Elsevier

World Neurosurgery

Volume 149, May 2021, Pages e460-e468
World Neurosurgery

Original Article
Prospective Study of Surgery for Traumatic Brain Injury in Addis Ababa, Ethiopia: Trauma Causes, Injury Types, and Clinical Presentation

https://doi.org/10.1016/j.wneu.2021.02.003Get rights and content

Background

Traumatic brain injury (TBI) is a public health problem in Ethiopia. More knowledge about the epidemiology and neurosurgical management of TBI patients is needed to identify possible focus areas for quality improvement and preventive efforts.

Methods

This prospective cross-sectional study (2012–2016) was performed at the 4 teaching hospitals in Addis Ababa, Ethiopia. All surgically treated TBI patients were included, and data on clinical presentation, injury types, and trauma causes were collected.

Results

We included 1087 patients (mean age 29 years; 8.7% females; 17.1% <18 years old). Only 15.5% of TBIs were classified as severe (Glasgow Coma Scale score 3–8). Depressed skull fracture (44.9%) and epidural hematoma (39%) were the most frequent injuries. Very few patients had polytrauma (3.1%). Assault was the most common injury mechanism (69.9%) followed by road traffic accidents (15.8%) and falls (8.1%). More than 80% of patients came from within 200 km of the hospitals, but the median time to admission was 24 hours. Most assault victims (80.4%) were injured >50 km from the hospitals, whereas 46% of road traffic accident victims came from the urban area. Delayed admission was associated with higher Glasgow Coma Scale scores and nonsevere TBI (P < 0.01).

Conclusions

The injury panorama, delayed admission, and small number of operations performed for severe TBI are linked to a substantial patient selection bias both before and after hospital admission. Our results also suggest that there should be a geographical framework for tailored guidelines, preventive efforts, and development of prehospital and hospital services.

Introduction

According to recent global estimates, close to 90% of all trauma-related deaths occur in low- and middle-income countries (LMICs).1 Neurological injuries are the most important causes of death and disability from trauma, particularly in children and young adults.2 However, studies on head and spinal injuries from LMICs are underrepresented in the international literature.3,4 Importantly, as different regions have their own needs and obstacles, neurotrauma research and management must be contextualized. It is not feasible to directly transfer cost-demanding, evidence-based guidelines from Western countries to LMICs, which lack the necessary finances, equipment, and human resources. Thus, there is a great need for more and better data on epidemiologic aspects and the entire continuum of care to facilitate development of locally tailored guidelines, improve quality of care, and identify region-specific focus areas for preventive efforts.5,6

Ethiopia is the second most populous country in Africa with about 115 million inhabitants.7 Notably, it is a country of young people, as 70% are <30 years of age.8 Ethiopia has one of the fastest growing economies in the world with a rapid rate of urbanization and industrialization and has some of the highest numbers of road traffic injuries and deaths worldwide.9,10 Fall accidents among construction workers are very common,10 and there are high rates of injuries resulting from violence and assaults.11,12 In studies from the emergency department (ED) at Black Lion Specialized Hospital in Addis Ababa, traumatic brain injury (TBI) was the leading cause of mortality and the most important indication for neurosurgical procedures.13, 14, 15 The burden of trauma, especially neurotrauma, weighs heavily on Ethiopian society,11 and research that can lead to improved patient care and identify relevant focus areas for Ethiopian authorities is timely and highly warranted.

The Ethiopian/Norwegian training program in neurosurgery was started in 2006 and has been instrumental in developing a sustainable neurosurgical environment in Ethiopia.16 A key issue for further development is research, particularly within the most prevalent disease conditions. To this end, we prospectively registered TBI patients who were surgically treated at the 4 teaching hospitals in Addis Ababa in the period 2012–2016. In this article, we describe the trauma causes, injury types, and clinical presentation. In another article, we report on the surgical treatment, complications, and patient outcomes.17

Section snippets

Study Setting

This study was done at the 4 neurosurgical teaching hospitals in Addis Ababa, Ethiopia: Black Lion Specialized Hospital, Myung Sung Christian Medical Center, Alert Hospital, and Zewditu Memorial Hospital. These hospitals provide the majority of neurosurgical services in the country. Hospital management of TBI patients is based on the Advanced Trauma Life Support guidelines and the Brain Trauma Foundation guidelines.18 More details on hospital management are described elsewhere.17 This study is

Demographics and Injury Types

In the study period, 4412 TBI patients (90 patients from October to December 2012, 796 patients in 2013, 942 patients in 2014, 1284 patients in 2015, and 1300 patients in 2016) visited the ED of the 4 hospitals. A total of 1087 patients (24.6%) were surgically treated and included in this study. The mean age was 29 years, and 91.3% were males (Table 1). Female patients were younger than male patients (mean age 24.7 vs. 29.4 years; P = 0.01). Among all patients, 17.1% were children (<18 years

Discussion

In this study, we present novel data on TBI patients who were surgically treated in Ethiopia. Most patients were male adolescents or young adults with a mean age <30 years. DSF and EDH were the most frequent (>80%) injury types, and the majority of patients (>50%) had a GCS score of 14–15 at presentation. Approximately 70% of TBI patients were injured in assaults. Hospital admission was often delayed with a median time to admission of 24 hours. Delayed admission was associated with a nonsevere

Conclusions

TBI is a major public health problem in Ethiopia, and our novel data on neurosurgical management of TBI can help to improve the quality of care and identify focus areas for preventive efforts. Many young patients die or experience significant treatment delay because of limitations within prehospital services and local hospitals, and efforts should be made to address this (e.g., trauma resource allocation, ambulance services, systematic referral systems from district hospitals, telemedicine

CRediT authorship contribution statement

Tsegazeab Laeke: Methodology, Formal analysis, Writing - original draft, Writing - review & editing. Abenezer Tirsit: Methodology. Azarias Kassahun: Methodology. Abat Sahlu: Investigation. Tequam Debebe: Investigation. Betelehem Yesehak: Investigation. Samuel Masresha: Investigation. Negussie Deyassa: Formal analysis. Bente E. Moen: Writing - original draft. Morten Lund-Johansen: Methodology, Formal analysis, Writing - original draft. Terje Sundstrøm: Methodology, Formal analysis, Writing -

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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