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Original Research (Original Article) 


Qasem Alalwan et al, 2019;3(8):663–668.

International Journal of Medicine in Developing Countries

Cross-sectional imaging of head trauma: a retrospective analysis of the incidence and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia

Qasem Alalwan1†, Hisham Al Dossary1†, Hassan A. Alsayegh2*, Maram Alothman2

Correspondence to: Hassan Ali Alsayegh

*Radiology Department, King Faisal University, College of Medicine, Al-Ahsa, Saudi Arabia.

Email: has.alsayegh [at] gmail.com

Full list of author information is available at the end of the article.

Received: 06 January 2019 | Accepted: 09 March 2019

†These 2 authors contributed equally to be the first author.


ABSTRACT

Background:

Traumatic brain injury (TBI) occurs when an external force injures the brain. A motor vehicle accident is the leading cause of brain trauma or brain injuries. It is one of the major etiologies of morbidity and mortality nationally and internationally, occurring in all age groups. Imaging plays an essential role in diagnosing or ruling out TBI. Brain computed tomography (CT) scan is the modality of choice in case of acute brain-related injuries. Brain magnetic resonance imaging (MRI) is more sensitive and is employed mostly in detecting tiny lesions happening due to TBI. The current study aims at the retrospective analysis of the incidence and imaging findings of TBI in King Fahad Hospital, Al-Ahsa, Saudi Arabia.


Methodology:

A retrospective study was conducted at the trauma center in King Fahad Hospital, Al-Ahsa, Saudi Arabia during the period from October 2016 to October 2018. The study assessed the demographic data and the primary and secondary brain lesion images of the study subjects.


Results:

The study assessed 487 brain CT-scan images of 382 male and 105 females. The age group between 20 and 29 years of age was the highest among the assessed brain injury findings (brain CT scans). Brain contusions, subarachnoid hemorrhage, and acute epidural hemorrhage were the common brain injuries found during the study. Brain MRI was conducted for 31 patients among the total studied subjects (487) after a negative brain CT-scan.


Conclusion:

The study found motor vehicle accidents to be the most common cause of head traumatic injury locally and worldwide. MRI was found to be beneficial in detecting minor lesions in case of TBI.


Keywords:

Traumatic brain injury, computed tomography, magnetic resonance imaging, Al-Ahsa.


Introduction

Traumatic brain injuries (TBIs) are one of the major causes of disability, mortality, and medical costs internationally, especially among the population under the age of 44 [1]. The mean value of the number of hospitalized patients with fatal TBI in Europe is 235 per 100,000 and it is almost double in the US [2]. About 50,000 deaths occur annually in the US, and 1.4 million TBIs globally costing $60 billion annually [3,4]. In the Kingdom of Saudi Arabia, an 8-year retrospective study reported 1,219 patients below the age of 18 years to be diagnosed with TBI [5]. Motor vehicle crash-related head injuries were the leading cause of these injuries [6,7]. Currently, there are several clinical guidelines available for the diagnosis and management of mild TBI [8]. TBI consists of multiple pathological entities and it is defined by an “alteration in brain function,” otherwise evidence of other brain pathology which could be caused by an external force [9]. Imaging plays an important role in assessing and diagnosing TBI cases, especially it plays a valuable role for triage in the acute setting to determine the patients who require emergent neurosurgical intervention. The imaging modality of choice for evaluation of the acute injuries of the head is computed tomography (CT). It is non-invasive, quick, and widely accessible and has limited contraindications. CT pros are valuable in the assessment of TBI, including its sensitivity for demonstrating acute intra-axial and extra-axial hemorrhage, ventricular size, mass effect, and bone fractures. The limitations include low sensitivity in detecting small non-hemorrhagic lesions like cortical contusions and diffuse axonal injuries (DAIs), as well as an inability to detect early demonstration of hypoxic-ischemic encephalopathy [10]. In contrast, magnetic resonance imaging (MRI) is more sensitive than CT in detecting small post-traumatic focal brain lesions. It is seldom performed in the acute setting of TBI because of the complex logistics involved in patient transport and monitoring, long imaging time, and its sensitivity to the patient [11]. MRI is considered the modality of choice for patients with subacute and chronic TBI and is recommended for patients with acute head trauma when CT fails to explain the neurological findings. Thus, the radiologist and treating practitioner should be familiar with different imaging findings of TBI cases and their impact on clinical presentation, prognosis, and management. In the current study, the primary goal was to determine the frequency of the brain CT-scan findings, MRI findings after a negative CT-scan with TBI and patients who required urgent neurosurgical intervention. Our secondary objective was to analyze the demographic data and mechanism of TBI in the Al-Ahsa region of Saudi Arabia.


