Romanian Neurosurgery | Volume XXXII | Number 1 | 2018 | January-March
Article
Management and outcome of moderate head
trauma: our experience
Mohammed T. Alshaimaa, Mohammed A. Sultan, Wael K. Zakaria, Mohammed E. Elshehawi
EGYPT
DOI: 10.2478/romneu-2018-0016
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 129
DOI: 10.2478/romneu-2018-0016
Management and outcome of moderate head trauma: our
experience
Mohammed T. Alshaimaa, Mohammed A. Sultan, Wael K. Zakaria,
Mohammed E. Elshehawi
Department of Neurosurgery, Mansoura University Hospital, Mansoura, EGYPT
Abstract: Objective: The aim of this study is to follow up patients with moderate head
trauma who were admitted to Mansoura University Hospital in the period from 1 Dec.
2015 to 30 Jul. 2016 until discharge and determine the outcome of head trauma. Material
and Methods: This prospective study were conducted on all patients with moderate head
trauma admitted to Mansoura Emergency Hospital during the period from 1 Dec. 2015
to 30 Jul. 2016 with exclude Polytrauma, bleeding disorders, severe liver and kidney
disease patients. Results: In this study, we correlated different risk factors with
management and with outcome. Management may be surgical or conservative and
outcome may be alive or dead. We have 60 patients with 17 cases (28.3%) were treated
surgically and 43 cases (71.6%) were treated conservatively. According to outcome 36
cases (60%) were alive and 24 cases (40%) died, all cases managed in ICU. According to
sex, 10 cases (17%) were female and 50 cases were male (83%) with statistically non-
significant effect on outcome (P = 0.7) and management (P =0.7). road traffic accidents
is most common cause of injury with 33 cases (55%), and Cause of injury had
statistically significant effect on management (P = 0.02) and statistically non-significant
effect on outcome (p = 0.4). GCS on admission had no statistically significant effect on
management (P=0.8) and outcome (P=0.1) with mean of 10.1±1.2 and GCS on discharge
had no statistically significant effect on management (P=0.6). Conclusion: There were
significant effect of age of patients, systemic diseases (such as DM, HTN, chronic kidney
diseases, and chronic liver diseases), type of lesions (especially SDH, SAH), and serum
electrolytes (especially serum Sodium) on outcome which determined by GCS at
discharge, length of hospital stay, and the state of the patient at discharge.
Key words: Road Traffic accident, Glasgow coma scale
Introduction
In all of the world, Traumatic brain injury
(TBI) considered as a critical public health and
socio-economic problem. It is considered a
major cause of death, in young adults, and
result in lifelong disability in those who
recovered³²’³³. TBI looks like a silent epidemic,
130 | Alshaimaa et al - Moderate head trauma
because unawareness of the society about the
magnitude of this problem²⁸’⁴⁰. In Egypt, TBI
is a serious public health problem ³⁹.
Treating patients with TBI in USA cost
about more than 9$ billion per year ⁴⁹. TBI has
two peaks of high incidence: first among
young adult male between 15 to 24 years old,
and other among elderly people of both sex
older than 75 years ³⁹’⁴⁰⁴¹. Incidence in male is
about 12–16% which double females incidence
(8%). Male have high incidence to be
hospitalized and are nearly 3 times more to die
from this injury ³’¹⁰.
Most people who survived a head injury
presented with a normal or mild deterioration
of conscious level (Glasgow Coma Scale more
than 12) with the majority of fatal outcomes
happened in the moderate or severe head
injury groups, which represent only 5% of
cases. We defined Head injury as any trauma
to the head other than any superficial injuries
to the face ³⁹’⁴⁰. It can be classified by
mechanism of injury to closed injury or
penetrating injury, by morphology to
fractures, focal intracranial injury, and diffuse
injury, or by severity of injury to mild,
moderate, and severe. Primary brain injury
define as immediate brain damage happened
upon time of impact. This includes different
verities as cerebral contusions, diffuse axonal
injuries, and acute subdural or epidural
hematomas, subarachnoid hemorrhage and
intracerebral hemorrhage. Secondary brain
injury include other pathology as progressive
cerebral oedema, ischemia, and increase size
of cerebral contusions and the surrounding
focal oedema, which lead to increase in
intracranial pressure and can lead to cerebral
herniation and death¹⁹’⁴⁰’⁴¹.
Disabilities of TBI patients change
according GCS: we have 47% moderate to
severe disabilities at 12 months and a third do
not return to work For patients with mild
injuries (GCS 13–15),. For patients with
moderate brain injuries (GCS 9–12),
moderate to severe disabilities are 45% , and
while 48% of severely injured patients have
moderate to severe disabilities, only 14% have
a good outcome at one year after trauma ⁴⁹’⁵⁵.
Pathophysiology of TBI:
We divided traumatic brain injury into the
primary neuronal injury which followed by
secondary injury. The primary injury define as
the initial injury of neuron that occurs
immediately at time of impact. ⁴’²². While
secondary injury occurred minutes, hours or
days after injury impact and lead to worsen
the primary lesions ⁵⁷’⁵⁹.
