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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 95-100

Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre


Division of Neurological Surgery, Department of Surgery, University of Benin Teaching Hospital, P.M.B.1111, Benin City, Edo State, Nigeria

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. David O Udoh
Division of Neurological Surgery, Department of Surgery, University of Benin Teaching Hospital, PMB 1111, Benin City, Edo State 300283
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_14_19

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  Abstract 


Background: The decreased mortality and improved outcomes associated with constantly metamorphosing trauma systems is particularly relevant in traumatic brain injuries (TBI) in which the duration from injury to neurosurgical intervention is an important determinant of outcome. With defective organization of trauma systems comes reduced access to quick and effective neurosurgical care which impact inexorably on outcomes. Using a time honoured scale, we took a critical look at TBI outcomes on the background of time of arrival to specialist neurosurgical care. We sought the association of various demographic factors with outcomes of traumatic brain injury in patients who arrived at our neurosurgical facility at various time intervals following injury.
Patients and Method: A retrospective study of 385 of 483 patients with TBI admitted to neurosurgical care from 2009 to 2011 at our teaching hospital. Data was obtained from a computerized log of all TBI patients, case files and intensive care unit records, and analyzed using STATA software version 12.
Results: Seventy percent (70%) of the patients arrived within 24 hours, especially between 12 to 24 hours i.e. 27.01%. However, only 5.71%, comprising those with mean age 22.59(±12.31) years arrived within the first hour Young patients arrived significantly earlier to specialized care than those ≥40 years. Regardless of injury duration, most patients had severe TBI (p value 0.012). Most, 77.69%, outcomes were favourable (Glasgow outcome scores, GOS, 4 and 5); 16.54% died (GOS 1). The middle strata of GOS 2 and 3 were almost absent. Injury duration did not influence duration of intensive care or overall hospital stay. Mortality was highest after 24hours.
Conclusion: There is a dearth, in this region, of any auditing of the relationship between time of arrival of patients with TBI to specialized care, recovery characteristics (post-neurosurgical care) and eventual outcome using the Glasgow outcome scale.

Keywords: Glasgow outcome scale, mortality, outcome, time interval, traumatic brain injuryDecreased mortality, Glasgow outcome scale, improved outcomes, interval from injury to neurosurgical care, traumatic brain injury


How to cite this article:
Udoh DO, Aghahowa OO, Obeta EC. Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre. Arch Int Surg 2018;8:95-100

How to cite this URL:
Udoh DO, Aghahowa OO, Obeta EC. Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre. Arch Int Surg [serial online] 2018 [cited 2019 Oct 19];8:95-100. Available from: http://www.archintsurg.org/text.asp?2018/8/3/95/268123




  Introduction Top


Traumatic brain injury (TBI) is a significant cause of death in young adults, contributing largely to the burden of morbidity arising from accidents and expenditure on health care, particularly in those living with disabilities.[1],[2] Due to insufficient accurate data, the global incidence of TBI is underestimated resulting from substandard records, poor reporting from countries with inadequately organized trauma system, and notable discrepancies in defining TBI between health care systems of various countries. The other reasons are absence of any data on patients with mild TBI, who never sought medical care and who died before reaching hospital (especially in rural areas).[3] The Glasgow coma scale (GCS) issued at accident scenes and emergency rooms, and Glasgow outcome score (GOS) issued at discharge; are neurological scales widely utilized in the management of patients with TBI. The GCS assesses three criteria including eye-opening response (maximum score of four), verbal response (maximum score of five), and motor response (maximum score of six); summed-up to a total minimum score of three in patients in coma and unresponsive patients and a maximum score of 15 for patients with full alertness.[4],[5]

The GOS assesses the level of disability or recovery after TBI with scores ranging from 1-5; for death, persistent vegetative state, severe disability, moderate disability, and good recovery, respectively.[6]

