Traumatic brain injury from a developing country in the CT-scan era: a 13-year prospective in-hospital cohort study

Introduction Most previous reports from Africa and other low middle-income countries (LMIC) on cranial neurotrauma address a more loosely defined subject of head injury (HI), rather than traumatic brain injury (TBI), and lack deployment of standardized scoring systems. We present a prospective TBI cohort from an academic neurosurgery practice at Ibadan, Nigeria, the nation's foremost university teaching hospital where TBI constitutes a core component of our clinical activity. Materials and methods This was a prospective cohort study of patients enrolled in a TBI registry over 13 years. We analyzed the clinical epidemiology of TBI, defined as cranial trauma with definite perturbation of brain function, qualified/quantified using relevant clinical features, the Glasgow Coma Scale (GCS), the Abbreviated Injury Scale-Head (AIS-Head), and Injury Severity Score (ISS). Brain imaging was graded using the Rotterdam CT scoring system. In-hospital outcome was assessed with Glasgow Outcome Scale (GOS), dichotomized for analysis. Results There were 1,440 TBI cases, 1,110 (77.1%) males, mean age [32.2 Standard deviation (SD), 19] years. Most (76%) were referrals, with delayed presentation from outlying health facilities, median duration 13 [interquartile range (IQR) 5, 48] hours. Road trauma accounted for 1,173 (82%), even in the elderly, predominantly by two- and three-wheelers (57%); fall for 136 (9.4%), this mainly in childhood. Clinically, loss of consciousness (LOC) occurred in 89%, median duration 11.0 (IQR 2, 48) hours, vomiting 25%, seizures 16%, and anisocoria in 27%. In 86% the AIS-head was >2; the TBI was moderate-severe, GCS 3–12, in 47.0%. Brain CT was obtained in 1,046/1,440 (72.6%), while 13% received acute operative treatment. In-hospital mortality was 21%, mostly among the young and the severely injured. Good outcome (GOS: good recovery/moderate deficit) was 75%. The outcomes were significantly associated with the TBI severity per the GCS scores and brain CT severity. Conclusions The clinical epidemiology of TBI from this single-institution LMIC series differs substantially from that of high-income countries. A 21% mortality predominantly affecting young economically productive adults represents a serious public health burden. Substantial gaps persist across many aspects of the TBI-management continuum, presenting clear opportunities to improve the current sub-optimal outcome-metrics in sub-Saharan Africa.