Socio-demographic characteristics
A total of 91 neurosurgery patients with intracranial hematoma visited JUMC and managed. Seventy-three (80.2%) of the study subjects were males and 18(19.8%) were females with a male to female ratio of 4:1 (table 1). The mean age was 34 years±sd (ranging from 2 to 90 years), of which 15(16.5%), 57(62.6%), and 19(20.9%) were less than 15, between 15 and 49, and greater than 49 years old respectively. Regarding to their marital status, 53 (58.2%) were married and 38(41.8%) were single. Most 29(31.9%) of the patients were farmers followed by students 23(25.3%), the rest are employees, drivers, and merchants. Nearly equal patients came from urban and rural. Seventy-nine patients (86.8%) have no comorbidities, while 10 (11%) of the patients were hypertensive, one cardiac, and one diabetic patient. Eighty-six (93.4%) of patients had trauma while the rest five patients didn't have trauma. Road traffic accidents and fighting account for the commonest mechanism of injury, 29(31.9%) each followed by falls 20(22%). There was no known mechanism of injury for two patients (Table 1).
Table 1: Sociodemographic characteristics neurosurgery patients admitted at Surgery unity of JUMC from June to December 2020.
Variable
|
Categories
|
Frequency
|
Percent
|
Sex
|
Male
|
73
|
80.2
|
Female
|
18
|
19.8
|
Age
|
<15
|
15
|
16.5
|
15-49
|
57
|
62.6
|
>=50
|
19
|
20.9
|
Marital status
|
Married
|
53
|
58.2
|
Single
|
38
|
41.8
|
Occupation
|
Farmer
|
29
|
31.9
|
Student
|
23
|
25.3
|
Employee
|
16
|
17.6
|
Merchant
|
9
|
9.9
|
Others
|
12
|
14.3
|
Residence
|
Urban
|
46
|
50.5
|
Rural
|
45
|
49.5
|
Chronic illness
|
HTN
|
10
|
11
|
DM
|
1
|
1.1
|
Cardiac
|
1
|
1.1
|
No
|
79
|
86.8
|
History of medication intake
|
Antihypertensive
|
10
|
10.8
|
Antidiabetics
|
1
|
1.1
|
Cardiac
|
1
|
1.1
|
Personal habit
|
Smoking
|
2
|
2.2
|
Alcohol
|
6
|
6.6
|
History of trauma to the head
|
Yes
|
85
|
93.4
|
No
|
6
|
6.6
|
Mechanism of injuries
|
Road traffic accident
|
29
|
31.9
|
|
Fighting
|
29
|
31.9
|
Falls
|
20
|
22
|
Thrown stone
|
3
|
3.2
|
Not known
|
2
|
2.2
|
Others
|
2
|
2.2
|
Place of occurrence of Trauma or complaint and Time of arrival to the hospital
Most of the patients were in the outdoor environment 49 (53.8%) during the trauma scene or their health-seeking complaint whereas vehicle occupant and pedestrian were 13(14.3%) each, and the rest 16 patients (17.6%) were in the home environment. The majority 44 (48.4%) of the patients arrived in hospital in the range of 4 to 24 hours after injury, and 32 (35.2%) patients arrive after 24 hours. Among the 91 study patients, 75(82.4%) patients reported a history of loss of consciousness and 16 patients didn't have a loss of consciousness. Sixty-nine of the patients have a loss of consciousness that lasts greater than 30 minutes, while six patients have a loss of consciousness for less than 30 minutes. The shortest time was 10 minutes while the longest time was 6 days. Historically, 21 patients (23.1%) have at least one episode of convulsion while the rest 70 patients (76.9%) did not report a complaint of convulsion (Table 2).
Table 2: Place of occurrence of trauma, time of arrival after complaint, and history of loss of consciousness of neurosurgery patients admitted at Surgery unity of JUMC from June to December 2020.