Secondary injury considered as cellular and
molecular processes which started by the
primary injury and aggravated by the cerebral
damage as result of hypotensive or hypoxic
events, hypoglycemia, and elevated
intracranial pressure cause cerebral ischemia.
Andrriesson³’⁴. Glutamate excitotoxicity,
neuronal depolarization, disturbance of ionic
homeostasis, nitric oxide and oxygen free
radicals, lipid peroxidation, disruption of
blood-brain barrier, cerebral edema and
ischemia, mitochondrial dysfunction, axonal
disruption and necrotic cell death considered
as mechanisms of secondary injury ³⁸’⁴⁵.
TBI start a close circle of neurotoxic
phenomena which aggravate each other and
end finally in cell death either by apoptosis or
cell necrosis ⁵⁹.
Diagnosis of TBI:
Assessing the GCS and size of pupils and
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 131
reaction to light considered as initial
neurologic examination. Prove alcohol
intoxication lowers initial GCS in TBI patients
¹⁸’²⁴.
Computed tomography (CT) of the head is
used for both confirming TBI and follow up
patients over time after impact. CT scan can be
used to know the type and severity of the
injury; with upper hand for detecting
intracranial hematoms ³²’³³. 50% of moderate
TBI patients have abnormal finding in CT
scan¹⁹.
Treatment:
Treatment divided into: pre-hospital,
casualty department, and other, which
includes both surgical treatment and intensive
care unit treatment ⁸’⁹.
Prognosis and Outcome:
Mortality in moderate TBI is 15 %, and 75
% of these deaths happen in sever injured
patients¹⁹’²⁹. More than 50% of the survivors
after moderate TBI suffer cognitive problem
and whose recover without significant
disability only 20 %²¹.
Death incidence 3.5 years after injury in
teenagers and adults affected by moderate or
severe TBI who were discharged from hospital
after treatment was more than twice
compared to persons in the general population
of similar age, sex, and race ³’¹⁹.
There are many predictors factors of
outcome after TBI include GCS after
resuscitation, age, pupillary reactivity, CT
findings, and the presence of major associated
extra-cranial injury ⁴⁵’⁵⁷.
Material and Methods
This prospective study, after approval by
the local ethical committee of anesthesia &
surgical intensive care department Mansoura
university hospital were conducted on all
patients with head trauma admitted to
Mansoura Emergency Hospital during the
period from 1 Dec. 2015 to 30 Jul. 2016.
Inclusion criteria:
Patients with head trauma only, different
age group (pediatrics from 0 to 15 years, adults
from 15 to 65 year, geriatrics more than 65
year)., patients with moderate head injury
GCS (9-12), patients with intracranial
hemorrhage, patients with skull fracture
depressed or linear, patients with cerebral
contusions, patients treated surgically and
treated conservative, drug abuse patients and
alcohol drinkers, diabetic patients smokers,
controlled hypertensive patient, patient with
mild liver disease and mild renal disease
controlled with treatment.
Exclusion criteria:
Polytrauma patients (abdominal injury,
chest injury, fracture spine, bone fractures),
patients with bleeding disorders, patients on
anticoagulant therapy, severe liver disease
patients, severe kidney disease patients, mild
head injury GCS (13-15) and severe head
injury GCS (8 or less).
Results
In this study, we correlated different risk
factors with management and outcome.
Management may be surgical or conservative
and outcome may be alive or dead. We found
that total number of cases treated surgically
was 17 cases (28.3%) and 43 cases (71.6%) were
treated conservatively. According to outcome
36 cases (60%) were alive and 24 cases (40%)
132 | Alshaimaa et al - Moderate head trauma
died, all cases managed in ICU, figures (1, 2).
In this study, total number of cases was
divided into 3 groups according to age: 1)
Children: 16 cases (26.7%) with age ranging
from 1 month to 16 years. 2) Adult: 38 cases
(63.3%) with age ranging from 17 years to 59
years. 3) Elderly: 6 cases (10%) with age ≥ 60
years, table (1) and figure (3).
According to sex, 10 cases (17%) were
female and 50 cases were male (83%),
according to P value sex had statistically non-
significant effect on outcome (P = 0.7) and
management (P =0.7), table (2) and figure (4).
According to the cause of injury, falls was
19 cases (31.6%), road traffic accidents (RTA)
33 cases (55%), struggle 4 cases (6.6%) and
direct head trauma (DHT) 4 cases (6.6%).
Cause of injury had statistically significant
effect on management (P = 0.02) and
statistically non-significant effect on outcome
(p = 0.4), as shown in table (3, 4) and figure (5).
In this study, patients who had DM 10
cases, 9 cases had HTN, only 1 case had history
of drug abuse and 6 cases had other medical
disorder e.g. CLD, CKD, epilepsy, cardiac
diseases. These cases might have only one
disease or might have more than one systemic
diseases, as shown in table (5).
