Outcome of traumatic brain injury and its associated factors among pediatrics patients treated in Amhara national regional state comprehensive specialized hospitals, Ethiopia 2022.

Traumatic brain injury is physical insult that happen once the brain is exposed to an excessive external force and the common clinical presentation after trauma is confusion, loss of consciousness, coma and seizure.¹

Traumatic brain injury is more common in children. There are a variety of contributing factors that make children more vulnerable to TBI, including the size of their of head is larger than their body weight and other physiologic aspects ². Fall from a height, road traffic accidents, and direct head trauma are the most prevalent causes of traumatic brain injury in children ³.

Previous study showed that worldwide prevalence and incidence of Traumatic brain injury in children is continuing to be a serious community health concern, with 47 to 280 traumatic brain injury cases per hundred thousand children.⁴

In USA, study showed that yearly 99,796 of children were die due to traumatic brain injury .⁵ As well as Study conducted in resource limited Low- and Middle-Income countries reveled that mortality among traumatic brain injury of children was 7.3% ⁶

Previous study in African study found that high burden of deaths due to trauma-related brain injury among children. According to those study, traumatic brain injury caused 41.8 %, 18.75 %, and 8% of deaths in Egypt, South Africa, and Sub-Saharan Africa, respectively. ^{3, 7, 8}

In Ethiopia study suggest that trauma is one of major public health challenge and the most prevalent contributing reasons include RTAs, falls, and animal-related injuries, however there is scarcity of data towards outcome of TBI and associated factors in children. ^{9, 10}

Different study shows that unfavorable outcome of traumatic brain injury in children is still higher and one of the major community heath challenges in worldwide. Such as, study conducted in Europe 10 % , Netherlands 5%, Germany 27.6% and in Singapore 30% .^{11, 12, 13, 14}

A study conducted in India found that 10.6% of children who suffer traumatic brain injuries have unfavorable outcomes. ¹⁵ And other similar study done in China 12.6% death among all TBI and in Pakistan among decompressive craniotomy of severe TBI 36 % of children results unfavorable outcome of traumatic brain injury of children. ^{16, 17}

Study conducted in Qatar National Trauma Center showed that 13% and Saudi Arabia 14.8% children was reported that unfavorable outcome from TBI. ^{18, 19}

In resource limited setting of low- and middle-income country different study revealed that death of children’s from TBI are still high such as study done in south Africa 18.75% , in Togo at Sylvanus Olympio University Hospital 31.9 % , in Uganda 35% and in Egypt at Cairo University Hospitals 41.7% of TBI in children. ^{3, 7, 20, 21}

Study conducted in Sub-Saharan Africa showed that the overall mortality from traumatic brain injury of children was report that 8% and other cross-sectional study done in age of under 14 children in south Ethiopia Hawassa University Compressive Specialized Hospital revealed that 15.8% of TBI children results unfavorable outcome .^{8, 10}

According to WHO and other similar worldwide study revealed that age of less than four and male children was associated with unfavorable outcome pediatric TBI in children. ^{4, 22} Other study conducted by Centers for Disease Control and Prevention showed that rural residence is significantly higher in hospitalization and death among TBI children .²³

Study done in France revealed that educational level of children and parental education level significantly associated with outcome of TBI. ²⁴ However, study done on under age of 14 in Ethiopia Hawassa University Hospital showed parental education level were not associated with outcome of TBI of children. ¹⁰

Different Study revealed that RTA the most common Mechanism of traumatic brain injury of pediatrics traumatic brain injury such as, study in German , Sub-Saharan Africa and Ethiopia .^{8, 10, 25, 26}.However ,study conducted in USA ,in Netherland , Hong Kong and India shows that fall down accident was the major cause of TBI among children ^{14, 27, 28, 29} Other study conducted in China reveled that assaults was the most common mechanism of traumatic brain injury in children ³⁰.Study done in India reveled that TBI of children who had additional injury with chest and spinal cord significantly associated with unfavorable outcome.And other similar study in and chain showed that TBI children who had chest injury significantly associated with unfavorable outcome ^{15, 16} .

Early availability of TBI patient in hospital for neurotrauma management is very crucial for early privation of ongoing pathological brain injury. ³¹ study in Uganda and Pakistan revealed that let to hospital presentation more than four hours is associated with unfavorable outcome. ^{17, 32} And other study in United States reveled that short (< 1day) in hospital length of stay associated with unfavorable outcomes of traumatic brain injury. ³³

Pathophysiology of TBI classified as Primary brain injury which occurs during at time of trauma includes soft tissue injury , bleeding in to extra axial (epidural ,sub Dural, subarachnoid space and intraventricular), skull fracture and intracranial lesions (DAI, cortical contusion and vascular injury) and were as secondary brain injury occurs after trauma due to hypotension, hypoxia and increased ICP which is significatively associated with unfavorable outcome. ^{29, 34, 35}

A systematic study conducted in Europe, as well as other studies in, Hong Kong, Germany and Pakistan, showed that having a skull fracture on a CT scan finding were significantly associated with a unfavorable outcome of traumatic brain injury in children .^{17, 25, 26, 27}

