Refractory intracranial hypertension (RICH) is the main factor associated with an increased risk of death and/or morbidity in acute brain injury patients.[12,13,40] Currently, decompressive craniectomy (DC) and basal cisternostomy are the only surgical treatments of last resort for RICH.[4,14,18] DC is a long-standing neurosurgical technique that is experiencing a resurgence of interest due to the worldwide increase in traumatic brain injury (TBI) (69 million/year).[24] The Brain Injury Association of America defines TBI as an impairment of brain function or other evidence of brain injury caused by mechanical force.[34] DC is a major public health problem, particularly in low- to middle- income countries, where it places a heavy burden on the healthcare system.[7,36] Road accidents are the leading cause of TBI in developing countries, particularly in sub-Saharan Africa, where almost 90% of global TBI deaths are concentrated (5 million/year).[1,9,24,36] Nevertheless, the indications for DC must be rigorous, as the severity of cerebral lesions and comorbidities greatly influence the postoperative course.[21,24,42]
A multidisciplinary approach is required for patients who have undergone DC. However, this approach faces many challenges at the National Hospital of Niamey (NHN). The main challenges are, first, the absence of universal health coverage to cover the cost of care, which is too high in relation to the average purchasing power of the Niger population. This cost is particularly high because of the need for a second cranioplasty surgery and rehabilitation care.[4] Second, the neurosurgical operating theatre does not meet international neurotrauma standards. Third, it is essential to highlight the absence of a neuroresuscitation unit for the management of massive traumatic brain injury and of a specialized rehabilitation service for the management of severe disability.
Faced with these challenges, we conducted a study at the NHN to analyze the quality of management and prognosis of patients with DC; and to identify the impact of limited resources, which are typical of low- to middle -income countries, on patient management.
CONTEXT
Niger, with a surface area of 1,267,000 km², is the largest country in West Africa. It is a landlocked country situated between latitudes 11°37 and 23°33 North, and longitudes 0°06 and 16° East. It is bordered to the north by Algeria and Libya, to the east by Chad, to the south by Nigeria and Benin, and to the west by Burkina Faso and Mali. Administratively, it is subdivided into eight regions (Agadez, Dosso, Maradi, Tahoua, Tillabery, Zinder, Diffa and Niamey), which are divided into 67 departments. According to the latest data published in December 2022, Niger’s population was estimated to be 23,591,983. The population is unevenly distributed across the country, with the highest average density occurring in the capital (Niamey), at 5,356.6 inhabitants/Km2, compared with an average density of 18.6 inhabitants/Km2 nationwide. The population is also characterized by extreme youth (56.3% are under 15), and more than over 84% of the population lives in rural areas. The national electrification rate was 17.9%. On the economic front, the primary sector contributes 36.5% of the gross domestic product (GDP), which earned it 131st place in the “doing business 2021” ranking. On the health front, indicators showed insufficient health coverage (53.2%), with 4051 registered health facilities and 1132 practicing doctors, for a percentage of 20,841 inhabitants per doctor (the World Health Organization standard is one doctor per 10,000 inhabitants). Note that Niger’s health policy is focused mainly on the management of infectious diseases (malaria, tuberculosis, hepatitis, pneumonia, AIDS, etc.), childhood illnesses (infant malnutrition, diarrhea, vaccinations, etc.) and the activities of maternity units.[32,35]
The history of neurosurgery in Niger began with the return of the late Professor SANOUSSI Samuila from Strasbourg to NHN in the late 1990s. He was instrumental in establishing the first neurosurgery department (36 beds) and installing the country’s first computed tomography (CT) scanner.[5,30] Today, Niger has four functional neurosurgery departments, with fourteen active neurosurgeons, i.e., one neurosurgeon for every 1,685,142 inhabitants, half of whom live at the NHN hence a strong referral to this hospital. Multidisciplinary management of neurotrauma patients is difficult because of the lack of specialized medical staff (five intensive care physicians and one rehabilitation physician for the entire hospital). Only one of the twelve operating theaters is dedicated to neurosurgical activities (emergencies and scheduled surgery), with an average of four to five patients per day. This operating room no longer meets international standards because most cranial flaps are performed in an old fashion (using drill bits and a Gigli saw), which significantly increases the operating time. Hemostasis is performed almost exclusively with bipolar forceps because of the recurrent shortage of hemostatic products. The latter, the ventriculoperitoneal shunt kit, and osteosynthesis materials such as trauma screws and Roy Camille plates are available at the patient’s expense. This situation has an impact on the time taken and quality of treatment because of the low purchasing power of the general population.