GCS on admission had no statistically
significant effect on management (P value
=0.8) and outcome (P=0.1) with mean of
10.1±1.2 and GCS on discharge had no
statistically significant effect on management
(P=0.6), as shown in table (6).
In our study, we depended on CT diagnosis
to illustrate type of TBI and its relation to
management and outcome. Patients who had
EDH were13 cases, 20 cases had SDH, 8 cases
had SAH, 18 cases had contusions, 2 cases had
ICH, 4 cases had DAI, 12 cases had brain
edema, 19 cases had fissure fracture, 2 cases
had depressed fracture, 1 case had fracture
base of skull, 5cases had pneumocephalus,
tables (7, 8,9) and figure (6).
According to measured data we observed
that blood pressure had statistically significant
effect on outcome (P value = 0.006 for systolic
BP and P value = 0.002 for diastolic BP) and
non-significant effect on management (P
value=0.2 for systolic BP & P=0.1 for diastolic
BP). Arterial Blood Gases (ABG) had
statistically significant effect (P = 0.04) on
management and no statistically significance
on outcome (P=0.7). Serum sodium (Na.)
value had statistically significant effect in
outcome (P=0.004) while it had no statistically
significant effect on management (P=0.5).
Serum potassium (K.) had neither statistically
significant effect on management (P=0.3) nor
on outcome (P=0.2). INR in most cases was
within normal range with mean 1.2±0.2 which
had neither statistically significant effect on
management (P=0.9) nor on outcome (P=0.4).
Liver enzymes (ALT) had no statistically
significant effect on management (P=0.08)
while it had statistically significant effect on
outcome (P=0.03). All cases had leukocytosis
(normal WBCs 4000-11000) which had
neither statistically significant effect on
outcome (P=0.9) nor management (p=0.07).
Hemoglobin (Hg.) had neither statistically
significant effect on management (P=0.7) nor
outcome (P=0.1). Platelets had neither
statistically significant effect on management
(P=0.6) nor outcome (P=0.3). Serum
creatinine had statistically non-significant
effect on management (P=0.6) while it had
statistically significant effect on outcome
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 133
(P≤0.001). Random Blood Sugar (RBS) had no
statistically significant effect on management
(P=0.4) while it had statistically significant
effect on outcome (P≤0.001), as shown in table
(10).
According to the duration of hospital stay,
survived patients had longer duration of
hospital stay than dead patients with mean
duration of hospital stay for survived 8(4-45)
and for dead 7(1-27), which had statistically
non-significant effect on outcome (P =1).
Patients treated surgically had longer duration
of hospital stay than treated conservatively
with mean of duration of hospital stay for
surgical treatment 8 (2-45) and for
conservative treatment 7.5(1-30) day which
had no statistically significant effect on
management (P =1), as shown in figures (7, 8).
Figure 1 - illustrates percentage of dead to alive
Figure 2 illustrates percentage of surgical to
conservative treatment
Figure 3 illustrates age groups
Figure 4 illustrates percentage of male to female
Figure 5 illustrates cause of injury
Figure 6 illustrates relation between hospital stay and
outcome
Figure 7 illustrates relation of hospital stay to
management
134 | Alshaimaa et al - Moderate head trauma
TABLE I
Correlates age groups to management and outcome
Management Outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test
Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
Child 3(17.6) 13 (30.2) P = 0.5 MCT
P=0.5
15 (41.7) 1 (4.2) P = 0.003* MCT
P=0.001*
Adult 13(76.5) 25 (58.1) P = 0.3 20 (55.6) 18 (75) P = 0.1
Elderly 1(5.9) 5 (11.6) P = 0.8 1 (2.8) 5 (20.8) P = 0.07
TABLE II
Correlates sex to management and outcome
Management Outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
Age:median
(min-max)
25 (2 - 74) 20 (0.5 - 74) Z =0.3, P = 0.7 18.5 (0.5 - 71) 49.5 (5 -74) Z = 4.1, P ≤ 0.001*
female 2 (11.8) 8 (18.6) FET
P= 0.7
7(19.4) 3(12.5) FET
P= 0.7
male 15 (88.2) 35 (81.4) 29(80.6) 21(87.5)
Z of Mann-Whitney test SD: standard deviation
FET: Fisher’s Exact Test MCT: Monte Carlo Test
P: Probability P value is significant if ≤ 0.05, highly significant if ≤ 0.0001
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 135
TABLE III
Correlates cause of injury to management and outcome
Management Outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test
Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
falls 2(11.8) 17 (39.5) P = 0.08 MCT
P = 0.02*
14(38.9) 5(20.8) P = 0.2 MCT
P = 0.4
RTA 12(70.6) 21 (48.8) P = 0.2 17(47.2) 16(66.7) P = 0.2
struggle 3 (17.6) 1 (2.3) P = 0.1 2(5.6) 2(8.3) P = 1
DHT 0 (0) 4 (9.3) P = 0.5 3(8.3) 1(4.2) P = 0.9
*There is significant correlation between cause of injury and management (P=0.02)
TABLE IV
Correlates cause of injury to age groups
Cause of injury Significance test
Falls
n = 19
RTA
n =33
Struggle
n =4
DHT
n =4
Age group
Child 10 (52.6) 4 (12.1) 0 (0) 2 (50) MCT
P = 0.001*
Adult 4 (21.1) 28 (84.8) 4 (100) 2 (50)
Elderly 5 (26.3) 1 (3) 0 (0) 0 (0)
*There is statistically significant correlation between age of patient and the cause of injury (P=0.001)
136 | Alshaimaa et al - Moderate head trauma
TABLE V
Correlates systemic diseases to management and outcome
Management
outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test
Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
DM 3 (17.6) 7 (16.3) FET
P = 1
1(2.8) 9(37.5) FET
P = 0.001*
Hypertension 1 (5.9) 8 (18.6) FET
P= 0.4
1(2.8) 8(33.3) FET
P= 0.002*
Drug abuse 1 (5.9) 0 (0) FET
P= 0.3
1(2.8) 0(0) FET
P= 1
Other systemic
diseases…..
