Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 19  |  Issue : 1  |  Page : 72-76

Computed tomographic findings in pedestrians with head trauma in a Nigerian teaching hospital


Department of Radiology, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria

Date of Web Publication7-Jun-2017

Correspondence Address:
Festus O Ehigiamusoe
Department of Radiology, University of Benin Teaching Hospital, P.M.B. 1111, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomt.jomt_52_16

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  Abstract 


Background: To describe the computed tomographic findings in pedestrians, who presented with head trauma at the University of Benin Teaching Hospital (UBTH).
Materials and Methods: This was a descriptive, retrospective study conducted at the UBTH from January 2011 to January 2014 involving 103 pedestrians with suspected intracranial injury following head trauma, who presented for computed tomography (CT). The CT findings, Glasgow coma scale (GCS) score as well as the demographic details of the patients were analysed using the Statistical Package for the Social Sciences version 16 software.
Results: A total of 103 patients were reviewed, which comprised 69 males (67.0%) and 34 females (33.0%) with a male-to-female ratio of 2:1. Patients 10 years and below had the highest incidence, whereas the least incidence was recorded in those above 80 years. The mean age was 30.59 ± 2.07 years and 38.55 ± 2.93 years for males and females, respectively. Motor car collision (60.2%) was the most common mode of injury. The findings on computed tomographic scan were intracerebral haemorrhage 23.8%, cerebral contusion 18.0%, subdural haematoma 10.5%, subarachnoid haematoma 7.6% and extradural haematoma 2.9%. Others were calvarial fracture 15.1%, facial fractures 6.4% and base of skull fracture 4.7%. Only one case of diffuse axonal injury was reported. On the basis of the admission GCS, 33 patients had severe head injury, 30 patients had moderate head injury while mild head injury was observed in 15 patients. Normal GCS was observed in 25 patients.
Conclusion: CT is a useful tool in the management of pedestrians with head trauma in the acute setting.

Keywords: Computed tomography, fracture, haemorrhage, head trauma, pedestrian


How to cite this article:
Ogbeide E, Ehigiamusoe FO. Computed tomographic findings in pedestrians with head trauma in a Nigerian teaching hospital. J Med Trop 2017;19:72-6

How to cite this URL:
Ogbeide E, Ehigiamusoe FO. Computed tomographic findings in pedestrians with head trauma in a Nigerian teaching hospital. J Med Trop [serial online] 2017 [cited 2020 Aug 14];19:72-6. Available from: http://www.jmedtropics.org/text.asp?2017/19/1/72/207599




  Introduction Top


The burden of road traffic accident (RTA) is not only medical but also social. The economic toll on patients, relatives and the nation is unquantifiable. Injuries from RTA are ranked ninth among the global causes of disability. About 80% of mortality from RTA globally are accounted for by the developing countries, of which Nigeria is one.[1] It is also noteworthy that most victims of RTA from most parts of the world are pedestrians, cyclists and bus passengers.[2],[3]

Pruthi et al.[4] opined that pedestrians accounted for 30–40% of all traumatic brain injuries in a study conducted in Bangalore, India. Unlike passengers in vehicles, pedestrians are directly exposed to the variables of accidents; thus, there is a higher likelihood of head injury in such patients.

Historically, the imaging of head-injured patients relied on skull radiographs.[5] However, the advent of computed tomography (CT) transformed imaging and by extension, the management of patients with head injury. CT scan helps in rapid and accurate imaging of trauma patients to diagnose surgically amenable lesions for prompt treatment.[5],[6] It is widely available, rapid and permits close monitoring of unstable patients. It is very sensitive in detecting acute haematomas and depressed fractures that require emergency surgery.[6] Magnetic resonance imaging has no advantage over CT in the acute evaluation of head trauma. It may be useful in the imaging of patients with a normal CT but persistently abnormal clinical signs or in evaluating the complications of head injury.[5]

This study of pedestrians with head trauma documents our experience at the University of Benin Teaching Hospital (UBTH) with regard to causative factors, age, gender distribution and imaging findings.


