Appropriateness of Computed Tomography Scan in Mild Traumatic Head Injury Among Adult Patients in Mulago National Referral Hospital, Uganda: a Cross-sectional Hospital Based Study

doi:10.21203/rs.3.rs-2202262/v1

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Research Article

Appropriateness of Computed Tomography Scan in Mild Traumatic Head Injury Among Adult Patients in Mulago National Referral Hospital, Uganda: a Cross-sectional Hospital Based Study

https://doi.org/10.21203/rs.3.rs-2202262/v1

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Background

Computed Tomographic (CT) scanning of the head can detect acute intracranial injury and help to identify patients requiring neurosurgical intervention. The inappropriate utilization of CT scan strains meagre imaging resources especially in resource-constrained settings and risks the patients to unnecessary radiation. The Canadian CT head rule (CCHR) is a validated clinical tool used to predict mild head injury patients that will have a clinically significant intracranial injury on head CT scan. This reduces the number of requested CT scans while at the same time ensuring that those who would benefit from it are easily identified. However, this tool has not been previously applied in many low income settings where it would be very useful.

Objective

To determine the appropriateness of head CT scans performed among patients with mild traumatic head injury based on the Canadian CT head rule (CCHR).

Methods

This was a cross sectional study conducted at the emergency department of Mulago Hospital involving 259 adults clinically diagnosed with mild head injury with a head CT scan performed. They were assessed using the CCHR for a prediction of whether a head CT scan was appropriate or inappropriate. The proportion of appropriate head CT scans was obtained. The participants were followed up to assess their health status.

Results

The common abnormal CT scan findings were comminuted and depressed skull fractures. The proportion of appropriate head CT scans performed based on the CCHR was 70.7%. Most participants with positive CT scan findings were classified as appropriate when the CCHR was applied. 81.6% (n = 62) of the participants whose CT scans were classified as inappropriate had normal findings. There was a statistically significant association between categories of CCHR classification (appropriate vs inappropriate) and CT scan findings (normal vs neurologically insignificant).

Conclusion

About one-third of head CT scans performed in this study were inappropriate by applying the CCHR. Avoidance of CT scan in such patients is unlikely to miss any important injuries. Findings from the study can guide the adoption and adaptation of CCHR use in emergency departments.

Mild head injury

Canadian CT head rule

emergency departments

Uganda

Computed Tomographic (CT) scanning of the head is the preferred modality of choice in detecting acute intracranial injury and identifying patients requiring neurosurgical intervention (1). Utilization of brain CT scan has increased due to its availability in major health facilities and its sensitivity has been reported to be good (2). In Uganda like many other low income countries, there has been an increase in the availability of CT scan equipment in major public as well as private hospitals (3). An audit of radiology equipment in Uganda showed a current total of 25 CT scans (3). This has led to a noticeable increase in the utilization of CT scan services. Despite these positive developments, CT scan uses ionizing radiation which may potentially be detrimental rather than beneficial if used inappropriately. Ionizing radiation has been established as a risk factor to many known cancers (4). In addition, the inappropriate utilization of CT scan constrains the meagre imaging resources. (5) (6).

Identifying patients with mild traumatic brain injury (mTBI) who also have a clinically important brain injury can be challenging for emergency department clinicians worldwide, hence the frequent use of head CT scan (7). In order to assist physicians to identify patients who are at risk of intracranial damage following minor head injury, a number of guidelines have been reported (8). The Canadian CT head rule (CCHR) published in 2001 was developed in North America as a clinical tool to predict mild head injury (MHI) patients that will likely have a clinically significant intracranial injury (ICI) on CT and consequently reduce the number of inappropriate CT scans performed. Since then, the CCHR has been applied in many settings especially in high income countries. Low income settings have not applied the CCHR widely and many inappropriate head CT scans have continued to be performed in patients with mild traumatic head injuries.

