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Table of Content - Volume 10 Issue 2 - May 2018
Clinical profile and etiology of craniocerebral trauma patients
Haroon Salaria1, Vikar Hussain Qazi2
1Associate Professor, 2Department of Neurosurgery, 2Department of Internal Medicine, Govt. Medical College Hospital, Jammu, JandK, 180001, INDIA. Email: haroon_salaria@hotmail.com
Abstract Background: Traumatic brain injury has a high mortality and morbidity especially in developing nations. Head injury following trauma is the cause of death in about one-third of patients that die after accidents. Objectives: To study the clinical profile and etiology of craniocerebral trauma cases. Material and Methods: A prospective follow up study conducted in Postgraduate Department of surgery and the Department of Neurosurgery, Govt. medical college and hospital Jammu on consecutive 937 cases admitted for head trauma. Detailed history was taken, data was entered in to excel and analyzed using SPSS version 20. Results: Out of total 937 cases, 731 (78.01%) were males and 206 (21.99%) were females. Road traffic accidents was the most common cause( 49.55%). 148 patients had vomiting as most common symptom. 97 (10.35%) cases had a score of 3-7 at the time of admission. Out of 937 cases 103 (10.99%) cases died in this study. Conclusions: It is concluded that in Jammu region, with rapid urbanization and industrialization and ever increasing number of automobiles, head injuries have become a common occurrence and a serious health hazard. Keywords: Craniocerebral Trauma, Road Traffic Accidents, Glasgow Coma Scale
INTRODUCTION Ever since the advent of mankind, trauma to various parts of the body in a variety of ways has been encountered by man, injury to the head being one of those. The recorded history of the diagnosis and treatment of head injury goes back to ancient Egypt, as was deciphered from 1700 BC. "Edwin Smith papyrus" scroll by James Brested in 1930.1 In modern times, with increasing industrialization and introduction of more rapid methods of transport, the incidence and severity of head injuries have increased.2 According to World Health Organization (WHO), road traffic injuries are the sixth leading cause of death in India with a greater share of hospitalization, deaths, disabilities and socio-economic losses in young and middle aged populations. Road traffic injuries are the leading cause of death among young people aged 15-29 and cost the countries 1-3% of Gross Domestic Product (GDP).3 It is important to appreciate that severe brain damage can occur in the absence of external injury. Conversely severe external laceration and even skull fractures do not necessarily indicate injury to the underlying brain.4 In clinical practice the brain is damaged by trauma of three main types. Firstly the impacting force producing a head injury may strike either on a stationary head with an accelerating injury. Secondly head in motion may strike against a stationary or a mobile object - a decelerating injury. The third form of head injury results from transmitted forces or indirect trauma.5 The commonest sites of laceration and contusion in acceleration and deceleration injuries are the inferior surfaces of the frontal lobes and the anterior aspects of the temporal lobes, in the region of the lesser wing of the sphenoid.6 With the development of computed tomography by Hounsfield in 1972, care of the patients with acute craniocerebral trauma got revolutionized.7 Inspite of all the advances made, head injuries have become one of the major cause of death in the developing countries of the world.1 India is no exception to the world scenario. The vastness of its land, difficult terrain, varying climate, faulty roads, non observance and poor enforcement of traffic rules and poor education of the people make the picture look even grim.8 There is less data available regarding etiology of craniocerebral trauma in this region. Therefore in order to evaluate clinical profile and etiology of craniocerebral injuries we carried out this study in Postgraduate Department of Surgery and Department of Neurosurgery, Govt. Medical college and hospital Jammu.
MATERIAL AND METHODS The present study was conducted in Postgraduate Department of Surgery and Department of Neurosurgery, Govt. Medical college and hospital Jammu for a period of one year from November 2016 to November 2017. All 937 patients admitted in neurosurgery department formed the sample size. All those with isolated moderate to severe traumatic head injury and head injuries associated with other injuries formed Group-I, while all those with mild head injury who showed neurological deteoriation subsequently during the mandatory period of observation was included in the study group Group-II. The patients of head injuries who had associated trauma to other organ systems or had significant comorbid medical conditions was categorized separately as Group III. After informed consent from patient or their attendants was taken a detailed history was obtained from the patient or from the attendants of the patient. General physical examination and examination of central nervous system was done. This included serial recording of the level of consciousness (GCS Score), pupillary reflexes, and gross examination of motor and sensory system. All the necessary blood test, X rays and plane CT were done on all patients. The neurological or functional outcome of patients were assessed by using Glasgow outcome score (GOS, fig. 1) at the end of 3 months. Treatment protocol was well defined before the start of the study. The study included only the standard and established investigative workup and management protocol.
RESULTS Table 1: Age and Sex wise incidence of Head Injuries
The analysis of 937 cases as depicted in Table-1 revealed that 731 (78.01%) were males and 206 (21.99%) were females, thus giving an over all male to female ratio of 3.5:1. The co-efficient of variation (cv-56.8) was significantly higher in males as compared to females (cv-53.8) implying that males are at greater risk of sustaining head injury.
Table 2: Distribution of subjects as per GCS at the time of admission
97 (10.35%) cases had a score of 3-7 at the time of admission, 496 (52.6%) cases were having a score of 8-12 while as 344 (37.05%) had a score of 13-15.