Immediate management of TBI needs multidisciplinary approach such as resuscitation, management airway , intubation when GCS < 8 TBI, monitoring ICP, prevention of secondary TBI and neurosurgical management. ^{36, 37}

Study conducted in USA, Singapore, and Ethiopia reveled that Presence of ICP were significantly associated with unfavorable outcome of traumatic brain injury .^{10, 11, 38}

In Germany Study conducted in short term outcome of severe TBI showed that decompressive craniotomy significantly associated with unfavorable outcome of TBI. ¹² other similar study done in India shows that sever TBI and Fixed bilateral dilated pupil significantly associated with unfavorable outcome of TBI in children. ¹⁵

Study conducted in Singapore showed that clinical presentation of vomiting, severity of TBI , hypotension, use of inotropic and comorbid with anemia significantly associated with unfavorable outcome. ¹¹And other similar Study in chain shows that SAH significantly associated with unfavorable outcome. ¹⁶ Study in Togo was reported that presence hypotension , comorbidity with anemia, hyperthermia and GCS of < 6 associated with unfavorable outcome of TBI. ²¹ Other similar study conducted in, Singapore , Ankara Turkey and Hawassa Ethiopia showed that hyperglycemia were significantly associated with unfavorable outcome of TBI ^{10, 39, 40}.

There were 3,384 TBI in pediatrics visited in Amhara National Regional State Comprehensive Specialized Hospitals during the past three years, from January 1, 2019 G.C to December 30, 2021G.C. Data were gathered by using data extraction tools, and 404 charts had complete documentation from 423 randomly selected charts, with a response rate of 95.5 %.

The aim of this study was to evaluate the outcome of traumatic brain injury and associated factors in pediatric patients seen at Amhara National Regional State Comprehensive Specialized Hospitals in Ethiopia. The overall prevalence of unfavorable outcome of traumatic brain injury among pediatrics patients was found that 12.13 % (95 % CI: 9.1 % - 15.7 % ).This study finding was consistent with study conducted in India 10.7 % (15) and study conducted in Saudi Arabia 14.8% (19) . In contrast, it was higher than study conducted in Netherlands 5% (12) . This difference could be due to variability in socio demographic states, study design and availability of advance equipment like CT-scan and MRI. On the other hand , the current study result was lower than study conducted in Mulago National Referral Hospital in Uganda 21.25% (20). The possible discrepancy may be due to difference in study setting, study design and study period it was conducted in community based and long term follow up study.

The findings of this study indicated that pediatrics with severe TBI 5.11 times and moderate TBI 2.44 higher risk of unfavorable outcomes than those who had mild traumatic brain injury. This finding were consistent with in study conducted in Germany, Singapore and Togo.^{11, 12, 21} The similarities may be due to increased risk for secondary brain injury in severe and moderate TBI cases , like hypoxia, and elevated intracranial pressures. ^{29, 34, 35}

This study also revealed that Hyperglycemia in traumatic brain injury pediatrics patients were 3.01 times more likely to develop unfavorable outcome than those with normal range of blood glaucous level , This study finding in line with study conducted in Singapore , Ankara Turkey and Hawassa Ethiopia. ^{10, 39, 40} Possibility explanation could be impaired cerebral mitochondrial dysfunction following TBI and acute stress response causes hyperglycemia, which worsens impairments of microcirculatory blood flow, increases blood-brain barrier permeability, promotes inflammation, triggers osmotic diuresis, hypovolemia, and immunosuppression .^{27, 40, 58}

The odds of unfavorable outcome among those TBI pediatrics patients who had sign of increased intracranial pressures 7.4 times higher than those who had not increased intracranial pressures signs , This finding is supported by a study done united states of America, Singapore and Hawassa Ethiopia (10,11,38). This may due to the fact that brain tissue itself is swelling from injury that the fluid under pressure tends to deform the brain and pushes tissue results Diffuse cerebral ischemia of the brain (60,61).

This study finding showed that the odds of having unfavorable outcome from TBI pediatrics patients were 2.65 times higher in those having medical comorbidity than those had no medical comorbidity. This finding in line with study conducted in Togo and Singapore. ^{11, 21} The possible explanation of similarity may be due to having comorbid medical illness like anemia, epilepsy and heart failures compromise adequate oxygenated blood supply to the brain .^{62, 63}

One of the study's limitations was dealing with insufficient data from the patients' charts. However, data collators received training, and incomplete chart was treated as a non-response and lack of local data for comparison and conclusion.

According to this study, about twelve present of traumatic brain injury of pediatrics patient results unfavorable outcome and the most common predictive factors associated with unfavorable outcome of traumatic brain injury were severity of traumatic brain injury, signs of increased ICP, hyperglycemia and medical comorbidity. This study indicates that need for precaution and appropriate management for moderate and sever form of traumatic brain injury, sign of increased intracranial pressures, hyperglycemia and medical comorbidity. To address possible risk factors including children's educational backgrounds, families, and other variables that are not properly captured from patient charts, it is preferable to conduct prospective studies.

The authors are grateful for university of Gondar, hospitals administration staff for their cooperation and helpful information, data collectors' and supervisor’s cooperation throughout the data collection.

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