Neurotrauma care in Ethiopia: Building for the future
Abstract
Bakgrunn: Nevrotraumer er et stort folkehelseproblem i Etiopia, og hovedmålet med denne oppgaven var å studere behandlingen av nevrotraumepasienter i landet.
Materiale og metoder: Vi brukte prospektive (artikkel I, II og IV) og retrospektive (artikkel III) studiedesign og inkluderte pasienter fra 2012 til 2017. I artikkel I og II studerte vi 1087 opererte hodeskadepasienter i Etiopia. I artikkel III sammenlignet vi 314 etiopiske og 284 norske pasienter operert for kronisk subduralt hematom (KSDH). I artikkel IV studerte vi 117 sykehusbehandlede og 51 rettsmedisinsk undersøkte fallofre med hodeskade eller ryggmargsskade i Etiopia.
Resultater: I artikkel I fant vi at den vanligste årsaken til hodeskade var overfall, mens impresjonsbrudd og epiduralblødning var de hyppigste skadene. Mange pasienter opplevde store forsinkelser, og det var en invers sammenheng mellom skadens alvorlighet og tid til innleggelse. I artikkel II viste vi at de hyppigste operasjonene var elevasjon av impresjonsbrudd og kraniotomi for epiduralblødning. Komplikasjonsraten var 17 % og 3 % av pasientene ble reoperert. I artikkel III fant vi at kirurgisk praksis var lik i Etiopia og Norge, men etiopiske pasienter med KSDH var yngre, hadde mindre komorbiditet, brukte sjelden antikoagulasjon/platehemmer, fikk sjelden postoperativ bildediagnostikk og hadde færre reoperasjoner og medisinske komplikasjoner. I artikkel IV viste vi at de fleste fallofrene ble skadet på byggeplasser, og få brukte verneutstyr. Komplett ryggmargsskade var vanlig blant de innlagte pasientene og få pasienter med ryggmargskade ble operert. Hodeskade var den vanligste dødsårsaken blant rettsmedisinsk undersøkte fallofre og de fleste pasientene døde på ulykkesstedet.
Konklusjoner: Behandling av nevrotraumer i Etiopia er assosiert med betydelige ressursbegrensninger og stor pasientseleksjon både før og etter sykehusinnleggelse. Mange pasienter har imidlertid hatt nytte av utviklingen av nevrokirurgi i Etiopia, og våre studier kan bidra til å forbedre kvaliteten på omsorgen ytterligere, utvikle kostnadseffektive helsetjenester, identifisere fokusområder for forebyggende innsats og veilede lovgivningsprogrammer. Background: Neurotrauma is a major public health problem in Ethiopia, and the main aim of this thesis was to study the management of neurotrauma patients in the country.
Material and methods: We used prospective (paper I, II, and IV) and retrospective (paper III) study designs and included patients from 2012 to 2017. In papers I and II, we studied 1087 surgically treated traumatic brain injury (TBI) patients in Ethiopia. In paper III, we compared 314 Ethiopian and 284 Norwegian patients operated for chronic subdural hematoma (CSDH). In paper IV, we studied 117 hospital-treated and 51 forensically examined fall victims with TBI or spinal cord injury (SCI) in Ethiopia.
Results: In paper I, we found that the most common cause of TBI was assault, while depressed skull fracture (DSF) and epidural hematoma (EDH) were the leading injuries. Many patients suffered significant time delays, and injury severity and time to admission were inversely related. In paper II, we showed that the most frequent operations were DSF elevation and craniotomy for EDH. The complication rate was 17% and 3% of the patients were reoperated. In paper III, we found similar surgical routines in Ethiopia and Norway, but Ethiopian CSDH patients were younger, had fewer comorbidities, rarely used anticoagulants/antiplatelets, infrequently underwent postoperative imaging, and had less reoperations and medical complications. In paper IV, we found that most fall victims were injured at construction sites, and few used protective equipment. Complete SCI was common among hospitalized patients and few SCI patients were operated. TBI was the most common cause of death among forensically examined patients and most patients died at the accident scene.
Conclusions: The management of neurotrauma in Ethiopia was associated with significant resource limitations and substantial patient selection both before and after hospital admission. Many patients have however benefitted from the development of neurosurgical services in Ethiopia, and our studies might help to further improve the quality of care, develop cost-effective health services, identify focus areas for preventive efforts, and guide legislative programs.
Has parts
Paper I: Laeke T, Tirsit A, Kassahun A, Sahlu A, Debebe T, Yesehak B, Masresha S, Deyassa N, Moen BE, Lund-Johansen M, and Sundstrøm T. Prospective study of surgery for traumatic brain injury in Addis Ababa, Ethiopia: Trauma causes, injury types, and clinical presentation. World Neurosurg 2021 May; 149: e460-e468. The article is available in the thesis file. The article is also available at: http://dx.doi.org/10.1016/j.wneu.2021.02.003Paper II: Laeke T, Tirsit A, Kassahun A, Sahlu A, Yesehak B, Getahun S, Zenebe E, Deyassa N, Moen BE, Lund-Johansen M, and Sundstrøm T. Prospective study of surgery for traumatic brain injury in Addis Ababa, Ethiopia: Surgical procedures, complications, and postoperative outcomes. World Neurosurg 2021 Jun; 150: e316-323. The article is available in the thesis file. The article is also available at: http://dx.doi.org/10.1016/j.wneu.2021.03.004
Paper III: Laeke T, Kalleklev L, Tirsit A, Moen BE, Lund-Johansen M, and Sundstrøm T. Surgical treatment and outcome of chronic subdural hematoma: A comparative study between Ethiopia and Norway. Acta Neurochir (Wien) 2023 Jan; 165: 49-59. The article is not available in BORA due to publisher restrictions. The published version is available at: https://doi.org/10.1007/s00701-022-05435-z
Paper IV: Laeke T, Tirsit A, Moen BE, Lund-Johansen N, and Sundstrøm T. Neurotrauma from fall accidents in Ethiopia. The article is not available in BORA.