Variable
|
Place
|
Frequency
|
Percent
|
Place of occurrence
|
Vehicle occupant
|
13
|
14.3
|
Pedestrian
|
13
|
14.3
|
Outdoor
|
49
|
53.8
|
Home
|
16
|
17.6
|
Time in Hours
|
<4
|
15
|
16.5
|
4-24
|
44
|
48.4
|
>24
|
32
|
35.2
|
Hx of LOC
|
Yes
|
75
|
82.4
|
No
|
16
|
17.6
|
Duration of LOC
|
≤30 minutes
|
6
|
6.6
|
>30 minutes
|
69
|
75.8
|
Physical findings at presentation
Forty-four patients (48.4%) had a loss of consciousness at presentation. Ten patients (11%) and nine patients (9.9%) had convulsion and aspiration respectively at presentation. Eleven patients (12.1%) had signs of increased ICP. Moderate category 34 (37.4%) and 12 (13.2%) patients were comatose. The lowest GCS record in this study was 6 and 38 patients had GCS of 15 at presentation. The study found that Body weakness in 32 patients, hemiparesis in 27 patients, and hemiplegia in five patients. Twenty patients (22%) had unilaterally dilated and fixed pupils while one patient had bilaterally dilated fixed pupils. The majority of the patients fall into the category of mild head injury 45(49.5%) followed by moderate category 34(37.4%) and 12(13.2%) patients were comatose. The lowest GCS record in this study was 6 and 38 patients had GCS of 15 at presentation. The associated extracranial injury was seen in 14 patients (15.4%), the majority of which is extremity fracture in 9 patients (9.9%) followed by chest/abdominal injury in 4 patients (4.4%) (Table 3).
Table 3: Clinical findings at presentation and Associated Extracranial injury neurosurgery patients admitted at Surgery unity of JUMC from June to December 2020.
Variables
|
Categories
|
Frequency
|
Percent
|
LOC at presentation
|
Yes
|
44
|
48.4
|
No
|
47
|
51.6
|
Convulsion
|
Yes
|
10
|
11.0
|
No
|
81
|
89.0
|
Aspiration
|
Yes
|
9
|
9.9
|
No
|
82
|
90.1
|
Increased ICP
|
Yes
|
11
|
12.1
|
No
|
80
|
87.9
|
GCS after resuscitation
|
3-9
|
12
|
13.2
|
10-13
|
34
|
37.4
|
14-15
|
45
|
49.5
|
Body weakness
|
No
|
59
|
64.8
|
Hemiparesis
|
27
|
29.7
|
Hemiplegia
|
5
|
5.5
|
Pupillary sign
|
Midsized and reactive
|
70
|
76.9
|
Unilaterally fixed
|
20
|
22.0
|
Bilaterally dilated
|
1
|
1.1
|
Associated extracranial injury
|
No
|
77
|
86.6
|
Extremity bone fracture
|
9
|
9.9
|
Chest injury
|
4
|
4.4
|
Mandibular fracture
|
1
|
1.1
|
CT scan findings and Type of Hematoma
The majority of the patients had acute epidural hematoma 62 (68.1%) followed by sub-acute subdural hematoma 12 patients (13.2%) whereas, the rest were caused by acute and chronic subdural hematoma in 10 (11%) and 7 (7.7%) patients respectively. Forty-seven patients (51.6%) had right side hematoma while 39(42.9%) had left side hematoma. Five patients had hematomas on both sides. The majority of patients 44 (48.4%) had hematoma volumes of greater than 60cc followed by 38 (41.8%) of the patients had hematoma volumes between 30 and 59 cc. Thirty-eight patients (41.8%) had no midline shift or less than 3mm if at all followed by those having midline shift of greater than 5mm, 37 patients (40.7%). Linear skull fracture, DSF, and contusion were seen in 26(28.6%), 21(23.1%), and 16(17.6%) patients respectively (Table 4).
Table 4: Type of Hematoma, lateralization volume and other CT scan findings of neurosurgery patients admitted at Surgery unity of JUMC from June to December 2020.
Variable
|
Categories
|
Frequency
|
Percent
|
Type of hematoma
|
Acute epidural
|
62
|
68.1
|
Acute subdural
|
10
|
11.0
|
Sub-acute subdural
|
12
|
13.2
|
Chronic subdural
|
7
|
7.7
|
Hematoma lateralization
|
Right
|
47
|
51.6
|
Left
|
39
|
42.9
|
Both
|
5
|
5.5
|
Volume in cc
|
<30
|
9
|
9.9
|
30-59
|
38
|
41.8
|
≥60
|
44
|
48.4
|
Midline shift in mm
|
<3
|
38
|
41.8
|
4-5
|
16
|
17.6
|
>5
|
37
|
40.7
|
Other CT scan findings
|
Linear skull fracture
|
26
|
28.6
|
DSF
|
21
|
23.1
|
Contusion
|
16
|
17.6
|
Management and anesthesia types and surgical intervention
Among the 91 patients, 79 (86.8%) were operated and 12 (13.2%) patients were managed conservatively. Mannitol was given for 44(48.4%) patients. Five patients were admitted to ICU. Among the operated patients 62 (78.5%) took general anesthesia and the remaining 17 patients (21.5%) took local anesthesia. Craniotomy & evacuation were the leading procedure done for 41 patients (52%) followed by elevation & evacuation and burr hole (Table 5).