1 (5.9) 5 (11.6) FET
P= 0.7
2(5.6) 4(16.7) FET
P= 0.2
*There is significant correlation between DM, HTN and outcome (P=0.001), (P=0.002) respectively
TABLE VI
Correlates GCS to management and outcome
Management Outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test
Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
Initial GCS 10.1±1.2 10.3 ± 1.2 P = 0.6 10.2778 ±1.1 10.1 ± 1.3 P = 0.6
9.00 8 (47.1) 14 (32.6) P=0.9 MCT
P = 0.8
10 (27.8) 12 (50) P = 0.08 MCT
P = 0.1
10.00 3 (17.6) 12 (27.9) P =0.6 12(33.3) 3 (12.5) P = 0.1
11.00 3 (17.6) 8 (18.6) P=1
8 (22.2) 3 (12.5) P = 0.5
12.00 3 (17.6) 9 (20.9) P =1 6 (16.7) 6 (25) P = 0.4
GCS on discharge
14.00 2 (4.3) 7 (28.6)
FET
P = 0.6
15.00 7 (35.7) 20 (71.4)
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 137
TABLE VII
Correlates type of lesion to management and outcome according to CT on admission
Management Outcome
Surgical
N=17
No (%)
Conservative
N=43
No (%)
Significance test
Alive
N=36
No (%)
Dead
N=24
No (%)
Significance test
EDH:
Only
Other lesion
4(44.4)
5(55.6)
1(33.3)
3(66.7)
FET
P = 1
5 (50)
5 (50)
0 (0)
3 (100)
FET
P = 0.2
SDH:
Only
And other lesion
3(33.3)
6 (66.7)
5(45.5)
6(54.5)
FET,
P = 0.7
4 (57.1)
3 (42.9)
4(30.8)
9 (69.2)
FET
P= 0.4
SAH:
Only
And other lesion
0(0)
0 (0)
2(12.5)
6 (87.5)
FET
P = 1
0 (0)
1 (100)
2 (28.6)
5 (71.4)
FET
P= 1
Contusion:
Only
And other lesion
0
2 (100)
2(100)
14 (87.5)
FET
P = 1
2 (25)
6 (75)
0 (0)
10 (100)
FET
P = 0.2
ICH:
Only
And other lesion
0(0)
0 (0)
1(50)
1 (50)
FET
P = 1
0 (0)
1 (100)
1 (100)
0 (0)
FET
P = 1
Fissure fracture:
Only
And other lesion
0
7 (100)
2(16.7)
10 (83.3)
FET
P = 0.5
2 (18.2)
9(81.8)
0 (0)
8 (100)
FET
P = 0.5
depressed Fracture:
Only
And other lesion
0
1 (100)
0 (0)
1(100)
FET
P= 1
0 (0)
1 (100)
0 (0)
1(100)
FET
P=1
Fracture base skull:
Only
And other lesion
0
0
0 (0)
1 (100)
FET
P =1
0 (0)
1 (100)
0 (0)
0 (0)
FET
P=1
Brain edema:
Only
And other lesion
0
0
4(33.3)
8(66.7)
FET
P = 1
3 (33.3)
6 (66.7)
1 (33.3)
2 (66.7)
FET
P=0.4
DAI:
Only DAI
DAI and other lesion
0 (0)
0(0)
4 (100)
0
FET
P = 1
4 (100)
0 (0)
0 (0)
0 (0)
FET
P = 0.1
Pneumocephalus:
Only
And other lesion
0 (0)
2 (100)
0 (0)
3 (100)
FET
P = 1
0 (0)
5 (100)
0 (0)
0 (0)
FET
P = 0.07
138 | Alshaimaa et al - Moderate head trauma
TABLE VIII
Correlates type of lesion to outcome
Outcome Significance test
Alive
n = 36
Dead
n = 24
No (%) No (%)
EDH 10 (27.8) 3 (12.5) 1.9=2א
P = 0.2
SDH 7 (19.4) 13 (54.2) 7.8 = 2א
P = 0.005*
SAH 1 (2.8) 7 (29.2) FET
P = 0.005*
Contusion 8 (22.2) 10 (41.7) 2.6 = 2א
P = 0.1
ICH 1 (2.8) 1 (4.2) FET
P = 1
Fissure fracture 11 (30.6) 8 (33.3) 0.05= 2א
P = 0.8
Fracture depressed 1 (2.8) 1 (4.2) FET
P = 1
Fracture base of the skull 1 (2.8) 0 (0) FET
P = 1
Brain edema 9 (25) 3 (12.5) FET
P = 0.3
DAI 4 (11.1) 0 (0) FET
P = 0.1
Pneumocephalus 5 (13.9) 0 (0) FET
P = 0.08
*There is significant correlation between SDH, SAH and outcome (P=0.005), (P=0.005) respectively.
