Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 650-655
World Neurosurgery

Original Article
Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa

https://doi.org/10.1016/j.wneu.2017.09.084Get rights and content

Background

Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting.

Methods

This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis.

Results

There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8–15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79–4.95).

Conclusions

TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality.

Introduction

Globally, trauma is a significant cause of morbidity and mortality, with more than 4.7 million deaths and approximately 40–50 million disabled after injury annually.1 Traumatic brain injury (TBI) is the most important single injury contributing to traumatic mortality and morbidity. Injury as a whole, and TBI in particular, is expected to become a leading cause of global morbidity and mortality by the year 2020.

In low- and middle-income countries (LMICs), where an estimated 90% of all trauma-related deaths occur,2 data suggest that up to half of all trauma-related mortality can be attributed to injury to the central nervous system.3 The odds of mortality in patients with TBI in LMICs, including sub-Saharan Africa, are more than twice as high as patients in high-income countries.4 TBI incidence ranges between 150 and 316 cases per 100,000 inhabitants per year in LMICs.5 The increasing incidence of TBI deaths is caused by a combination of urbanization, a growing middle class, the availability of cheaper cars and motorcycles, and a growing and aging population in the absence of a mature health care system. The effects of TBI are not limited to an individual's health but are also a cause of increased socioeconomic burden.6

There is little information on TBI in Africa to inform necessary public health policy, and resource-appropriate clinical management to help reduce TBI-related mortality and morbidity burden. We therefore established a TBI database at our tertiary care center in Malawi to better characterize the presentation, management, and functional outcomes after TBI in our low-resource setting.

Section snippets

Methods

This is a retrospective review of prospectively collected data from Kamuzu Central Hospital (KCH). All admitted patients who presented from October 2016 through May 2017 with a history of head trauma and associated altered level of consciousness or radiographic evidence of TBI were included. Patients who were brought in dead, or treated and discharged from the emergency department, were excluded, as were patients who had head trauma but no loss of consciousness, a decrease in their Glasgow Come

Results

During the 8-month study period, 280 patients were admitted to KCH with a primary diagnosis of TBI (Table 1). Based on data from the KCH trauma database8 from 2009 to 2015, the mean number of trauma patients admitted to KCH per month is 192 patients. Given our 8-month time frame, approximately 1542 trauma patients were admitted during the study period, with TBI patients comprising 280, or 18.2% of all admitted trauma patients. Most patients were men (n = 215, 80.5%), with a mean age of 28.8 ±

Discussion

Most literature from sub-Saharan Africa discusses head injury, and not the more precise clinical entity of TBI.5 To our knowledge, this study is a first report of a TBI database established at a tertiary care center in sub-Saharan Africa. The prospective collection of clinical and radiographic data on all patients presenting with TBI allows us to characterize patterns and functional outcomes in TBI, in an effort to inform public health and assess interventions to reduce morbidity and mortality

Conclusions

Trauma is a significant contributor to global morbidity and mortality, and a growing public health concern, particularly in LMICs. The attenuation of TBI-related morbidity and mortality is critical to reduce the global impact of trauma. In our setting, significant mortality is seen even in patients with mild TBI. Contextualized management protocols may help attenuate TBI-related mortality and improve functional outcome in our low-resource setting.

Acknowledgments

The authors wish to thank the Department of Surgery at Kamuzu Central Hospital and UNC-Project Malawi for their support of this work.

References (26)

  • A.A. Hyder et al.

    The impact of traumatic brain injuries: a global perspective

    NeuroRehabilitation

    (2007)
  • Trading Economics. Malawi GDP per Capita. Available at: https://tradingeconomics.com/malawi/gdp-per-capita. Accessed...
  • J.A. Lanlois et al.

    The epidemiology and impact of traumatic brain injury: a brief overview

    J Head Trauma Rehabil

    (2006)
  • Cited by (0)

    Conflict of interest statement: The Fulbright Program supported this work and the National Institutes of Health through the Fogarty Global Health Fellows Program Consortium comprised of the University of North Carolina, John Hopkins, Morehouse, and Tulane (R25TW009340).

    View full text