Subjects and Methods

A retrospective study was conducted including all cases of TBI reported during the period between October 2016 and October 2018 in King Fahad Hospital, Al Ahsa. The King Fahad Hospital in Al Ahsa, Saudi Arabia has a 500-bed capacity and is one of the frequent accessed reference hospital and trauma center in the region serving about 40,000 beneficiaries, with 18,000 inpatients, in addition to performing 5,818 surgeries. A data registrar was employed to collect the data and perform its appropriate review. The data questionnaire included a part that covered demographic characteristics, including patient gender and age, and the other part focused regarding domains, including etiology, location, and mechanism of injury, radiological findings, and diagnosis of various forms of TBI. The data collected included primary brain lesions which are acute epidural hematoma, acute subdural hematoma, subarachnoid hemorrhage, contusions, intracerebral hematoma, and DAI. The data also contained information regarding secondary brain injuries, including brain herniation, hydrocephalus, and brain edema [12]. Patients were stratified according to the mechanism of head injury and their radiological findings. The inclusion of all age groups from both genders randomly underwent CT-scan at the Department of Radiology in King Fahad Hospital, Al-Ahssa in the setting of head trauma which was randomly included, utilizing the hospital picture archiving and communication system data. Excluded samples included inconclusive diagnosis or inappropriate imaging and imaging that does not reveal any brain injury. A review of the findings was done by a senior radiology resident or specialist and then verified by radiology consultant to whom both final diagnosis and study report were strictly obscured to prevent bias.

All the data were entered into a computer-based database and data analyzed using Statistical Package for the Social Sciences (SPSS 24.0). Descriptive statistics was represented in the form of mean and standard deviation. Data were presented as proportions and frequencies. In order to determine the risk factors for the presence of intracranial pathology in patients with mild TBI, the study group compared the variables between a two-sided p-value of less than 0.05 considered statistically significant.


Results

A total of 487 brain CT-scans were included in the study covering radiographs of 105 (21.6%) females and 382 (78.4%) males. Patients aged between 20 and 29 years old (29.6%) were the most common age group that performed brain CT-scan after a brain injury, compared with patients aged between 50 and 59 (4.9%) which were the least common group that had done brain CT-scan without having a brain injury. Overall, 82.8% of the patient who had brain injury was not admitted in the hospital and 17.2% were admitted for multiple reasons. The most common mechanism of injury was motor vehicle accident which represents (60%) of all patient who had performed brain CT-scan, followed by fall (38%) and hit (2%) (Table 1). There were eight (1.6%) among the studied subjects who underwent neurosurgical intervention. Also, there were 31 (6%) of patients who underwent brain-MRI study after a negative brain CT-scan. There were 16 subjects who had a positive finding in MRI after a negative CT-scan (Table 1). Regarding the CT finding that has been found among the study subjects, brain contusion represented the majority of brain injuries (8.2%), followed by acute subarachnoid hemorrhage (6.6%), acute epidural hematoma (4.9%), brain edema (4.6%), acute subdural hematoma (4.3%), intracerebral hematoma (3.7%), and brain herniation represents 1.8%. Among the studied subjects, 0.8% of cases were found to have pneumocephalus. 0.6% of the cases were found to have a DAI and incidental arachnoid cyst. Furthermore, 0.4% of the cases were found to have cerebellar hematoma and hydrocephalus. Consequently, 0.2% of cases were found to have encephalomalacia and cisterna magna (Fig. 1). The present study found a strong relationship between age and type of brain injury but was statistically insignificant (p-value ≥ 0.05). The present study also compared the gender and type of brain injury and found no significant relationship between them. Also, the relationship between the mechanism of injury and primary brain lesion was compared and we found that subarachnoid hemorrhage, brain contusion, and brain edema had a significant relationship. Nevertheless, we found a significant relationship between the mechanism of injury and age (Table 2). Mechanism of injury was stratified by age groups. TBI caused by fall encountered with (<10) age group. On the other side, TBI caused by motor vehicle accident encountered with 20–29 age group. Moreover, TBI resulted from hit injury to the skull was minor even in younger subjects (Fig. 2; Table 3).

Table 1. The baseline characteristics of the 487 subjects with a TBI.