For example, in a study by Abdalla et al in Aga Khan University Hospital, it was reported that there was a significant proportion of patients (90.5%) in whom cranial CT scan was performed but would have been avoided if the CCHR had been applied (9). In most emergency departments in Uganda, there are variations in the use of CT for patients with mild traumatic brain injury (mTBI) since there are neither guidelines nor standards implemented. Adoption of CCHR has been found effective in reducing inappropriate use of CT scan among such patients in settings such as Coast General Hospital, Mombasa Kenya, Aga Khan University Hospital, Nairobi Kenya(9, 10). Basing on its low application in low-income settings, the purpose of this study was to determine the appropriateness of head CT scans performed among patients with mild traumatic head injury based on the CCHR at the emergency department of Mulago National Referral Hospital in Uganda.

Design and Setting

This was a cross sectional hospital based study involving 259 adults clinically diagnosed with mild head injury and able to obtain a head CT scan within one week of injury.

The study was conducted between February and June, 2022 in the emergency department of Mulago National Referral Hospital (MNRH). MNRH is a public tertiary facility, in Uganda. The hospital provides services in all medical and surgical specialties including accident and emergency.

The accident and emergency unit is the main entry for neuro-surgical patients. The unit receives an estimate of 1200 patients with traumatic head injury monthly with an average of 300 patients presenting with mild head injury.

There are two CT scanner units in the hospital; a 128 slice Phillips model and a 32 slice siemens model. On average 300 head CT scans and 360 head CT scans are performed monthly due to traumatic head injury with the two scanners respectively. With an average of 150 and 240 patients having mild head injury seen in the two units respectively.

Study Procedure

A consecutive sampling procedure was used and enrollment was done from the emergency department of Mulago National referral hospital. Adults who met the inclusion criteria were briefed about the study and those willing to participate underwent the informed consent process. The PI and research assistants recorded the socio-demographic characteristics, clinical history and physical examination findings of the study participants from their files. Study participants were then assessed using the CCHR tool and the CCHR recommendation was noted. This was recorded as appropriate head CT scan if it was in compliance with the CCHR or inappropriate head CT scan if it was non-compliant with the CCHR. The head CT scan findings were interpreted by the PI and the attending radiologist on duty and were recorded in the data tool. The proportion of appropriate head CT scans based on CCHR was obtained. The participants were followed up with a phone call after two weeks to assess their health status which was recorded as improved, no change in status and worsened condition. Follow up was to assess for development of acute neurological changes.

Data Management And Analysis

Data collected using a structured questionnaire was double entered into Epi data software version 3.1 and later exported into STATA software version 14.0 for cleaning and analysis.

Data was summarized using frequency and percentages.

Comparison between variables were made using Pearson’s chi square test.

We recruited 259 participants into the study. Of these, 139 (53.7%) were referred from other medical facilities while 120 (46.3%) participants were brought directly to Mulago national referral hospital following injury. Majority of the participants were male 227(87.6%). The rest were female. The ages of the participants ranged from 18 years to 75 years.

The majority of the participants 147 (56.8%) were in the age group of 18 to 29 years. Only two participants were above 70 years.

Mechanism Of Injury

The mechanism of injury for the majority of participants resulted from road traffic accidents. 118 (45.6%) were due to motorcycle accident, 33 (12.7%) were due to motor vehicle accident and 4 (1.5%) were participants involved in bicycle accident. Assaults were the second most common cause of head injury accounting for 83 (32.18%), 21 (8.1%) participants were involved in other mechanisms of injuries like fall from a height.

Clinical Symptoms Of The Participants

The most common symptoms reported by the participants was history of loss of consciousness that occurred in 213 (82.2%) of the participants, followed by history of bleeding from the site of injury that was reported by 201 (77.6%) participants. 170 (65.6%) participants reported history of headache, 98 (37.8%) participants had history of dizziness and only 26 (10.0%) participants reported history of vomiting following injury. Findings are summarized in Table 1.

