|Year : 2014 | Volume
| Issue : 2 | Page : 80-84
Pattern and outcome of motorcyclists head injury in Ilorin, Nigeria
Ayodeji Salman Yusuf1, Timothy Olugbenga Odebode1, James Olaniyi Adeniran1, Adekunle Ganiyu Salaudeen2, Nurudeen Abiola Adeleke1, Mustapha Faiz Alimi3
1 Department of Surgery, Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
2 Department of Epidemiology and Community Health, Faculty of Clinical Sciences, University of Ilorin, Ilorin, Nigeria
3 Spine Unit, National Orthopaedic Hospital, Igbobi, Lagos, Nigeria
|Date of Web Publication||6-Sep-2014|
Dr. Ayodeji Salman Yusuf
Department of Surgery, Faculty of Clinical Sciences, University of Ilorin, PMB 1515, Ilorin
Source of Support: None, Conflict of Interest: None
Background: Head injuries are a leading cause of death and morbidity among motorcycle users. Objectives: To determine the pattern, severity and outcome of motorcyclists' head injury presenting to our facility over 12 months. Materials and Methods: We prospectively studied 104 consecutive head injured motorcyclists using a predesigned questionnaire. Results: Seventy per cent of our patients were young adult males. Motorcycle versus other vehicle collision (49%) was the commonest mechanism of injury followed by lone cycle crash (26.0%). Only six motorcyclists, who were all riders (5.8%), wore crash helmet at the time of the crash. Brain contusions (33.3%) and intra-cerebral haematomas (26.7%) were the leading intracranial lesions. Seventy-eight percent of the patients suffered associated injuries, including face (63%) and extremities (24%). Mortality rate from lone crash was 37%, followed closely by motorcycle-vehicular collision. Conclusion: Outcome of head injury was significantly predictable by the nature of intracranial pathology and injury severity score (P = 0.000), being more favourable in younger age group, patients with normal brain computed tomography (CT) scan and those with extra-dural haematoma. Outcome was less favourable in patients with severe head injury, acute subdural haematoma and multiple intracranial haematomas.
Keywords: Head head injury, motorcycle, outcome, pattern
|How to cite this article:|
Yusuf AS, Odebode TO, Adeniran JO, Salaudeen AG, Adeleke NA, Alimi MF. Pattern and outcome of motorcyclists head injury in Ilorin, Nigeria. Niger J Basic Clin Sci 2014;11:80-4
|How to cite this URL:|
Yusuf AS, Odebode TO, Adeniran JO, Salaudeen AG, Adeleke NA, Alimi MF. Pattern and outcome of motorcyclists head injury in Ilorin, Nigeria. Niger J Basic Clin Sci [serial online] 2014 [cited 2020 Jan 18];11:80-4. Available from: http://www.njbcs.net/text.asp?2014/11/2/80/140340
| Introduction|| |
The motorcycle constitutes an important means of transportation in Asian and African countries. The increasing use of motorcycles particularly for commercial commuter service has been a source of concern. Motorcyclists tend to sustain multiple injuries, including injuries to the head, chest, abdomen and extremities. Head trauma is the main cause of death and morbidity in motorcyclists contributing to around 75% of deaths among motorcyclists in European countries and it is estimated to account for 55-88% of motorcyclist deaths in Malaysia. ,, Substantial growths in motorcycle use in low-income and middle-income countries like Nigeria are being accompanied by an increase in head injuries. The main risk factor for motorcyclists is the use and non-use of crash helmets. Use of crash helmets has been shown to reduce fatal and serious head injuries by between 20% and 45% and to be the most successful approach for preventing injury among motorcyclists.  In Nigeria, there is renewed effort in enforcing the mandatory helmet use by all motorcyclists.
Skull fracture is the commonest type of head injury among motorcycle riders in most reported series with about half being located at the base of the skull. ,,, Focal brain injury and epidural haematoma were the commonest types of intracranial injuries in Tehran and other centres. , The use of helmet resulted in a reduction in incidence of skull fractures, intracranial haematomas, neurologic deficits and loss of consciousness among motorcyclists in Singapore and Italy. , The reduction in intracranial haematoma with use of helmets is mainly due to the disappearance of epidural haematoma which is usually associated with the presence of a skull fracture. Subdural haematoma and diffuse injuries which generally occur from high-speed impacts are much less affected by helmet use. 