Variable Value
Gender
   Male 382 (78.4%)
   Female 105 (21.6%)
Age
   <10 102 (20.9%)
   >60 35 (7.2%)
   10–19 66 (13.6%)
   20–29 144 (29.6%)
   30–39 76 (15.6%)
   40–49 40 (8.2%)
   50–59 24 (4.9%)
Mechanism of Injury
   Motor vehicle accident 291 (60%)
   Fall 185 (38%)
   Hit 11 (2%)
Patient admitted?
   Yes 84 (17.2%)
   No 403 (82.8%)
The patient did MRI after negative CT?
   Yes 31 (6%)
   No 456 (94%)
A positive finding in MRI?
   Yes 16
   No 15
The patient underwent neurosurgical intervention?
   Yes 8 (1.6%)
   No 479 (98.4%)
Positive CT finding
   Yes 386
   No 101

Figure 1. CT-scan findings.


Discussion

This study was aimed at determining the frequency of TBIs in relation to demographic factors and etiology. The present study found 487 subjects who underwent CT-scan for TBI during the study period. It was predicted that male proportion was higher than female due to the increase in the incidence of motor vehicle accidents. The cause may be attributed to the law that male-only can drive motor vehicles in the last centuries in Saudi Arabia. The trend of young males affected more than females was mostly reported in all studies over the last 2.5 decades with some variations in the type of estimates among regions and the period of reporting [13]. The 20–29 age group was the most commonly affected age group in the studied subjects who had performed a brain CT-scan. According to a previous study, 47% of TBI subjects were between 11 and 30 years of age [14]. In a systematic review conducted in Saudi Arabia, young age subjects were more affected as the youth in Saudi Arabia consider car driving as a kind of entertainment, as other alternatives are barely available, such as sports arenas, amusement parks or gyms, and others [13]. There were 17.2% of admissions due to causes that were directly or indirectly related to brain injuries, such as neck pain, spinal injury, severe vomiting, severe brain injury, multiple injuries, follow-up studies, and dizziness. In our study, most of TBI were caused by motor vehicle accident (60%), followed by fall (38%) and hit to the skull (2%). A similar study has been done in another Asian country which showed totally, 41.75% of head injuries reported due to vehicle accidents, 30.01% due to various types of falls, and 7.93% due to assault by body forces [15]. In a prospective cohort study of the highest incidence of falls and injuries due to cycling has been reported between 1–9-years-old and 10–18 years-old age groups [16]. In Australia, it has been reported that motor accident, falls, and assaults are three main causes of trauma in the last 10 years [17]. TBI, especially acute head and neck traumas are one of the major causes of death and loss of heterogeneity (LOH) in Hamadan province. Therefore, attention to the identification and well-established trauma care system in this province is a top priority [15]. Most prevalent three findings of brain CT-scan finding in this study were related to brain contusions (8.2%), acute subarachnoid hemorrhage (6.6%), and brain edema (4.6%). Among the total, 31 of the subjects underwent MRI after a negative CT-scan and 16 of them revealed a positive finding which may or may not be related to TBI. In a study comparing 40 children with TBI between CT-scan and MRI showed that each of these magnetic resonance sequences had varied specificity of lesion type detection, all were shown to be sensitive in detecting lesions associated with outcome in children with TBI [17]. MRI findings after brain CT-scan include brain contusions, DAI, epidural collections, and subdural collections. Furthermore, the reason for requesting MRI to those subjects was related to the persistence of neurological symptoms. Moreover, the reason for neurosurgical intervention in those subjects was the presence of brain herniation, brain compression with effaced sulci, hematoma evacuation, and paresis. Overall, prevention programs are very effective in reducing morbidity and mortality worldwide. Police records report a 27% significant reduction in TBI cases during the years 2005–2010 [18]. The use of seatbelts for cars and helmets for motorcyclists could reduce the incidence of axial and non-axial injuries to a larger extent [19,20].

Table 2. Presence of CT-scan findings according to gender and mechanism of injury.

Type of brain injury Male Female Total p-value Fall Hit MVA p-value
   Acute epidural hematoma 22 2 24 0.106 4 1 19 0.081
   Acute subdural hematoma 19 2 21 0.170 4 0 17 0.121
   Subarachnoid hemorrhage 29 3 32 0.083 4 4 24 0.000
   Contusions 36 4 40 0.063 5 6 29 0.000
   Intracerebral hematoma 17 1 18 0.092 4 0 14 0.264
   Diffuse axonal injury 3 0 3 0.362 0 0 3 0.362
   Microangiopathy 0 3 3 0.362 0 0 3 0.362
   Cerebellar hematoma 2 0 2 0.0457 0 0 2 0.508
   Encephalomalacia 1 0 1 0.600 0 0 1 0.714
   Pneumocephalus 4 0 4 0.292 0 0 4 0.257
   Arachnoid cyst 3 0 3 0.362 0 0 3 0.362
   Mega cisterna magnum 1 0 1 0.600 0 0 1 0.714
   Brain Edema 28 3 31 0.096 4 4 23 0.000
   Hydrocephalus 2 0 2 0.457 0 0 2 0.508
   Brain herniation 8 1 9 0.442 1 0 8 0.197

MVA, motor vehicle accident.