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 139
TABLE IX
Correlates age with type of lesion
Child
n=16
No (%)
Adult
n=38
No (%)
Elderly
n=6
No (%)
Significance test
EDH 3(18.8) 9(25) 1(12.5) MCT
P = 0.7
SDH 1(6.3) 15(41.7)* 4(50) MCT
P= 0.03*
SAH 1(6.3) 5(13.9) 2(25) MCT
P = 0.5
Contusion 5(31.3) 10(27.8) 3(37.5) MCT
P = 0.9
ICH 0(0) 1(2.8) 1(12.5) MCT
P = 0.3
Fracture: fissure 9(56.3) 10(27.8)* 0(0) MCT
P = 0.02*
Fracture: depressed 0(0) 2(5.6) 0(0) MCT
P= 0.7
Fracture base skull 1(6.3) 0(0) 0(0) MCT
P= 0.4
Brain edema 5(31.3) 7(19.4) 0(0) MCT
P= 0.2
DAI 1(6.3) 3(8.3) 0(0) MCT
P= 0.8
Pneumocephalus 2(12.5) 3(8.3) 0(0) MCT
P= 0.7
*There is significant correlation between age of patients and type of lesion SDH, fissure fracture (P=0.03),
(P=0.02) respectively.
140 | Alshaimaa et al - Moderate head trauma
TABLE X
Correlates lab. Data to management and outcome
*There is significant correlation between PH and management (P=0.04), Sr. Na and outcome (P=0.004), ALT and
outcome (P=0.03), Sr. creatinine and outcome (P≤0.001).
Discussion
We discussed in this study different risk
factors which affect management and outcome
of TBI patients. These risk factors include age,
sex, cause of injury, systemic diseases, drug
abuse, GCS on admission, and type of lesion.
In the present study we found that children
and adults had better outcome than elderly
who had poor outcome. There is significant
correlation between age and outcome
(P=0.001), especially child group and outcome
(P= 0.003). Some studies found that increasing
age is a strong independent factor in prognosis
of TBI, with a significant increase in fair
outcome in patients older than 60 years of age,
Parameter Management Outcome
Surgical n=
17
Mean ± SD
Conservative
n=43
Mean ± SD
Significance
test
Alive
N=36
Mean ± SD
Dead
N=24
Mean ± SD
Significance
test
Systolic Bl.\P 118.3 ±18.6 127.1 ± 25.8 P = 0.2 116.9 ± 17.5 135.8 ± 28.1 P = 0.006*
Diastolic Bl.\P 73.9 ± 6.9 78.1 ±14.2 P = 0.1 72.8
±10.03
82.9±13.7 P = 0.002*
INR 1.2 ± 0.1 1.2405± 0.2 P = 0.9 1.2 ± 0.2 1.3 ± 0.2 P = 0.4
ABGPH 7.29 ± 0.1 7.34 ± 0.07 P = 0.04* 7.3 ± 0.1 7.3 ± 0.07 P = 0.7
ABG.PCO2 37.7 ± 11.1 35.5 ± 8.8 P = 0.4 36.4± 9.1 35.7± 10.3 P = 0.8
ABG.HCO3 20.7 ± 3.2 20.1 ± 4.2 P = 0.6 20.5 ± 3.8 20.01 ± 4.2 P = 0.7
ABG: Na 147.1 ± 8.3 148.8 ± 8.1 P = 0.5 145.9 ± 7.3 151.9 ± 8.04 P = 0.004*
ABG.K 3.4 ± 0.5 3.3 ± 0.5 P = 0.3 3.4 ± 0.5 3.2 ± 0.6 P = 0.2
ALT: median(min-max) 20 (13 - 50) 25 (13 - 196) Z = 1.7, P =
0.08
22 (13 - 196) 26 (16 - 92) Z = 2.1, P = 0.03*
WBCs 19370.6 ±
3954.1
16786.1±5172.9 t= 1.9,P = 0.07 17530.6 ±
5464.99612
17500 ±
4222.50698
t= 0.02,P = 0.9
HB 11.3±1.6 11.5±2.2 t= 0.3,P= 0.7 11.1 ±2.3
11.9 ±1.5 t= 1.7,P= 0.1
Platelets 248823.5
±72919.7
233253.5
±101687.2
t=0.6,P = 0.6 249083.3 ±
100879.7
220537.5 ±
81934.09
t=1.2,P = 0.3
RBS 171.9 ±63.9 157.1 ±55.1 t=0.9,P = 0.4 135.7 ±34.4
199.8 ±64.2 t=4.5,P≤0.001*
Sr. creatinine 0.9 ±0 .2 0.8 ±0.3 t=0.5,P= 0.6 0.7 ± 0.3
1.02 ± 0.3 t=3.7,P≤0.001*
Duration of hospital stay:
median(min-max)
8 (2 - 45) 7.5 (1 - 30) Z = 0, P = 1 8 (4 - 45) 7 (1 - 27) Z = 0.9, P= 1
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 141
that's due to a higher rate of co-medication
and anticoagulants administration which
increase the extent of intracerebral bleeding⁸’⁹.
