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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 67-72

Pattern of computed tomographic findings in patients referred with head injury secondary to road traffic accident in a Nigerian otolarhyngologic center


Department of Radiology, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Submission28-Jan-2020
Date of Acceptance28-Mar-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Tokan S Baduku
Department of Radiology, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_5_20

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  Abstract 


Background: Head injuries are common causes of morbidity and mortality in trauma patients. Computed tomography (CT) is an important imaging modality in the management of patients with a head injury. This study aimed at documenting the pattern of CT findings among patients with a head injury who presented to the Radiology Department of a tertiary hospital which has neither a Neurology nor a Neurosurgical unit.
Patient and Methods: This is a one-year retrospective study carried out on 127 patients seen at the National Ear Care Centre (NECC), a premier Ear Nose and Throat health institution, which serves as a referral center for cities and towns within Nigeria. Radiology request cards, duplicate copy of radiology reports, and soft copy of their CT images were analyzed. All patients with a history of head trauma from other causes were excluded from the study.
Results: A total of 127 patients were recruited from January 2017 to December 2017 and had cranial CT done. Their mean age was 35.5 (range 1–70 yrs) with M: F of 3:1. The most frequently involved age group was 21–30 years, accounting for 26.7%. Referrals from secondary and primary health centers accounted for 22% and 28%, respectively. Thirty-seven (29%) patients had normal brain CT findings. The most common abnormal findings were skull fractures and intracerebral hemorrhage in 63 (26%) and 55 (18.8%) patients, respectively. Less common findings include midline shifts, intracranial pneomocoeles, metallic foreign bodies, ventricular hemorrhages, effacements, and compressions.
Conclusions: The patronage of CT imaging modality by primary and secondary health centers is significant, constituting 50% of the referrals. This suggests that medical personnel in the secondary and primary health centers are maximizing the use of CT as a diagnostic modality. Also, skull fracture still dominates the CT findings.

Keywords: Brain CT scan, head injury CT, head injury, road traffic accident


How to cite this article:
Baduku TS, Tabari AM. Pattern of computed tomographic findings in patients referred with head injury secondary to road traffic accident in a Nigerian otolarhyngologic center. Arch Int Surg 2019;9:67-72

How to cite this URL:
Baduku TS, Tabari AM. Pattern of computed tomographic findings in patients referred with head injury secondary to road traffic accident in a Nigerian otolarhyngologic center. Arch Int Surg [serial online] 2019 [cited 2020 Nov 26];9:67-72. Available from: https://www.archintsurg.org/text.asp?2019/9/3/67/295923




  Introduction Top


Head injury is a major health problem worldwide and is a frequent cause of death and disability.[1],[2] Road traffic accident (RTA) is the most common etiological factor in traumatic brain injury (TBI) cases worldwide.[3] In developing countries, the incidence of TBI from RTA is increasing as traffic increases.[3],[4],[5] This is besides other confounding factors such as industrialization, falls, and ballistic trauma head injuries.[6] The third and fourth decades of life are the commonest age group affected by this event, with a higher frequency in the male gender because they are involved in economic and social movements more than the female counterpart.[3] There have been reports documenting cranial CT findings in patients with head injury secondary to RTA in some other parts of Nigeria.[7],[8] However, none of these covered Kaduna and its environs.

Kaduna town, being the gateway to Abuja the capital city of the most populous country in Africa, experiences high vehicular traffic to and from many northern states of Nigeria. This high vehicular traffic has its attendant effect. The aim of this study was to determine the pattern of intracranial pathologies visible on CT scans in patients with head injuries secondary to RTA.


  Patients and Methods Top


This is a retrospective study carried out over one year from January 1st to December 31st, 2017 at the Radiology Department of the National Ear Care Center, Kaduna, Nigeria. It is a specialized tertiary health institution, which serves as a referral center for ear, nose, and throat related problems, with patients referred from all parts of the country. However, many patients who present to the radiology department of this center for CT services are referred from outside, since there is a paucity of functional modern imaging facilities in most tertiary centers around.

Only head-injured patients resulting from RTA referred to the Radiology Department for cranial CT during this period were included in the study. Their imaging records, as well as their CT reports, were retrieved and evaluated. Head injuries from other causes were not included.