Figure 2. Mechanism of injury according to age groups.

Table 3. Data collection form.

Characteristics of interviewees
Gender Male
Female
Age <10
10–20
20–30
30–40
40–50
50–60
>60
Mechanism of Injury Fall
Motor vehicle accident
Hit
Unknown
CT findings 1. Primary brain damage
A. Acute epidural hematoma
B. Acute subdural hematoma
C. Subarachnoid hemorrhage
D. Contusions
E. Intracerebral hematoma
F. Diffuse axonal injury
 
2. Secondary brain injuries
A. Brain Herniation
B. Hydrocephalus
C. Brain Edema
D. Normal
MRI done after negative CT? Yes
No
If Done. What additional MRI Finding?  
Patient admitted? Yes
No
Did patient undergo neurosurgical intervention? Yes
No

Conclusion

The most common cause of traumatic brain injury is motor vehicle accidents locally and worldwide, followed by falls and direct trauma affecting the skull. Age group between 20 and 39 years of age was the most common age group who has performed CT-scan of the brain to rule out TBI. Brain contusion was the most commonly encountered brain lesion in CT-scan post-TBI. MRI may have a role in detecting minor lesions in case of TBI.


List of Abbreviations

CT Computed tomography
DAI Diffuse axonal injuries
MRI Magnetic resonance imaging
SPSS Statistical Package for the Social Sciences
TBI Traumatic brain injury

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Not applicable.


Ethical approval

The research was approved by the committee of Research & Ethics in the College of Medicine, King Faisal University. Letter no. 05/01/2018. Dated 4/11/2018.


Author details

Qasem Alalwan1, Hisham Al Dossary1, Hassan A. Alsayegh2, Maram Alothman2

  1. Radiology Department, King Fahad Hospital, Al-Ahsa, Saudi Arabia
  2. Radiology Department, King Faisal University, Al-Ahsa, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alalwan Q, Dossary HA, Alsayegh H, Alothman M. Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. IJMDC. 2019; 3(8): 663-668. doi:10.24911/IJMDC.51-1546788085


Web Style

Alalwan Q, Dossary HA, Alsayegh H, Alothman M. Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. http://www.ijmdc.com/?mno=24855 [Access: September 23, 2019]. doi:10.24911/IJMDC.51-1546788085


AMA (American Medical Association) Style

Alalwan Q, Dossary HA, Alsayegh H, Alothman M. Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. IJMDC. 2019; 3(8): 663-668. doi:10.24911/IJMDC.51-1546788085



Vancouver/ICMJE Style

Alalwan Q, Dossary HA, Alsayegh H, Alothman M. Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. IJMDC. (2019), [cited September 23, 2019]; 3(8): 663-668. doi:10.24911/IJMDC.51-1546788085



Harvard Style

Alalwan, Q., Dossary, . H. A., Alsayegh, . H. & Alothman, . M. (2019) Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. IJMDC, 3 (8), 663-668. doi:10.24911/IJMDC.51-1546788085



Turabian Style

Alalwan, Qasem, Hisham Al Dossary, Hassan Alsayegh, and Maram Alothman. 2019. Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. International Journal of Medicine in Developing Countries, 3 (8), 663-668. doi:10.24911/IJMDC.51-1546788085



Chicago Style

Alalwan, Qasem, Hisham Al Dossary, Hassan Alsayegh, and Maram Alothman. "Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.." International Journal of Medicine in Developing Countries 3 (2019), 663-668. doi:10.24911/IJMDC.51-1546788085



MLA (The Modern Language Association) Style

Alalwan, Qasem, Hisham Al Dossary, Hassan Alsayegh, and Maram Alothman. "Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.." International Journal of Medicine in Developing Countries 3.8 (2019), 663-668. Print. doi:10.24911/IJMDC.51-1546788085



APA (American Psychological Association) Style

Alalwan, Q., Dossary, . H. A., Alsayegh, . H. & Alothman, . M. (2019) Cross-sectional imaging of head trauma: a retrospective analysis of the incidence, and imaging findings of traumatic brain injury in King Fahad Hospital, Al-Ahsa, Saudi Arabia.. International Journal of Medicine in Developing Countries, 3 (8), 663-668. doi:10.24911/IJMDC.51-1546788085