Xueyan et al. ⁵⁷, illustrated in his study, several
factors were found to contribute to the poor
outcome in elderly patients, including lower
Glasgow Coma Scale scores, existing systemic
diseases as hypertension, systemic
complications, midline shift, and inefficient
intensive care unit.
In the present study, we found that
incidence of TBI in male was higher than
female with a ratio of (5:1) respectively which
indicates that male gender was a risk factor for
TBI due to the higher incidence of RTA which
affects mainly males who are the main workers
and drivers in Egypt although sex did not
affect outcome of TBI. This finding was in
agreement with Taha᾽s (2015) results of his
study which was about closed severe traumatic
brain injury and was done in Egypt. He found
that out of 80 cases, 71 male (88.8%), and the
rest are female (11.2%) with mean age of
27.45± 16.46 year.
Brock᾽s et al. ¹⁰ also reported that the
incidence of TBI in male was 12–16% and 8%
in females so men were more likely to be
admitted in hospital and are nearly three times
more likely to die after TBI. Albrecht et al. ²
found that same mortality following isolated
TBI among older adults in both sex.
In the present study, we found that the
most frequent causes of TBI were road traffic
accident, falling from height, struggle and
direct head trauma (DHT) respectively. There
is statistically significant correlation between
age of patient and the cause of injury (P value
=0.001). Falls represented the most common
cause of traumatic brain injury in extremes of
age group while RTA and struggle were the
most common causes in adult group.
This finding was in agreement with Taha᾽s
(2015) results of his study which was done in
Egypt, as he reported that RTA was the most
important cause of head injury in 52 (65%) of
patients with severe TBI followed by falls in 12
(15%) of those patients.
Tagliaferri and his collagues ⁵²and Raja et
al. ⁴⁷considered road traffic accidents is the
commonest causes of head injury in adults
(40%) and falls (37%). The commonest cause
of injury was pedestrian (36%), and falls (24%)
In children.
Maas et.al. ³² illustrated in his study that the
incidence of TBI was increasing due to the
increased use of motor vehicles especially in
middle and low income countries but in high
income countries which have traffic safety
regulations result in decline in traffic-related
TBI. Vulnerable road users (pedestrians,
cyclists, etc.) were particularly at risk.
According to systemic diseases and
substance abuse we found that patients with
systemic diseases had poor prognosis and
worse outcome than other patients who did
not have systemic diseases. There is significant
correlation between DM, HTN and outcome
(P=0.001), (P=0.002) respectively.
Lustenberger et. al. ³¹ found that TBI
associated with diabetes mellitus have an
almost 1.5 fold increased mortality when
compared to patients with isolated TBI. They
reported significantly increased in-hospital
mortality in patients with vs without DM
(22.6% vs. 16.8%. p=0.002).
142 | Alshaimaa et al - Moderate head trauma
Timur et. al. ⁵⁴ reported in his result that
patients with TBI and pre-hospital HTN
showed significantly higher mortality than
TBI patients with normotensive blood
pressure (13.5% vs. 25.3%, p<0.001). Changes
in blood pressure during the pre-hospital
period, also resulted in higher hospital
mortality.
Rixen et.al. ⁴⁸ illustrated the mechanism by
which HTN increase morbidity and mortality
through elevating cerebral perfusion pressure,
which leads to enforced dilatation of cerebral
arterioles and rise in cerebral blood volume
with elevating intra-cerebral pressure. This in
turn leads to deterioration of the blood brain
barrier with inversion of the hydrostatic
gradients and finally to the formation of
cerebral edema and/or hemorrhage.
In our study, we found that there is
significant correlation between ALT and
outcome (P = 0.03). Lustenberger et.al. ³⁰,
illustrated that TBI with liver disease was
associated with two-fold increased mortality.