Table 1

Clinical symptoms of the study participants.
Variable	frequency	Percentage
Loss of consciousness after injury
No	46	17.8
Yes	213	82.2
Witnessed convulsion after injury
No	254	98.1
Yes	2	1.9
Vomited after injury
No	233	90.0
Yes	26	10.0
Leakage of clear fluid from ear/nose
No	256	98.8
Yes	3	1.2
History of bleeding form site of injury
No	58	22.4
Yes	201	77.6
History of visual loss
No	247	95.4
Yes	12	4.6
History of hearing loss
No	250	96.5
Yes	9	3.5
History of any dizziness
No	161	62.2
Yes	98	37.8
History of limb weakness
No	257	99.2
Yes	2	0.8
Past history of epilepsy
No	259	100.0
Yes	0	0.0
History of memory loss after injury
No	225	86.9
Yes	34	13.1
History of headache
No	89	34.4
Yes	170	65.6
History of drug abuse
No	253	97.7
Yes	6	2.3
History of smoking
No	255	98.5
Yes	4	1.5
Alcohol abuse
No	247	95.4
Yes	12	4.6

Head CT scan findings of patients with mild traumatic head injury presenting to the emergency department of Mulago National referral hospital.

Generally, CT scan findings were more pronounced among male patients than females.

Most patients had more than one neurologically significant CT scan findings, 42(16.3%). The most prominent neurologically significant CT scan finding was comminuted skull fractures, 26(10.1%) and this was only among male patients. Epidural hemorrhage was the most common extra-axial bleed noted in 8(3.1%) patients with median size of 25mm, IQR (24-34.1) followed by subdural hemorrhage, 6 (2.3%) with median size of 24mm, IQR (23.5–27) and subarachnoid 2(0.9%). Contusions were noted in 11(4.3%) patients with median size of 10mm, IQR (8–12) while intra-cerebral hemorrhage was noted in 3(1.2%) patients. This information is summarized in Table 2.

Table 2

Head CT scan findings of patients with mild traumatic head injury presenting to the emergency department of Mulago National Referral Hospital
Variable	n(%)	male	female
Normal	88(34.1)	74(32.7)	14(43.8)
Neurologically insignificant findings*	51(19.8)	48(21.2)	3(9.4)
Epidural hemorrhage	8(3.1)	6(2.7)	2(6.3)
Subdural hemorrhage	6(2.3)	6(2.7)	0(0.0)
subarachnoid hemorrhage	2(0.9)	1(0.4)	1(0.4)
brain edema	2(0.8)	1(0.4)	1(3.1)
Intra-cerebral hemorrhage	3(1.2)	2(0.9)	1(3.1)
Contusion	11(4.3)	8(3.5)	3(9.4)
Sulceal effacement	1(0.4)	1(0.4)	0(0.0)
depressed skull fracture	18(7.0)	16(7.1)	2(6.3)
comminuted skull fracture	26(10.1)	26(11.5)	0(0.0)
more than one neurologically significant finding	42(16.3)	37(16.4)	5(15.6)
*_includes; cephalohematomas, neither comminuted nor depressed fractures with/ without hemosinus, scalp/ soft tissue injuries

Proportion of appropriate head CT scans performed on patients with traumatic head injury presenting to Mulago national referral hospital.

The head CT scans performed in 259 participants, 183 (70.7%) were classified as appropriate CT scans and 76 (29.3%) were classified as inappropriate CT scans based on the Canadian CT scan head rule.

Generally, most patients with CT scan findings were classified by the Canadian CT scan head rule as appropriate. 81.6% (62) of the patients classified as inappropriate had normal CT scan findings, 2.6% (2) had contusion, and 15.8% (12) had neurologically insignificant CT scan findings. This is summarized in Table 3