Table 3: Distribution of study population as per outcome at the end of 3 month
103 (10.99%) cases in this study died, 53 (51.45%) of these deaths occured within 12 hours after head injury and 19 (18.45%) deaths took place between 12 and 24 hours, while 31 (30.10%) deaths were found to occur after 24 hours, while 31 (30.10%) deaths were found to occur after 24 hours.
Diagram 1 Diagram 2 Diagram 3 Diagram 1: Pie chart showing causes of head injury; Diagram 2: Distribution of subjects as per symptoms in gender; Diagram 3: Distribution as per lesion detected in study population In Diagram 1, Road traffic accidents was the most common cause 49.55%, next was falls with 29.18%. In Diagram 2, Total of 148 patients who had history of vomiting following head injury. Of these 96 (62%) cases were males and 52 (38%) were females. Only 55 cases had convulsions, 14 (33%) were females and 41 (67%) were males. 145 cases in this series had bleeding from the nose, mouth or ear or all the three together. 100 (72%) cases were males and 45 (28%) cases were females. In Diagram 3, Intracranial bleed seen 252 cases was the most common lesion in this study
DISCUSSION The profile of 937 head injury patients was studied for a period one year to evaluated to see clinical profile and etiology of head injuries. The mean age of the patients in this study was 27.8 years with a standard deviation of 15.44 years. The youngest patient in our study was eight months old and the oldest 90 years old. Although 79.2% (742) cases belonged to the first four decades of life, the maximum number of patients were in the age group of 21 to 30 years (25.3%). Similar observations have also been made by Tandon et al.9 who reported the mean age of 25.87 years in a series of 681 patients, whereas the mean age of the patients studied by Turazzi; et al10 was 34 years. Most of the patients in our study were males constituting 78.01% cases while females accounted for the remaining 22.99%, this giving the male to female ratio of 3.5:1. In the experience of most of the authors males were injured more frequently than females. In a series of 532 cases reviewed by Barr JB et al11 there were 79.1% males and male to female ratio was 3.8:1. Barber JB et al12 reported the male to female ratio of 3:1 in their series of 150 cases. The commonest mode of injury observed by us was the road traffic accident and it was responsible for 49.95% cases while falls and assaults caused 29.13% and 15.48% injuries respectively. Mode of injury depended to some extent upon the age of the patient, while in children below 12 years of age falls were the cause of 68.72% injuries, road traffic accidents resulted in most (55.79%) of the adult head injuries. In a study of 2000 cases Kalyanaraman et al13 found that road traffic accidents contributed 42% of the cases while as falls were responsible for 38.7% cases, this was in accordance with our study. Anderson et al14 observed that motor vehicle accidents were responsible for 49% head injuries and falls caused only 28% of them, this finding was in support of our study. Vomiting caused either by sharp increase in intracranial pressure following injury15 or because of irritation of the gastric mucosa following ingestion of blood Rowbotham GF et al16 was seen in 15.8% (148) cases and of these 76 (51.3%) patients were below the age of 12 years. Swann IJ et al.17 on the other hand observed vomiting in only 7% cases. Similar was seen with our study. Kalyanaraman et al.13 have also reported a higher incidence of convulsions in children. In their study 12.1% children and 4.2% of adults had convulsions following head injury, this was in accordance with our study. Orificial bleeding, which occurs either because of direct injury to the mouth, nose and ear or because of fracture of the base of skull, was seen in 15.5% (145) cases in our study. While 37 patients had bleeding from ear alone, 22 cases had it from two or more than two orifices. 3 cases in this series had cerebrospinal fluid otorrhoea. Devadiga KV et al18 reported a higher incidence of bleeding from ear, nose and mouth (21.8%) and bleeding from ear alone in 5.67% cases while only 2 patients had cerebrospinal fluid otorrhoea in their series of 1500 cases. Intracranial hemorrhages was found to be most common lesion in this study similar was seen with Adeyekun AA et al19 study. Mittal B et al20 observed 47.5% mortality in patients with the score of 3-7 and 10.7% deaths in those having the score ranging from 8 to 13 while only 7% cases with the score of 14-15 died. Mishra HB et al2 found mortality figures of 62% in those having score of 3-7 while 12.8% and 2.2% died who had Glasgow Coma Score of 8-14 and 15 respectively. Present study confirms the prognostic value of Glasgow Coma Score. In this series 69.07% (67) died who had a score of 3-7 and 7.265 (36) was the mortality rate in patients having score of 8-14 while no death was observed in those having the score of 15. Of all the head injury patients 103 died giving a mortality rate of 10.99% this is comparable with the rates of 14.90% observed by Rowbotham GF et al16 7.3% by Devadiga KV et al18 and 7.2% by Servadel F et al.21
CONCLUSION This clearly indicates that proper education of people with regard to traffic rules, use of helmet and abuse of alcohol along with scientific designing of roads will go a long way in controlling the ever-rising morbidity and mortality due to head injuries. Majority of the patients effected being those belonging to the productive age group of life resulting in a considerable strain on the economy of the society and a continuous burden on the family. The death and disability caused by head injuries need to be considered and emphasis needs to be laid on the prevention of such mishaps.
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