In our study, we found a significant effect
of chronic kidney diseases on outcome (p ≤
0.001) and this finding was in agreement with
Liao et. al. ²⁹results as they found a significant
difference between TBI with end stage renal
disease patients and patients without renal
disease on mortality (P ≤ 0.0001). This is due
to a greater number of comorbidities, such as
diabetes mellitus, stroke, systemic
hypertension, and heart disease in those
patients than non-ESRD patients admitted to
the ICU.
In the present study, we found that only
one case of drug abuse which had good
outcome, may be other cases of drug abuse
were missed, this was due to lack of screening
tests for substance abuse to patients with TBI
in our hospital. O᾽Phelan et.al. ⁴³unexpectedly
found that alcohol intake to be associated with
decreased mortality. Mathias and Osborn
(2016) found that alcohol had either
deleterious or protective effects on the brain
after a TBI and pre-injury alcohol abuse only
had a very limited impact on the cognitive
outcomes of their intoxicated mild TBI
sample.
Alternatively, Dinh et. al. (2014) found that
alcohol consumption may lead to more serious
injuries which, in turn, may contribute to
poorer cognitive outcomes. Intoxicated
patients affecting GCS through decreasing it
by 2–3 points are challenging to classify and
should be treated with higher attention (Harry
et.al. 2007).
According to GCS at time of admission as
a risk factor that affect outcome we found that
cases with GCS 9 had worse outcome than
cases with GCS 12. So the lower GCS, the more
chance for surgical treatment and the worst
outcome. Perel et al. (2008) and Agrawal et al.
(2012) considered that GCS after full
resuscitation was one of the most important
predictor factor of outcome after TBI. Baum J.
et.al. (2016) illustrated that every 1-point
decline in initial GCS at hospital presentation
was associated with a 14% increased risk for
fair outcome. Osler et.al. (2016) considered
that GCS was an important predictor of
mortality in both TBI and non-TBI patients
but GCS is a more stronger predictor of death
in TBI patients and patients with lower GCS
have poor outcome than others.
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 143
In the present study, most patients who
survived had GCS 15 on discharge and good
outcome and mostly managed conservatively.
We determined outcome of patients at
hospital discharge. We did not evaluate long
term outcomes because difficulty in follow-up
of many patients after discharge. Maas et.al.
(2008) suggested that outcome after head
injury is better to be assessed at 6 months after
injury, as experience showed that about 85% of
recovery happened within this time period,
but further improvement could occur later.
According to type of lesion, Baum et. al.
(2016) found that TBI outcome is more
dependent on the severity of the brain injury
and less so on extra cranial injuries. In the
present study, we found that most common
type of hemorrhage was SDH, its incidence
was 33% of cases of the study which was in
agreement with Mackenzie (2000) result who
found that acute SDH was the commonest type
of traumatic intracranial hematoma.
In the present study, acute EDH incidence
was 22% of cases of moderate head trauma and
was common in adult group 9 cases versus 3
children and 1 elderly. Bullock et. al. (2006)
illustrated that EDH is rare in the elderly
group, due to dura adherent to the skull. EDH
generally had good outcome 27% of patients
were alive but if associated with intracranial
lesions outcome become poor (12% died).
Grandhi et al. (2014) showed that ASDH
compared with EDH had worst outcome due
to severity of underlying brain damage
associated with ASDH, and the rate of
mortality are greater especially in elderly
patients group with poor initial GCS, and
other systemic injuries
In the present study, SAH was a common
intra-cerebral lesion, its incidence was 13% of
moderate head trauma. It had worst outcome
especially if associated with other lesion and
mostly treated conservatively if not associated
with other intra-cerebral lesions. Borczuk et.
al. (2013) found that patients with isolated
traumatic SAH were at lower risk of
deterioration in comparison with patients
having other intracranial injuries. Gaetani et
al. (1995) considered that SAH was a negative
prognostic factor in traumatic head injuries
especially if there was an associated intra-
cerebral hematoma. Quigley et al. (2013)
illustrated that management of traumatic SAH
was usually conservative in isolated traumatic
SAH without other intracranial lesions.
In the present study, cerebral contusions
were a common lesion, its incidence was 30%
of moderate head trauma patients and its
management was mainly conservative.
Generally CC had poor outcome especially if
associated with other intra-cerebral lesions.
This was in agreement with Houseman et. al.
(2012), Soustiel et. al. (2008) and Maas (2016)
results who found cerebral contusions were
one of the most common traumatic findings
and it presented in more than 50% of patients
of moderate and severe TBI. Saeed et al. (2014)
result reported not all patients with CC require
surgical intervention, 56% of patients can
manage conservative and the remaining 44%
need surgical evacuation, surgery was done for
other intracranial lesions. Chieragato et al.
(2005) study showed intracranial lesions
which increase the chances of a bad
neurological outcome were (cerebral
144 | Alshaimaa et al - Moderate head trauma
contusions, subdural hematoma and
subarachnoid hemorrhage).