In low-income countries, trauma systems are less organized; coupled with lean access to neurosurgical care and lack of central electronic database of traumatic brain injuries, and accounts for the dearth of verifiable evidence on the burden of TBI in these regions. In addition, socio-economic inequalities, dissimilarity in cultural practices and disease perception, as well as, slowly developing healthcare systems, contribute to eventual outcome in patients with TBI.[7]

Some descriptive studies from this region have evaluated the common mechanisms of injury and population at risk of TBI, using data from accident and emergency departments of some tertiary hospitals, including pediatric populations, but none documented the clinical characteristics and outcome (using GOS) of patients after neurosurgical intervention.[8],[9],[10],[11],[12],[13],[14],[15],[16]

Hence, this study sought the outcomes in patients with TBI arriving at various time intervals (or injury duration) in a tertiary center with specialist neurosurgical care.


  Patients and Methods Top


This was a retrospective study of patients with traumatic brain injury admitted into our Neurosurgical service from September 2006 till August 2012.

The Neurosurgical unit of University of Benin Teaching Hospital was established in June 2006. The U.B.T.H, Benin City is situated at the confluence of several interstate highways which provide access to the Northern, Southern, Eastern and Western parts of Nigeria. Since inception, it has served as a population of approximately 15 million people in at least eight states.

All patients were admitted through the Accidents and Emergency department arriving from the scene of the accident or through referrals from primary and secondary health centers. Resuscitation, on arrival, was instituted by the emergency unit and trauma team followed by the neurosurgical referral. Admission protocol included detailed neurosurgical evaluation as well as radiological and laboratory investigations. The radiological assessment included cranial computerized tomographic (CT) scan and cervical spine radiographs to determine the type and extent of brain injury and to rule out cervical spine injury, respectively. Relevant laboratory investigations included complete blood counts; serum electrolyte; urea, creatinine, and blood sugar estimation; which were potential indicators for the presence of risk of secondary brain injury.

The patients who had severe traumatic brain injury (i.e. Glasgow coma score (GCS) 3 to 8) and/or acute respiratory insufficiency were admitted into the intensive care unit (ICU). Those who had mild (GCS 13 to 15) and moderate (GCS 9 to 12) TBI were admitted to the neurosurgical ward.

Exclusion criteria

Around 98 patients, for whom complete data could not be obtained, were excluded from the study.

Data were analyzed using STATA software package (version 12). Categorical variables were analyzed using Chi-square test while continuous variables (age, duration of ICU care and length of hospital stay), in mean ± standard deviation, were compared using one-way analysis of variance (ANOVA).


  Results Top


Out of a total of 483 patients with TBI, 385 patients had complete data.

Injury duration

Majority of the patients (69.6%) arrived within 24 hours from the time of injury while others arrived >1 to 7 days (19.74%) and >7 days (10.65%) after injury [Table 1], [Figure 1]. Around 27.01% patients arrived within the time interval of 12 to 24 hours after injury while only 5.71% arrived within the first six hours [Table 1], [Figure 1].
Table 1: Distribution of six time categories of arrival at emergency room by patient characteristics and outcome

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Figure 1: Distribution of patients with traumatic brain injury by time interval to neurosurgical care

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Age of patients

The young patients (22.59 ± 12.31 to 32.46 ± 17.35 years) arrived at the specialist care significantly earlier than the older patients. (P-value 0.0006). Notably, those with a mean age 22.59 (±12.31) years arrived within the first hour of injury while those with a mean age of 40.29 (±21.48) years arrived after 7 days (P-value 0.0006) [Table 1].

Gender

In the study population, there were more males (80.78%) in ratio of 4:1 for all the patients who arrived at various time intervals. There was no statistical significance with respect to gender and duration of injury before arrival. (P-value 0.106) [Table 1].

Etiology

Although 77.02% of injuries were due to road traffic accidents and 11.5% were due to civil violence, there was no significant relationship between etiology and time before arrival at the specialist care [Table 1].

Severity of injury and Glasgow outcome score (GOS)

Irrespective of duration of injury before arrival, most patients (40.67%) had severe TBI (P-value 0.012) while others had mild (35.49%) and moderate (23.83%) TBI [Table 1].