Table 5: Management and anesthesia types and surgical intervention
Variable
|
Categories
|
Frequency
|
Percent
|
Management type
|
Conservative
|
12
|
13.2
|
Operative
|
79
|
86.8
|
Mannitol given
|
Yes
|
44
|
48.4
|
No
|
47
|
51.6
|
ICU admission
|
Yes
|
5
|
5.5
|
No
|
86
|
94.5
|
Type of anesthesia
|
Local anesthesia
|
17
|
21.5
|
General anesthesia
|
62
|
78.5
|
Type of surgical intervention
|
Burr hole
|
17
|
21.5
|
Craniotomy and evacuation
|
41
|
52
|
Elevation and evacuation
|
21
|
26.5
|
Discharge Outcome
Among the managed patients, 81 had improved discharged while 10 patients had died. Sixty-one
Patients had good neurologic outcomes while 16 had some disability followed by 10 dead patients. Four patients had a severe disability but there was no patient with a vegetative state in this study. Primary brain injury and respiratory failure were the major causes of death accounting for the death of six and four patients respectively (Table 6).
Table 6: Total discharge outcome and Neurologic outcome and causes of death.
Discharge outcome
|
Categories
|
Frequency
|
Percent
|
Improved
|
81
|
89
|
Died
|
10
|
11
|
Neurologic outcome
|
Good
|
61
|
67
|
Some disability
|
16
|
17.6
|
Severe disability
|
4
|
4.4
|
Died
|
10
|
11
|
Cause of the death
|
Primary brain injury
|
6
|
60
|
Respiratory failure
|
4
|
40
|
Cross tab of gender, age, type of hematoma, Increased ICP, and aspiration versus discharge outcome
Out of the 10 dead patients, seven were males and three were females. Reproductive age groups account for seven of the death out of 10. Among the 10 dead patients, 6(60% of dead) had acute epidural and 3(30% of dead) had acute subdural while the rest of one patient had a sub-acute subdural hematoma. Eight of the dead patients had hematoma volumes of equal or greater than 60 cc. Eleven patients had increased ICP of which 7 patients had died. Nine patients had an aspiration of which 7 had died (Table 7). There is a significant relationship between increased ICP & aspiration, and death (OR=44.9 and OR=92.167 respectively). Nine of the dead patients had other CT findings but there is no statistically significant relationship with the outcome. Eight of the 10 dead patients had a severe head injury (GCS=3-9). Patients with moderate head injury tend to have less risk of death than those with severe head injury (OR=0.031). Patients having pupillary signs tend to have more risk of dying than patients with the reactive pupil (OR=9.571) (Table 8).
Table 7: Cross tab of gender, age, type of hematoma, Increased ICP, and aspiration versus discharge outcome.
Discharge outcome
|
Gender
|
Age categories
|
Male
|
Female
|
<15
|
15-49
|
≥50
|
Improved
|
66
|
15
|
15
|
50
|
16
|
Died
|
7
|
3
|
0
|
7
|
3
|
Total
|
73
|
18
|
15
|
57
|
19
|
Discharge outcome
|
Type of hematoma
|
Acute epidural
|
Acute subdural
|
Sub-acute subdural
|
Chronic subdural
|
Acute epidural
|
Improved
|
56
|
7
|
11
|
7
|
56
|
Died
|
6
|
3
|
1
|
0
|
6
|
Total
|
62
|
10
|
12
|
7
|
62
|
Discharge outcome
|
Increased ICP
|
Aspiration
|
Yes
|
No
|
Yes
|
No
|
Improved
|
4
|
77
|
2
|
79
|
Died
|
7
|
3
|
7
|
3
|
Total
|
11
|
80
|
9
|
82
|
Table 8: Binary logistic regression of increased ICP, aspiration, GCS categories, and pupil sign versus discharge outcome.
Variables
|
Categories
|
B
|
OR
|
95% C.I.for EXP(B)
|
p-value
|
Increase ICP
|
No
|
|
1
|
|
|
Yes
|
3.805
|
44.9
|
(8.32, 242.23)
|
<0.001
|
Aspiration
|
No
|
|
1
|
|
|
Yes
|
4.524
|
92.167
|
(13.12, 647.16)
|
<0.001
|
GCS categories
|
3-9
|
|
1
|
|
|
10-13
|
-3.466
|
0.031
|
(0.005, 0.202)
|
<0.001
|
>13
|
-22.041
|
.000
|
|
.997
|
Pupil sign
|
Midsize reactive
|
|
1
|
|
|
Unilaterally fixed
|
2.259
|
9.571
|
(2.134, 42.931)
|
.003
|
Bilaterally fixed
|
24.309
|
36078938157
|
.000
|
1.000
|