Specific characterisation of epidemiology, structural pattern and outcome of motorcycle-related head injury is scarce in West Africa. This study is, therefore, aimed at determining the pattern, severity and outcome of head injury in motorcycle crash victims presenting to our facility over a 12 months.
| Materials and Methods|| |
This was a hospital-based prospective study of pattern, severity and outcome in 104 consecutive head injured motorcyclists presenting at the accident and emergency unit of the University of Ilorin Teaching Hospital, Ilorin in north central Nigeria, after a motorcycle crash. A pre-designed study proforma was administered on all recruited patients. The data collected in the proforma include the demographics, mechanism of injury, time of injury, anatomical site of injury, Glasgow Coma scale (GCS) score, associated injuries, skull X-ray or CT scan findings, treatment modality and outcome of definitive management. The Glasgow Outcome Score (GOS) was used to determine head injury outcome at discharge or death. The five-point GOS score was further categorised as either favourable (good recovery or moderate disability) or unfavourable (severe disability, persistence vegetative state or dead).  The injury severity score (ISS) was calculated for patients with associated injury or injuries based on the AIS-90. ,, Data collected on the study proforma was entered using numeric codes and analysed using Statistical Package for Social Sciences (SPSS) version 15.0 for windows. Chi-square test and Fisher Exact test where applicable were used to test significance of the differences between categorical variables and a P ≤ 0.05 considered as statistically significant.
| Results|| |
A total of 104 consecutive head injured motorcyclists comprising 97 (93.3%) male and 7 (6.7%) female aged 3-76 years with median age of 30 years were studied. Most of the patients (70.2%) were in the economically active age group (15-44 years) [Table 1].
Majority (51.9%) of the patients presented at the accident and emergency department within the first 6 hours of injury. Nineteen patients (18.3%) presented within an hour of the accident while only 13 (12.5%) patients presented after 48 hours of injury [Figure 1].
|Figure 1: Injury arrival time in patients with motorcycle-related head injury|
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Motorcycle - other vehicle collision (51, 49%) was the commonest mechanism of injury followed by lone motorcycle crash (27, 26.0%). Twenty-four (23.1%) cases result from motorcycle - motorcycle collision while motorcycle - pedestrian collision was the least collision type (2, 1.9%).
Most of the patients (80.8) presented either with a history of loss of consciousness or in an unconscious state. Seizures occurred in 17 (16.3%) patients, 41 (39.4%) patients presented with significant history of headache, 10 (9.6%) patients had cranial nerve deficits, while 26 (25.0%) had pyramidal deficits and 21 (20.2%) had otorrhea/rhinorrhea.
Brain contusions (33.3%) and intracerebral haematomas (26.7%) were the most common findings on CT scan [Table 2]. Twenty-three patients (22.1%) sustained skull fractures which was linear skull fracture in 10 (9.6%) patients and depressed 13 (12.5%) patients.
Eighty-one (77.8%) patients had associated injuries. Injury around the region of the face (51, 63%); the eye (31, 38.3%) and facio-maxillary (20, 24.7%) constituted the most common associated injuries. [Figure 2] Many of the patients (19, 23.5%) had associated injury to the extremities while 23 patients (22.1%) had no associated injury. [Figure 2] The Injury Severity Score was assessed as minor in 31 (38%) patients, moderate in 19 (24%) patients, severe in 17 (21%) patients and critical in 14 (17%) patients with associated injuries.
Irrespective of type of motorcycle collision, more than half (51.4%) of the patients sustained mild head injury. Motorcycle - other vehicle collisions resulted in greatest number (14, 54%) of patients with severe head injury. Most mortality (37%) resulted from lone motorcycle crash followed closely by motorcycle - other vehicle collision though the relationship between collision type and head injury severity was not statistically significant (P = 0.252) [Table 3].
|Table 3: Relationship between type of collision and severity of head injury|
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All the patients (4, 8.9%) with normal brain CT scan and those with extradural haematoma (EDH) (4, 8.9%) had favourable outcome while outcome was unfavourable in greater number of patients with SDH (5, 71%) and multiple intracranial haematomas (1, 50%). [Table 4].
In the Critical Category of injury severity score (ISS), 10 (71%) of 14 patients with associated injuries died, 3 of them had associated upper airway obstruction from maxillofacial injuries while 1 patient had associated cervical spinal cord injury. Twenty-five (80.6%) of 31 patients in the minor category had good recovery. The relationship between ISS and outcome was statistically significant (P = 0.000) [Table 5].
|Table 5: Injury severity score and outcome in patients with associated injuries|
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Complications occurred in 27 patients while on admission; 8 (29.6%) patients developed pressure sores, 6 (22.2%) patients developed chest infections, 4 (14.8%) patients each had pyrexia of unknown origin and personality changes, 2 (7.4%) patients each developed post operative wound infections and urinary tract infections while only one (3.7%) person had thrombophlebitis.
| Discussion|| |
The commonest age group affected (15-44 years) are the economically active members of the society thus resulting in loss of work and income to their families and the country at large.