  Materials and methods Top


This was a retrospective study conducted at the Department of Radiology of the UBTH, a level I urban trauma centre. The request forms as well as the CT scan reports from January 2011 to January 2014 of 224 pedestrians, who sustained head injury were retrieved from our record. Other data such as cause of injury and their Glasgow coma scale (GCS) score on admission were retrieved from the accident and emergency department. All CT scans were performed using a four-slice Bright speed helical GE CT scan machine. Out of the 224 patients recruited for this study, only 103 patients were unanimously agreed upon by the authors, because others had incomplete data.

Their demographic details and CT scan findings were obtained and entered into a Microsoft excel spreadsheet. Data were analysed using the Statistical Package for the Social Sciences version 16 software (SPSS Inc., Chicago, IL, USA). The test of significance was performed with chi-squared test, and correlation was assessed with Pearson’s correlation test. Confidence interval of 95% was used. P value less than or equal to 0.05 was considered statistically significant.


  Results Top


This was a retrospective study of 103 pedestrians, who were treated for various degrees of head injury at the UBTH. There were 69 males (67.0%) and 34 females (33.0%) with a male-to-female ratio of 2:1. For both sexes, the occurrence of head injury was highest in those about 10 years and below. The least incidence was recorded in those above 80 years of age as shown in [Table 1]. The mean age of the study population was 30.59 ± 2.07 years and 38.55 ± 2.93 years for males and females, respectively.
Table 1: The sex and age distribution of pedestrians with head injury

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Motor car accident was the most common cause of head injury (62, 60.2%), followed by motorcycle accident (31, 30.1%). The least incriminating cause was articulated truck accident (1, 1.0%) [Figure 1].
Figure 1: Bar chart showing the cause of head injury to pedestrians

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A total of 172 abnormalities were seen on cranial CT scan with some patients having multiple findings as shown in [Table 2]. Intracerebral haemorrhage was the most common finding accounting for 23.8% (41). This was followed by cerebral contusion 18.0% (31), subdural haematoma 10.5% (18), subarachnoid haematoma 7.6% (13) and extradural haematoma 2.9% (5). Others were calvarial fracture 15.1% (26), facial fractures 6.4% (11) and base of skull fracture 4.7% (8). Only one case of diffuse axonal injury was reported, and the patient died few hours after the cranial CT scan was performed. Incidental findings not related to trauma, such as cerebral atrophy 2.3% (4) and sinusitis 1.7% (3), were also reported in some of the patients [Table 2].
Table 2: Findings on cranial CT scan of pedestrians with head injury

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[Table 3] and [Table 4] show the sex and age distribution of intracranial haematoma, and it was observed that subdural haematoma was more in females than males, and this was found to be statistically significant (P = 0.005). Subdural haematoma was also seen to be more in the age group 0–10 years. The five cases of extradural haematoma in this study were only in males and those in the age group 0–10 years. Intracerebral haematoma and contusion were seen more in males than females, and this was statistically significant for contusion (P = 0.029). Intracerebral haematoma was more in the age group 0–10 years, whereas contusion was more in the age group 31–40 years. Subarachnoid haemorrhage was also more in males than females and in the age group 0–10 years.
Table 3: Sex distribution of intracranial haemorrhage

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Table 4: Age distribution of intracranial haemorrhage

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Their level of consciousness at the time of cranial CT scan was estimated using the GCS score. On the basis of the admission GCS, 33 patients (32.0%) had severe head injury (GCS < 8) and 30 patients (29.1%) had moderate head injury (GCS: 9–12), whereas mild head injury (GCS: 13–15) was observed in 15 patients (14.6%). Normal GCS was observed in 25 patients (24.3%) [Table 5].
Table 5: Grading of head injury based on GCS

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When the presence of intra- or extra-axial haemorrhage was correlated with GCS score, it was observed that the presence of the former tended towards low GCS score except for extradural haemorrhage. However, this observation was not statistically significant (subarachnoid; P = 0.08, intracerebral; P = 0.31, subdural; P = 0.24, contusion; P = 0.096).


  Discussion Top


Our study showed a male preponderance in the occurrence of head injury in pedestrians with a male-to-female ratio of 2:1. Similarly, some other studies documented male dominance in pedestrian injury.[4],[7],[8] For both sexes, pedestrians under 10 years of age were the most commonly affected. Odewolo documented a peak incidence of pedestrians’ injury among 6–12-year-old children in Ilorin, northwest Nigeria, and in another study, it was documented to be at 6–10 years.[9] These are similar to that in our study. This trend is not surprising, because children of this age may not have developed the adaptive skills on motorized roads.

