Hospitals (AAUH) and Haukeland University Hospital (HUH) who had surgery for CSDH (2013-2017). Patients were included prospectively in Ethiopia and retrospectively in Norway. RESULTS We enrolled 314 patients from AAUH and 284 patients from HUH, with a median age of 60 and 75 years, respectively. Trauma history was more common in AAUH (72%) than in HUH patients (64.1%). More patients at HUH (45.1%) used anticoagulants/antiplatelets than at AAUH (3.2%). Comorbidities were more frequent in HUH (77.5%) than in AAUH patients (30.3%). Burr hole craniostomy under local anesthesia and postoperative drainage was the standard treatment in both countries. Postoperative CT scanning was more common at HUH (99.3%) than at AAUH (5.2%). Reoperations were more frequent at HUH (10.9%) than at AAUH (6.1%), and in both countries, mostly due to hematoma recurrence. Medical complications were more common at HUH (6.7%) than at AAUH (1.3%). The 1-year mortality rate at HUH was 7% and at AAUH 3.5%. At the end of follow-up (> 3 years), the Glasgow Outcome Scale Extended (GOSE) score was 8 in 82.9% of AAUH and 46.8% of HUH patients. CONCLUSION The surgical treatment was similar at AAUH and HUH. The poorer outcome in Norway could largely be explained by age, comorbidity, medication, and complication rates.
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Affiliation(s)
- Tsegazeab Laeke
- Neurosurgery Division, Surgery Department, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Line Kalleklev
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Abenezer Tirsit
- Neurosurgery Division, Surgery Department, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Bente E Moen
- Center for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Terje Sundstrøm
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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