Cranial CT examinations were done using the Toshiba Alexion 32 slice multidetector CT scanners. A multislice protocol with 3–8 mm (5 mm) cuts from the base to the vertex was used. Also, a tube voltage and current range of 120–150 kvp and 250–300 mAs were used for the cranial CT scans. Images were acquired in the axial plane with multiplanar reformatted sagittal and coronal images.

A proforma was used to document the obtained information about the patients. The imaging findings were documented in the proforma. Cranial CT findings documented include scalp injuries (swelling, laceration, subcutaneous emphysema, foreign bodies, and avulsion), intraaxialhemorrhage (intraparenchymal hemorrhage), extraaxialhemorrhage (subdural, epidural, and subarachnoid hemorrhage), cerebral edema, intracavitary hematoma, and skull vault fractures. The study was approved by the hospital ethics clearance committee. All information obtained about the patients was kept confidential. All data were entered and analyzed using the Statistical Package for Social Sciences (SPSS 23, Armonk, NY: IBM Corp). Numerical and graphical descriptors were used to summarize the data. These include mean, standard deviation, minimum, median, and maximum values for continuous variables while frequency and percentage were used to describe categorical variables. Frequency distributions (proportions), graphs, charts, and tables were constructed to present the data appropriately.


  Results Top


Within the one year under review, 127 patients satisfied the criteria for inclusion, with 96 (76%) males and 31 (24%) females (a ratio of 3:1). The age range was 1 to 70 years, with a mean of 28.7 years. The most frequently involved age group was 21 to 30, which made up 34 (26.7%) of the patients [Figure 1] was followed by those within the 4th decade of life who constituted 22% of the population. Children under 10 years constituted 16.5% of the population. The age group that was least affected are those within the seventh decade of life who made up only 3%. Males were more involved across all age groups.
Figure 1: Age distribution of patients

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The pattern of referral showed that 63 (50%) were referred from tertiary medical institutions, while 28% and 22% were referred from secondary and primary medical centers, respectively. The most common indications for CT scan were loss of consciousness (LOC), which was seen in 28 (22%) patients, followed by 18 (14.2%) patients who presented with headache [Figure 2]. Other indications were facial injuries, skull lacerations, peri-orbital swelling, red eye, and vomiting.
Figure 2: Indications for CT scan

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The result also showed that 37 (29%) of our patients had normal brain CT findings whilst 71% had varying forms of abnormal imaging findings. However, most of the abnormal slices had multiple findings. The most common abnormal finding seen was skull fracture, which constituted 21.6% [Figure 3]. The fractures were often linear and undepressed [Figure 4]. This was followed by intracerebral hemorrhage, which constituted 18.8% [Figure 3]. Intraaxial hemorrhages including multiple intracerebral hemorrhages [Figure 5] and parieto-temporal subdural hemorrhages [Figure 6] and [Figure 7] constitute 12.8%. Other abnormal findings such as ventricular compression, aerocele, cerebral, edema, metallic intracerebral foreign bodies, and ophthalmic globular rupture made up 12.4% while extracranial soft tissue swelling was seen in 4.4%.
Figure 3: The frequency of CT findings in the patients under review

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Figure 4: Showing a linear paramedian skull fracture in a 3D radiograph (see arrow)

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Figure 5: Axial slice shows multiple intracerebral hemorrhages in both frontal lobes, with surrounding edema

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  Discussion Top


TBI is increasing in both developing and developed countries.[9],[10] It is estimated that about 10 million people are affected annually by head injury worldwide.[11] The 2010 report of the Centre for Disease Control and Prevention, and the National Centre for Injury Prevention and Control, USA, documented that an estimated 1.7 million people receive medical treatment for head trauma every year in the United States alone, with high morbidity and mortality.[12] Most reports show that the leading cause of head injury is road traffic accidents.[7],[13],[14],[15],[16],[17],[18] CT scanning has undoubtedly become the mainstay in the diagnostic work-up of such patients.[19] Data of RTA in developing countries is relatively scarce, and thus the need to undertake more studies to establish the patterns of head CT Scan findings in head injuries.

Our findings show that males are predominantly involved in all strata of patients. This is in agreement with the majority of countries[13],[14],[15],[16],[17],[18] and 2016 World Health Organization (WHO) report on Kenya, an African country.[20] The most frequently involved age group was the third decade. This also agrees with the findings by Tagliaferre et al. in Europe,[13] Tomar et al. in India,[14] Ghebrehiwet et al. in Erithrea,[15] Emejulu et al.,[16] and Itanyi et al. in other parts of Nigeria,[17] but is contrary to the findings of Mustapha et al.[18] in Maiduguri Nigeria who found that the most frequently involved age group was those in the fourth decade of life.