Table 3

Head CT scan findings in patients with mild head injury classified as appropriate or inappropriate based on the Canadian CT head rule.
	Overall	Canadian CT head rule
Variable	n(%)	appropriate	inappropriate
Normal	74(34.1)	21(11.7)	53(67.0)
Neurologically insignificant findings*	65(19.8)	41(22.9)	24(30.4)
Epidural hemorrhage	8(3.1)	8(4.4)	0(0.0)
Subdural hemorrhage	6(2.3)	6(3.3)	0(0.0)
subarachnoid hemorrhage	2(0.9)	2(1.1)	0(0.0)
brain edema	2(0.8)	2(1.1)	0(0.0)
Intra-cerebral hemorrhage	3(1.2)	3(1.7)	0(0.0)
Contusion	11(4.3)	9(5.0)	2(2.6)
Sulceal effacement	1(0.4)	1(0.6)	0(0.0)
depressed fracture	18(7.0)	18(9.9)	0(0.0)
comminuted fracture	26(10.1)	26(14.5)	0(0.0)
more than one clinically significant finding	42(16.3)	42(23.1)	0(0.0)
*_includes; cephalohematomas, neither comminuted nor depressed fractures with/ without hemosinus, scalp/ soft tissue injuries

There was also a significant association noted between categories of Canadian CT head rule classification (appropriate vs inappropriate) and other CT scan findings (normal vs neurologically insignificant) with p < 0.001. The neurologically insignificant conditions were those conditions that had no significant neurological outcomes such as cephalohematomas.

On follow up, all participants 76(100%) who were categorized using Canadian CT head rule as inappropriate reported improvement on follow up after two weeks. One participant reported worsening of condition and one reported or no change in condition. These two participants had been categorized as appropriate by the CCHR.

The purpose of this study was to determine the appropriateness of head CT scans performed among patients with mild traumatic head injury based on the CCHR. In this study, most of the participants were male 227(87.6%) with majority (80.4%) in the age group of (18–39) years. This is consistent with other studies that also found a higher risk of injuries among young adult males than females (11–14). Male gender is a known risk factor for trauma. This is because young men are more involved in risky lifestyles i.e., motorcycle riding, alcohol abuse and other occupational hazards (11).

Regarding clinical symptoms, majority of the patients recruited reported a history of loss of consciousness (LOC) (82.2%) following trauma. This ranged from a brief interval of seconds to several minutes. None of the participants recruited reported an interval longer than 30 minutes. However, most of the patients reported other associated symptoms like headache, bleeding from site of injury in addition to the LOC.

Many studies have demonstrated LOC as a common symptom among patients with mild head injury (15, 16), In spite of these findings, a study assessing the need of head CT scan in patients reporting with loss of consciousness following MHI by Falimirski et al suggested that LOC alone is not predictive of significant head injury and is not an absolute indication for head CT scan (17).

The second most common symptom reported by the study participants was a history of bleeding from site of injury which was reported in 201 (77.6%) patients. The bleeding was however not significant enough to cause disruption in the cardiovascular homeostasis as all the participants in the study had blood pressure and pulse rate within normal range. We did not come across any studies analyzing blood loss in mild head injury. This characteristic was high in our study likely due to the fact that we did not quantify the blood loss and any bleeding from soft tissue injuries was taken as a positive finding.

Headache which was seen in 170 (65.6%) of the patients recruited in our study is another known frequent symptom encountered following MHI (18, 19). This is due to the biomechanics involved during brain injury (20) In a prospective study involving 1,101 patients analyzing the importance of clinical findings in the detection of patients at risk for intracranial lesions following MHI, headache was seen in 612 (55.6%) patients. Severe headache was more predictive of an intracranial lesion with Odds ratio (OR) 7.32, 95% CI 2.77–19.34 (18).

Our interrogation of the head CT scan findings revealed normal and neurologically insignificant CT scan findings like non displaced fractures (Fig. 1) and cephalohematoma (Fig. 2) seen in 140 (54%) participants while abnormal CT scan findings were seen in 119 (46%) participants. The most prominent findings being comminuted and depressed skull fractures which were seen in 44 (16.9%) patients (Fig. 3).