Motor car accounted for the highest number of pedestrian injury in our study. This was followed by motorcycle. Baldwin et al.[10] found that bus or car was responsible for 74 per cent of all pedestrian injuries in London, UK. On the contrary, Umaru et al.[7] reported that motor cycle was responsible for most of the pedestrian injuries in the northeastern part of Nigeria. Pruthi et al.[4] reported the two-wheeler as the most common cause of pedestrian injury in Bangalore, India. In the last 3 years of our study, the government of the state, where this study was conducted, has placed a ban on the usage of motorcycle in the metropolis, and this caused a surge in the number of cars and inexperienced drivers on the road. This may have accounted for the high incidence of pedestrian head injury caused by cars. Some authors have advocated setting safety standards for the front ends of motor vehicles to make them less hazardous for pedestrians.[9],[11] Furthermore, it was documented that a reduction in the number of trips per person made on foot and an increase in the number of trip made by vehicles could possibly result in a reduction in the incidence of pedestrian injury.[12] Hence, it is advocated that countries should properly motorize their roads and ensure adherence to minimum international standards in vehicles being manufactured or imported there.[9]

Computed tomographic scan has been the foremost imaging modality of choice in head injury because it is quick at acquiring images and can better characterize lesions. In our study, intracerebral haemorrhage was the most common finding on cranial CT scan while extradural haematoma had the least occurrence. Pruthi et al.[4] documented cerebral contusion as the most common CT scan finding in pedestrian head injured patients. Cerebral contusion was the second most common finding in our study. In another study in head injured patient due to other causes, extradural haematoma was the most common finding.[13] Ghebrehiwet et al.[5] reported intracerebral haemorrhage as the most common finding in head injured patients in a study conducted in Eritrea. Extradural haematoma is said to have a peak incidence in the second decade of life with a mean age of 20–30 years, rare in older and younger patients.[14],[15] This is in contradistinction to our study wherein the five cases of extradural haematoma were seen in patients aged 10 years and below. This observation may be due to the fewer number of patients we used and the study population being limited to pedestrians. Subdural haematoma has a mean age of occurrence of 31–47 years, with majority being males.[16],[17] However, our study showed subdural haematoma having a female preponderance and more in the first decade of life. Cerebral atrophy and sinusitis were incidental findings in our study. Bordignon and Arruda[18] reported brain atrophy, calcifications and arachnoid cyst as incidental findings in a series of 2000 patients with mild head injury in a city in southern Brazil, although in this later study, different causes of head injury were assessed including pedestrian injury.GCS is a clinical assessment of head injured patients, which evaluates the verbal, visual and motor responsiveness of such patients. Therefore, it is a test of the level of neural impairment and injury severity.[13] Lee et al.[19] correlated CT findings with GCS score and showed a positive correlation between the two, such that improved CT appearance showed improved GCS score, whereas worse GCS score showed worse CT findings. Farshchian et al.[20] opined that only three lesions, that is, extra-axial haematoma, subarachnoid haemorrhage and haemorrhagic contusion might be associated with low GCS score. However, Nayebaghayee et al.,[13] in their study in Iran, concluded that the presence of CT findings may not be truly indicative of the level of consciousness evaluated by GCS score. Chieregato et al.[21] further remarked that GCS score should be combined with another scoring system such as traumatic brain injury classification to adequately assess the level of consciousness impairment. Severe head injury (based on GCS score) was the highest in our study (32%). We also observe that those with lower GCS scores were those who had more intracranial haemorrhage.

In conclusion, the burden of pedestrian head injury as seen on computed tomographic scan in our society has been highlighted in this study. There is a need to formulate both social and health policies that will cater for pedestrians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Lee TT, Aldana PR, Kirton OC, Green BA. Follow-up computerized tomography (CT) scans in moderate and severe head injuries: Correlation with Glasgow Coma Scores (GCS), and complication rate. Acta Neurochir (Wien) 1997;139:1042-7.  Back to cited text no. 19
    
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