In this study, 29% revealed normal CT scans while 71% had pathological findings. This agrees with the findings of Itanyi et al.[17] and Mustapha et al.[18] but disagrees with those of Onwuchekwa et al.,[21] which showed only 19% of the patients with normal CT scan findings. Also, in this study, head trauma secondary to RTA has been documented to be more prevalent in the male gender in a ratio of 3:1. This is expected, as this has been the trend in both the developed and the developing world.[3],[4],[5],[6],[7],[8] Skull fractures are the most frequently encountered abnormal finding in this study, constituting 21.6% of all forms of CT features. These range from depressed, stellate, hair-line linear to comminuted fractures. This also agrees with other findings[7],[8],[9],[18] and the WHO report on Kenya.[10] The least CT finding in our study is intraventricular hemorrhage. This was seen in only 1% of the findings. Other observed minor abnormalities such as compressed ventricles, metallic foreign bodies, aeroceles and globular rupture were also seen. These findings constituted 12.4% of the total findings. These findings are consistent with other reports around the world.[7],[9],[12],[20]

The presence of intraventricular hemorrhage, effaced basal cisterns, diffuse axonal injury (cerebral edema), midline shift, and cerebral herniation were significantly associated with unfavorable outcomes as reported in the previous report by Khadka et al. and Ahmed et al.[19],[22] It is, therefore, necessary to get a CT scan result to the surgeon early enough to avert the irreversible outcomes associated with these findings. A good management outcome of head trauma patients rests on an accurate and prompt radiological diagnosis.[7] After the first use of CT in 1978, the conventional use of X-rays for skull imaging, angiography, and surgical intervention in diagnosing head injuries drastically reduced.[23] Presently, CT scanning is one of the primary modalities of choice in the diagnostic workup of patients with head trauma, which helps in the initial assessment, treatment planning, follow-up, and long-term management of patients.[5],[11],[24]

The WHO has projected that by the year 2020, head trauma from RTA alone will be the 3rd leading burden of diseases in developing countries,[1],[2] therefore, CT, which is an excellent guide to the care of the head-injured patient should become a readily available diagnostic tool in these countries.[25] Unfortunately, patient management is still not good in most developing countries, as the situation is further worsened by factors like poverty, lack of medical insurance cover, availability, and affordability of investigative and treatment modalities.[2],[11] Despite the fact that developing countries clearly have the highest rate of RTAs,[1],[2] governments in these countries are not committed to the healthcare of their citizens.[6],[7],[8],[9],[10] There are few CT scan centers scattered around our country, and they are not easily accessible to many of the referring doctors.[26] In areas where they are available, they are wide apart and therefore not easily accessible for emergencies.[27] This results in their limited utilization in the management of head trauma in Nigeria.

Where CT machines are available, they are mainly located in the major towns.[28] A limitation of this study is that it was hospital-based, hence only patients who survived and eventually presented for CT evaluation were included in the study. This may have led to an underestimation of the impact of head injury on the society thereby limiting extrapolation of the result to the wider society. The government should enhance the rule of law and advocate road safety campaigns to reduce RTAs. These include the enforcement of the use of helmets for motorcycles and the use of seat belts for motorists. The government should also improve the quality of our roads, which include resurfacing of sections of the road with potholes, widen many roads, increase the road networks, and improve the road signs. It is expected that middle-level health facilities should be equipped with appropriate medical diagnostic and treatment facilities, including CT scans to be able to detect and manage head injuries early, thereby reducing the morbidity and mortalities associated with delayed diagnoses. It is also suggested that at least every senatorial district of Nigeria should have a functional CT imaging facility.


  Conclusions Top


CT plays a very significant role in the management of head injuries, as demonstrated in this study, by making such diagnoses that guided eventual patient management. Regular use of CT in moderate to severe cases of head injury is advocated. RTA remains the leading cause of TBI, with an alarming increase due to the increase in vehicular traffic. It is also discovered that the referral rate by the primary and secondary health centers is surprisingly high.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mustapha Z, Ahidjo A, Minoza K, Abba AA, Usman AU, Namba SI, et al. CT findings in patients with head injury at a teaching hospital in Nigeria. Kanem J Med Sci 2016;10:28-35.  Back to cited text no. 18
    
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