Epidural hemorrhage was the most common extra-axial bleed noted in 8(3.1%) participants with median size of 25mm, IQR (24-34.1) (Fig. 4) followed by subdural hemorrhage, 6 (2.3%) with median size of 24mm, IQR (23.5–27) and subarachnoid 2(0.9%). Contusions were noted in 11(4.3%) participants with median size of 10mm, IQR (8–12) (Fig. 5) while intra-cerebral hemorrhage was noted in 3(1.2%) participants. These findings are in agreement with previous studies which also reported skull fractures as the most common abnormal CT scan finding in patients with mild head injury. This was found to be at 43% and 8.9% in studies done in Zagazig university, Egypt and in Brazil respectively (21, 22). In our setting, skull fractures were the most common abnormal CT scan finding likely due to the mechanisms of injury involving motorcycle riders and assaults that are high risk factors for skull fractures.

Proportion of appropriate head CT scans performed in patients with mTHI based on the CCHR.

In our study, the proportion of appropriate head CT scans performed in patients with mTHI based on the CCHR was estimated at 70.7%.

There are no comparison studies in Africa with similar findings to our study. However, two studies done in Brisbane Australia and Southern California showed comparable findings to our study with the proportion of appropriate CT scans performed higher than the inappropriately performed CT scans. The proportions of appropriate CT scans based on the CCHR were found to be 91% and 63.2% for the study in Brisbane and Southern California respectively (22, 23). For the study in Brisbane, CCHR had already been introduced for use in their ED and the study was assessing the compliance, this might explain the high proportion obtained.

A study carried out in Aga Khan university hospital determining the impact of introducing CCHR use in patients with mild head injury, the proportion of appropriate CT scans performed when CCHR was introduced was found to be 21.4% (9). The findings in this study were different from our study, reasons likely to be due to the different settings in which the studies were carried out; Mulago hospital is a national referral hospital. The referred patients are often very sick having deteriorated before referral and hence more likely to have injuries in which imaging by CT scan is justified. The other difference could have been brought about by the fact that in the Aga Khan study only the high-risk factors of the CCHR were used to determine need for the CT scan while in our study we used both the high and moderate risk factors.

Correlation Of Ct Scan Findings With The Cchr Classification Of Appropriate Vs Inappropriate

Almost all the neurologically significant CT scan findings were classified as appropriately performed CT scans when the CCHR was applied. Although there were some normal CT scan findings 21(28.3%) that were classified as appropriate, majority 53(71.6%) were classified as inappropriately performed CT scans when the CCHR was applied. Many studies carried out to assess the impact of implementation of CCHR use in mild head injury have found it to have a high sensitivity level but less specificity (24–26).

There was a statistically significant association noted between categories of Canadian CT head rule classification (appropriate vs inappropriate) and CT scan findings (normal vs neurologically insignificant), p < 0.001. A reasonable number of the neurologically insignificant findings 41(66.1%) were classified as appropriately performed CT scans by the CCHR. This is likely due to the large number of patients that were involved in dangerous mechanisms of injury and therefore ended up being categorized as appropriate based on the CCHR even when they sustained neurologically insignificant injuries. Majority of the studies assessing appropriateness of head CT scan use in mild head injury based on CCHR majorly had the outcome variable as any positive intracranial lesion without categorizing into abnormal or neurologically insignificant as was done in our study (17, 18, 27).

Follow up of participants who presented with mTHI at the ED of MNRH and had a head CT scan performed.

Out of the 259 participants recruited in the study, all the 76 (100%) participants that were classified as inappropriately performed CT scan by the CCHR reported improvement at two weeks follow up. Among the participants categorized as appropriately performed head CT scan, only one participant reported no significant change in his condition while another participant reported worsening of his condition at two weeks follow up. This particular participant had an episode of seizures requiring his re-admission into hospital.

Follow up was to ensure that the participants who were classified as inappropriately performed CT scan based on the CCHR and also had normal or neurologically insignificant head CT scan findings not requiring neurological intervention are assessed for development of acute neurological changes. In this study none of the participants in that category developed any acute neurological symptoms. Follow up was done after two weeks of injury because this is the critical period in which acute neurological lesions or complication of initially insignificant findings may occur (28). We did not find any studies following up mild head injury patients at two weeks, however in a study of 62,000 patients with mild head injury and normal head CT scan, follow up at two days, only 3 (0.005%) patients were deemed to have experienced an early adverse outcome (29).

