¹Senior Resident, ²Professor & HOD, Department of General Surgery, Government Medical College and Hospital, Miraj, Sangli, Maharashtra, INDIA.

Email: kumarplash@gmail.com

TABLE 1: Age and gender in relation to head injury

Road traffic accident was the most common cause of mode of injury (74%). Most common mode of head injury in males were road traffic accident (81%), followed by fall (14%) and assault (5%). In the female population fall was the most common cause of head injury (92%) and road traffic accident (8%) case.

Table 2: Mode of injury.

47(39%) patients had severe head injury according to GCS scoring system (GCS score ≤ 8). The remaining 73(61%) patients had moderate brain injury (GCS score 9- 12).

Table 3: Severity of head injury based on Glasgow coma scale.

In our study EDH and SDH were the most common findings on non-contrast brain CT scan. EDH comprising of 27% and SDH comprising of 26% making the majority 53% of the population. SAH was the third highest finding making up 18% of the population, followed by haemorrhagic contusion (11%) and intra-parenchymal haemorrhage (7%). In 11% of the head injured population CT scan could not be done as they were not in a stable condition. We found out that mortality was least with EDH, none of the patients who was diagnosed with EDH on CT scan imaging died in our study, whereas SDH had the highest mortality as 13 patients out of 44 died due to SDH, SAH and Intra-parenchymal haemorrhage comprised of 7 each mortality and Haemorrhagic contusion resulted only in 3 mortality out of 44. All patients whose CT was not done died eventually as they had severe head injuries.

Table 4: Intracranial findings on CT scan.

99 patients (82%) were managed conservatively with monitoring in the surgical intensive care unit without the requirement of operative intervention. Operative interventions were required only in 21(18%) patients which included Craniotomy (7 patients) and Burr Hole (14 patients).

Table 5: Mode of management

The patients with Favourable outcome i.e. Good recovery and Moderate Disablement were 69, and patients with Unfavourable outcome i.e. severely disabled and who died during treatment were 51. Out of the 108 Male population 63 (58%) had good recovery/moderate disability and 45 (42%) had severe disability/died. Whereas the female population had 6 (50%) favourable outcome and 6 (50%) unfavourable outcome.

Table 6: Gender in relation to outcome.

DISCUSSION

The initial goal of care should be immediate attention to Airway Breathing and circulation (ABC); Early identification of the potential for traumatic brain injury in any trauma victim and minimization of secondary insults, such as hypoxic-ischemic injury" The goal of Traumatic brain injury management is to prevent this secondary insult. In all multi-trauma cases, patients must be treated according to the Advanced trauma life support (ATLS) protocols, because any patient will die much more quickly from systemic injuries than from CNS injuries.⁴In a study by Haroon S. et al.,⁵ 79.2% cases belonged to the first four decades of life, the maximum number of patients were in the age group of 21 to 30 years (25.3%).^.Similar observations have also been made by Tandon et al.,⁶ who reported the mean age of 25.87 years in a series of 681 patients, whereas the mean age of the patients studied by Turazzi; et al.,⁷ was 34 years. Similar findings were noted in present study. The Male to female ratio was 9:1. Different Indian authors noted similar findings, such as Sambasivan M⁸ (15:1), Bharti P⁹ (5.6:1) and Haroon S⁵ (3.5:1). According to the global burden of disease study, India had highest rates of intracranial injury from road traffic accidents.² The Second leading cause of traumatic brain injury related outcomes in India was falls. Injuries are the seventh leading cause of mortality in India and 78% of these deaths are due to road traffic accident alone. Gururaj G.³ et al. noted that road traffic injuries are the leading cause (60%) of traumatic brain injuries. Followed by falls (20% to 25%) and violence (10%). Similar findings were noted in present study. In this study majority of head injuries did not require surgery and were managed conservatively, 99 (82%) out of 120 patients were managed conservatively making it the majority, the causes being that in 13 patients of severe head injury CT scan could not be done, Close relatives of few patients did not give consent for operation given the high risk nature of operation and therefore they were managed conservatively despite surgical indications, rest of the patients did not satisfy the indications for operative interventions. And therefore were managed conservatively. Out of the 21 patients managed operatively 14 patients underwent burr holes and 7 patients underwent craniotomy.12 out of 14 burr hole patients had favourable outcome and only 2 died. 6 out of 7 craniotomy had favourable outcome and only 1 died. We found that EDH had the best outcome. Our study correlates with the findings of the study done by Croce M. et al.,¹⁰ in his study 70% of 83 patients with GCS scores of 11-15 who had subdural hematomas less than 1 cm in width were successfully managed non-operatively with only 6% eventually requiring surgery. Another study by Patel NY et al.,¹¹ of 462 patients with head injuries with CT-imaged intracranial hematomas who were treated non-operatively found that only approximately 10% progressed clinically and eventually required surgery. Zaitun Zakaria et al.,¹² described three cases of EDH and their management, focusing on operative and non-operative treatment. They also reviewed, at that time, the available literature from the past three decades as well as the guidelines for management of EDH. They concluded that EDH can be managed non-operatively provided the GCS remains the same with symptomatic improvement^. A study done by Moussa et al.,¹³ found that 50 patients of EDH were managed successfully by conservative approach without the need of surgery. Many factors in head injury patients have been assessed and analysed, however, now is the time to expand our use of clinical knowledge beyond the Glasgow Coma scale, and create new scoring systems that take other variables like pupillary reactivity into account for establishing prognosis of head injury patients.

CONCLUSION

In this study majority of head injuries did not require surgery and could be managed conservatively, and those patients who were managed operatively with Burr Holes and Craniotomy had good outcome. If conservative approach to head injury management can be shown as a suitable alternative to surgical intervention, it will offer a mode of treatment that has fewer potential complications and risks than the traditional surgical route.

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