GOS showed that almost all the patients either had favorable outcomes (77.69%) with GOS 4 and 5 or died (16.54%). The middle strata of outcome scores (GOS 2 and 3) were almost absent for all time intervals following injury (P-value < 0.001) [Table 1].

Mortality was highest in patients arriving between 24 hours and one week of injury.

Duration of intensive care and length of hospital stay

The duration of injury before arrival did not significantly influence the duration of intensive care unit (ICU) care and overall period of hospital stay (P-values 0.8834 and 0.0928, respectively) [Table 1].


  Discussion Top


The advantages of expeditious neurosurgical care of TBI are well documented and have influenced the development of practical clinical guidelines in the management of patients with TBI, as well as, the evolution of sturdy trauma systems in more developed countries.[17],[18],[19] Seelig et al.[17] observed that the most relevant predictor of survival was the time to neurosurgical intervention in patients with traumatic acute subdural hematoma, with the outcome being better in patients who had neurosurgical intervention within 4 hours from the time of injury.

Both, crude and adjusted odd ratios revealed that, lower post-resuscitation GCS, presence of post-resuscitation pupil abnormality, hypotension, and increasing age were significant predictors for ICU mortality.[20],[21] No significant difference was found in demographic profile, mechanism of injury, type of injuries or severity, duration of ICU stay and mechanical ventilation among the patients admitted during weekdays, weeknights or weekends.[20] Moreover, this stresses the importance of a specialized neurosurgical intensive care unit (NICU), with adequate staffing and requisite diagnostic and therapeutic modalities.[20]

The presence of a trauma system has been associated with decreased mortality and improved outcomes, by potentially speeding up the transfer of trauma patients to major trauma centers.[[19],[22],[23],[24] This is particularly relevant in patients with a head injury, where time to neurosurgical intervention from the time of significant TBI is important in determining the outcome.[17] North American guidelines recommend a maximum of four hours from the time of injury to neurosurgical attention for patients requiring the evacuation of an intracranial hematoma.[17],[25],[26],[27]

Similarly, Kejriwal and Civil.[19] also showed that patients who were transferred from another hospital arrived well outside the recommended guidelines or took significantly longer than four hours to arrive at the neurosurgical care while patients transported from the scene of injury arrived and underwent surgery within a mean of 3.50 hours. However, there was no difference in mortality rate, length of ICU stay and length of hospital stay between patients admitted directly and patients transferred from other hospitals; mainly because expedite resuscitation and stabilization, urgent computed tomography brain scan, and electronic review by a neurosurgeon and intensivists were made possible.[19] On contrary, in our setting patients are received from facilities where a little resuscitation is possible.

Due to the heterogeneity of patient presentations; practice variations and the potential for secondary brain injury, the importance of early neurosurgical intervention on survival remains controversial, however studies show that the odds for in-hospital death are substantially less with early neurosurgical intervention.[28]

Studies of trauma systems have identified TBI as a frequent cause of death or disability and survival of the brain injured trauma patient increased with trauma system development and timely transfer to a Level 1 trauma center.[28],[29],[30],[31] The deterioration associated with delay in neurosurgical intervention was linked with secondary brain injuries resulting from swelling and compression of brain tissue, hypotension (systolic blood pressure <90 mmHg), and hypoxia (blood oxygen saturation <90%).[32]

In view of these findings, the outcome of patients with TBI in any trauma is highly influenced by early identification, triage and monitoring of patients, and differences in practice variations of neurosurgical interventions. For ensuring best practices, different trauma systems have adopted severity in classification scores to facilitate early triage of patients from the scene of injury to Level 1 trauma centers. In addition, disability at the discharge of patients is also assessed while planning for the return of survival in society.[32]

The guidelines for the management of patients with TBI are largely based upon the ability to improve physiological variables such as intracranial pressure (ICP) or cerebral perfusion pressure (CPP) and upon the known prognostic measure of these variables.[33],[34],[35],[36]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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