This is one of the few studies conducted in resource-limited settings to evaluate the appropriate use of head CT in mild traumatic head injury using the CCHR. Thus findings from the study contribute especially from the perspective of low-income settings with limited equipment resources that should be utilized optimally with the patients who deserve to use them. The strength of the study lies in its rigorous use of the CCHR in an emergency department where most head injury patients are presented first as well as follow up to ascertain of those patients characterized as inappropriately worked on with CT using the CCHR were indeed inappropriate. Despite this however, the key limitation in the study was the subjective nature of the follow up. Despite this limitation, the study still provides key information supporting the use of the CCHR to screen patients with mild traumatic head injury and identify those that really need to do CT or not. Further research in validating the CCHR in different settings is thus encouraged.

This study set out to determine the appropriateness of head CT scans performed among patients with mild traumatic head injury based on the Canadian CT head rule (CCHR) at the emergency department (ED) of Mulago National Referral Hospital, Uganda. The predominant clinical symptoms among these patients were history of loss of consciousness, history of bleeding from the injury site and headache. The major CT scan findings included comminuted and depressed skull fractures.

Findings from this revealed that the proportion of appropriate head CT scans performed among patients with mild head injury at the ED of Mulago Hospital based on the CCHR is estimated at 70.7%, therefore approximately a third of head CT scans performed in these patients at the ED were not appropriate and could be avoided when the CCHR is applied.

The study further demonstrates that application of the CCHR in our setting is able to identify patients with mild head injury who would not benefit from performing the head CT scan, thus avoiding unnecessary exposure to ionizing radiation, reducing wear and tear of the CT equipment and saving on the resources. At the same time, applying the CCHR can ably identify those patients with mild head injury in whom the head CT scan would absolutely be necessary, hence these can be easily identified and attended to quickly.

CT- Computed Tomography

mTHI- mild traumatic head injury

CCHR- Canadian CT head rule

MNRH- Mulago National Referral Hospital

Ethics approval and consent of participants

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board of Mulago Hospital, College of Health Sciences, Makerere University and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Approval to carry out the research was sought from and approved by the Institutional Review Board of Mulago Hospital, College of Health Sciences, Makerere University (REC REF 2021-211).

Written Informed consent was obtained for all the participants.

Consent of publication

Not applicable

Availability of data and material

All data generated and/or analyzed during this study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Funding for this study was from Health professional education partnership initiative (HEPI-SHSSU) in form of Master’s scholarship with partial research funding.

Author’s contributions: DB-conceptualized the idea, collected data, participated in analysis and drafted first manuscript; HK-refined the initial idea, assisted with data interpretation and participated in critical reading of the paper; ZM-participated in data collection, refining methods and reading the draft manuscript; JNS-contributed to refining the idea, provided guidance in data analysis and interpretation, read through the manuscript; WJ- participated in data collection, read through the manuscript and provided critical feedback; NM- participated in data collection and draft manuscript preparation; AGM-refined the idea, participated in interpretation of findings, design of the method, drafting and critical reading, and proof read final version of the manuscript.

Acknowledgement

We acknowledge the doctors, nurses and administrative staff of Mulago National Referral hospital and especially the staff working in the emergency department. Special acknowledgement to all the study participants. Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health, U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under Award Number 1R25TW011213. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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No competing interests reported.

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Appropriateness of Computed Tomography Scan in Mild Traumatic Head Injury Among Adult Patients in Mulago National Referral Hospital, Uganda: a Cross-sectional Hospital Based Study

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Abstract

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Objective

Methods

Results

Conclusion

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Background

Materials And Methods

Study Procedure

Data Management And Analysis

Results

Mechanism Of Injury

Clinical Symptoms Of The Participants

Discussion

Correlation Of Ct Scan Findings With The Cchr Classification Of Appropriate Vs Inappropriate

Conclusions

Abbreviations

Declarations

References

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