In the present study, we found that fissure
fracture was the most common type of
fracture, it had good outcome and was treated
conservatively especially if not associated with
other lesions. Raja et. al. (2013) had confirmed
this findings in his study as the dominant type
of skull fracture was linear (fissured) fracture
in 50% of cases followed by depressed fracture
in 30%, comminuted fracture in 20%.
In the present study, we found only one
case of fracture base of the skull that
documented on CT scan of the head. Actually
there were 15 cases of TBI presented with
periorbital hematoma, CSF rhinorrhea and\or
CSF otorrhea, bleeding per nose and\or per
ear. This finding was explained in Chawla et.al.
(2105) study, as to detect a fracture on a CT
scan there must be discontinuity of the skull. A
linear fracture that comes in the same plane of
a CT slice may not be visualised. Linear
fractures in the base of the skull were difficult
to be identified by CT scan unless depressed or
separated.
In the present study, we found 4 cases of
DAI and their CT scan was normal presented
by disturbed conscious level only and not
associated with other injuries and all were
treated conservative and had good outcome.
Yuh EL (2013) suggested that up to one third
of patients presented with mild traumatic
brain injury (GCS 13-15) and a normal CT
scan upon presentation will demonstrate
structural abnormalities on later MR imaging.
Joshue et. al. (2013) unexpectedly found that
diffuse axonal injury was rarely fatal but was
associated with increased possibilities of a
poor functional recovery, prognosis was
generally considered poor.
In the present study, we found that brain
edema was considered a secondary lesion
which mostly occurred associated with other
lesions and it was present in 20% of all
moderate TBI patients. Adults were more
susceptible to brain edema than children. It
was mostly treated conservatively and
generally had good outcome. Makarenko et. al.
(2016) found that secondary brain injury cause
a significant morbidity and mortality partly
due to brain edema which reduces intracranial
compliance and may cause a dangerous rise in
intracranial pressure which leads to reduced
cerebral blood flow and cerebral perfusion.
In the present study, the incidence of
pneumocephalus was 8.3% of moderate head
trauma, occurring in adult more than in
children. It always occurred associated with
other lesions, treated conservatively and had
good outcome.
In the present study, we found that
incidence of moderate traumatic brain injury
in children was 26.6%, the most common
hemorrhages in this group were contusion
(31%), EDH (19%), SDH (6.3%), and SAH
(6.3%) respectively. Fissure fracture was
common in child group (56%).
We found that adult group were more
prone to injury than any age group due to
increased incidence of RTA in our country,
common hemorrhages in these group were
ASDH (41.7%), contusion (27.8), EDH (25%),
SAH (13.9%) respectively. The common
fracture in this group was fissure (27.8%),
depressed (5.6%).
Romanian Neurosurgery (2018) XXXII 1: 129 - 148 | 145
Bullock et. al. (2006) found that elderly
population is more liable to hge due to
increased fragility of blood vessel walls and
increasing antithrombotic and anticoagulant
drugs usage. Also we found that the most
common hemorrhages in elderly were SDH
(50%) contusion (37.5%), SAH (25%), EDH
(12.5%), and ICH (12.5%) respectively.
In the present study, we found that Serum
Na had significant effect on outcome
(P=0.004). Hypernatremia may be attributed
to the use of normal saline (0.9%) for the first
24 hours, the use of hyperosmolar diuretics
(mannitol) and loop diuretics (furosemides)
and its allowed to have high serum Na till 160
-170 mmol\l in such patients. This cause
hyperosmolarity of blood which withdraws
water from brain cells and decreasing brain
edema.
Our results was in agreement with
Maggiore and Picetti (2009) results, they
reported the incidence of hypernatremia was
significantly related with increased patients
mortality (P = 0.003). This is due to the
coexistence of precipitating factors such as
impaired sensorium, altered thirst, central
diabetes insipidus, and increased insensible
losses. Also, these patients often receive
dehydrating measures to reduce cerebral
edema and controlling intracranial pressure.
Bradshaw and Smith (2008) and Xing et.al.
(2015) illustrated that electrolyte disorder was
a common problem in TBI patients who are at
a high risk for the development of
hypokalemia, hypernatremia. Hypernatremia
occurs in TBI patients less commonly than
hyponatremia. Hypernatremia is often an
indicator of the severity of the underlying
disease. Hypokalemia is a common electrolyte
disorder in hospitalized patients, with a
prevalence of 21% and according the severity
of post-traumatic hypokalemia, the severity of
head injury can be assisted.
Conclusion
The most common cause of injury is road
traffic accidents with Cause of injury had
statistically significant effect on management
and statistically non-significant effect on
outcome. Patient gender had no effect on
management and outcome. We found
significant effect of age of patients, systemic
diseases (such as DM, HTN, chronic kidney
diseases, and chronic liver diseases), type of
lesions (especially SDH, SAH), and serum
electrolytes (especially serum Sodium) on
outcome which determined by GCS at
discharge, length of hospital stay, and the state
of the patient at discharge.
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