Collision of motorcycles with other motor vehicles (49%) is the commonest mechanism of injury and this is similar to findings in Oshogbo,  Benin,  and in Taiwan.  Motorcycle- motorcycle collision-related head injury accounted for 23% of the patients in our study, higher than 16% reported in Taiwan. 
Collision between motorcycle and heavier vehicles understandably resulted more frequently in severe head injury and high mortality (31%), although the highest mortality (37%) resulted from lone motorcycle crash. Other factors such as delayed evacuation from scene of crash, riding under influence of alcohol may have contributed to the higher mortality.
About half (51.9%) of the patients presented to the accident and emergency unit within 6 hours of crash, reasons for delayed presentation in the remaining patients included distance from scene of accident to the hospital and initial admission in private or general hospitals. Many of these other hospitals do not have the personnel or facilities to adequately treat head injured patients, there is thus an urgent need to develop more functional trauma units in Kwara state and Nigeria as a whole in order to improve outcome from head injury and other life threatening injuries.
Brain CT scan utilisation is still inadequate in Ilorin. Although there is a CT scan machine available in the hospital, patients were required to pay before they can have the CT scan done, there is no effective health insurance coverage and there is a significant distance between its location and the accident and emergency department. In the process of waiting some patients deteriorated in the emergency room. Many patients with lateralising signs were thus subjected to exploratory burr hole either because they could not afford to pay for brain CT scan or they were not stable enough to be taken for this investigation. CT scan machines are just beginning to be readily available in many tertiary centres in Nigeria including our centre. However, the accessibility to patients is still inadequate.
A similar proportion of brain contusions and intracerebral haematomas found in this study was reported among motorcyclists with head injury by Ankarah et al. in the UK  while Oluwadiya et al. reported cerebral contusion as the second-most common type of head injury after concussion in three tertiary hospitals in southwest Nigeria. Extradural haematoma was more commonly associated with skull fractures. Linear skull fractures (9.6%) and open depressed skull fractures (9.6%) were the more frequent skull fracture types. The presence of skull fracture increased the risk of intracranial haematoma while open skull fractures have direct communication between the scalp laceration and the cerebral surface with increased risk of meningitis. ,
Motorcyclists that were not wearing crash helmets are at greater risk of sustaining skull fracture and head injury because the cranium is unprotected. The use of crash helmets resulted in a reduction in incidence of skull fractures, intracranial haematomas, neurological deficit and loss of consciousness among motorcyclists in Singapore and Italy. ,
The type and severity of intracranial injury dictates neurological and clinical outcome with skull fractures and extradural haematomas being associated with favourable outcome.
Nineteen percent of the patients had severe head injury all of whom by protocol should qualify for admission into intensive care unit (ICU) for management; however, some of our patients died in emergency room while waiting for ICU admission. The reasons for the delay or non admission into ICU included lack of bed space in the ICU, inability to pay for ICU admission and death of patients in accident and emergency unit. ICU admission is associated with increased incidence of chest infections (22.2%) and pyrexia of unknown origin (14.8%) most likely due to the use of invasive monitoring devices and catheters and occasional breach in aseptic techniques. This complications increased morbidity and mortality in patients with moderate and severe head injury.
Significant traumatic brain injury often occurs in association with injuries in other parts of the body. There was a statistically significant relationship between injury severity score among patient with associated injuries and outcome (P = 0.000). Associated injuries around the face (eye and facio-maxillary) were expectedly the majority. This is similar to findings in other studies both locally and internationally. ,,, Motorcyclists unlike vehicle occupants are unprotected and therefore more prone to injuries in multiple regions. Twenty-one percent and 17% of the patients with associated injuries had severe and critical ISS, respectively.
In conclusion, the study confirmed that collision with other vehicles results is the commonest cause of head injury among motorcyclists in Ilorin and that brain contusion and intra-cerebral haematoma were the most common intracranial lesions. The most important variables affecting outcome were the age of the patients, head injury severity, type of intracranial lesion and type and severity of associated injury.
| Limitations|| |
The study did not include information on patients who died before reaching hospital; hence the mortality rate from the study will probably underestimate the real rate. Autopsy results were not included; hence the exact cause of death could not be ascertained.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]