160 Med. Sci. Law (2002) Vol. 42, No.

Pattern of Fatal Head Injuries in Ibadan - A 10 Year Review

E E U AKANG, MAO KUTI, A 0 OSUNKOYA

Department of Pathology
E 0 KOMOLAFE, A 0 MALOMO, M T SHOKUNBI
Department of Surgery
S BAMUTTA
Department of Otorhinolaryngology
University College Hospital, PMB 5116, Ibadan, Nigeria

ABSTRACT injury results in scalp lacerations, skull frac-

Head injury is an important cause of mortality tures, surface contusions and lacerations ofthe
worldwide. The objective of the present study was brain, diffuse axonal injury and intracranial
to analyse the pattern of fatal head injury among
patients seen in University College Hospital, Ibadan. haemorrhage. Secondary damage produced by
The study was based on retrospective investigation complicating processes that are initiated at the
of cases of fatal head injury referred by the coroner to moment of injury but presenting some time
the Department of Pathology, University College after injury, includes damage due to raised
Hospital, between 1991 and 2000. Pertinent clinical
and postmortem findings were extracted from avail-
intracranial pressure, ischaemia, swelling and
able coroner's autopsy records. infection (Graham et al., 2000).
There were 529 cases (402 males and 127
females). Their ages ranged from <1 year to 90 years Severe head injury, with and without per-
(mean=33 years), the average age of females (27.8) ipheral trauma, is the most frequent cause of
being less than that of males (34.6) (p=0.00003). death and of severe disability up to age 45 years
83.8% were road traffic accidents, 8.9% falls from a in developed countries (Baethmann et al., 1998)
height, 3.8% assault, and 3% gunshot injuries. 79.1% causing approximately 75,000 deaths annually
had a GCS of 8 or less at presentation. The mean
survival period of children aged less than 15 years in the United States alone (Silvestri and
was 2 days while that of adolescents and adults aged Aronson, 1997). Adeloye et al. (1996) reported
15 years and above was 5.6 days (p=0.02). Subdural from Kuwait that 58% of 208 consecutive head
(62.4%), subarachnoid (24.6%), epidural 00.2%), and injuries were due to road traffic accidents, half
intracerebral 00%) haemorrhages were the major
causes of death. Skull fractures occurred in 38.2%,
of the victims being pedestrians. In a recent
while cerebral contusions occurred in 22.1%. Intra- study of coroner's autopsies from Ibadan, we
cranial infection was relatively uncommon in these observed that road traffic accidents accounted
patients. The present study has shown that young for 78% of accidental deaths, 57% of victims
adults, predominantly males in their most produc- being pedestrians, and the most frequently
tive years of life, are especially prone to fatal head
injury. recorded cause of death being craniocerebral
injuries (Amakiri et al., 1997). Other previous
Nigerian (Odesanmi, 1982) and African studies
INTRODUCTION
(Elmes, 1957) also emphasise the importance of
Head injury is defined as physical damage to
road traffic accidents as a major cause of death
the scalp, skull or brain produced by an
assuming epidemic proportions (Olumide and
external force (Olumide and Adeloye, 1978;
Adeloye, 1978).
Ingebrigtsen et al., 1998). The outcome of head
injury is a product of different mechanisms, The objective of the present study was to
types and amounts of head injury and their analyse the pattern offatal head injury among
anatomical location (Graham et aI., 2000). patients seen in the University College Hospi-
Primary damage triggered at the moment of tal,Ibadan.
 Akang et al.: Pattern of Fatal Head Injuries in Ibadan- A 10 Year Review 161

120 _Male
Bill Female
100
III
Q)
III
ca 80
o
'0
Qj 60
.0
E
:::l
Z 40

20

o
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Age range (years)

Figure 1. Age and sex distribution of cases of fatal head injury.

MATERIALS AND METHODS factor to the cause of death recorded in the

The present study is based on a retrospective coroner's records of the Department of Pathol-
analysis of cases of fatal head injury that were ogy during the study period.
referred by the coroner to the Department of These cases included 402 males (76%) and
Pathology, University College Hospital, Iba- 127 females (24%). The ages of the patients
dan between February 1991 and April 2000. ranged from <1 year to 90 years with a mean of
Cases recruited into the study were those in 33 years (SD=17 years), as shown in Figure 1.
which head injury was deemed to be a major There was a male preponderance at most ages
contributing factor to the demise of the apart from the first and fourth decades oflife.
patient, and for which adequate postmortems The average age of the females (27.8 ± 18.9
were available. Cases without adequate clin- years) was significantly less than that of the
ical or postmortem records were excluded from males (34.6 ± 16.3 years) (p=0.00003).
the study. Seventy-four (14%) of patients were children
The patients' clinical data, including age, aged less than 15 years, while 455 (86%) were
sex, interval between traumatic event and adolescents or adults aged 15 years and above.
death, antecedent events, associated injuries
or complications, postmortem findings, and The circumstances preceding head injury
radiological investigations, were extracted are shown in Table I. As can be seen, 83.8% of
from the clinical summaries on the hospital fatal head injuries were due to road traffic
coroner request form or Coroner's Form B,
where available, and from the coroner's re- Table I. Aetiological factors associated with head
cords of the Department of Pathology. injury in the present study.
The information obtained was entered into a Aetiological factors Number of cases %
questionnaire file using the Epi Info 6 pro-
gramme (Centres for Disease Control, Atlanta, Road traffic accident 443 83.8
Georgia, 1997), and statistically analysed, Fall from a height 47 8.9
with levels of significance set at p:S;0.05. Assault 20 3.8
Gunshot injury 16 3.0
RESULTS Collapsed building 3 0.6
There were a total of 529 fatalities in which
head injury played a major or contributory TOTAL 529 100
162 Med. Sci. Law (2002) Vol. 42, NO.2

Motorcyclist Table II. Neurological manifestations of head

3% injury in 48 cases.
I
Neurological signs Number of %
cases

Hemiplegia 10 20.8
Hemiparesis 2 4.2
Quadriplegia 6 12.5
Quadriparesis 2 4.2
Cranial nerve paralysis 7 14.6
Seizures 5 10.4
Anisocoria 4 8.3
Hypertonia 2 4.2
Hypotonia 2 4.2
Decerebrate posturing 4 8.3
Figure 2. Categories of road traffic accident Decorticate posturing 2 4.2
victims. Hyperreflexia 1 2.1
Ptosis 1 2.1
accidents, 8.9% due to falls from a height, 3.8%
due to assault, and 3% due to gunshot injuries. TOTAL 48 100

Concerning the road traffic accidents, 53.9%

of victims were passengers, 35.6% pedestrians,
7.6% drivers, and 2.8% motorcyclists GCS of 6 or less, and 79.1% had a GCS of 8 or
(Figure 2). less.
Figure 3 shows the Glasgow Coma Score As shown in Table II, neurologic manifesta-
(GCS) at presentation. It should be noted that tions were recorded in the clinical summary of
31.4% of patients had a GCS of3, 61.7% had a the postmortem records in 48 cases (9.1%).

90 -

80 -

70 -

VI
Q)
60 f---

VI
I'll
u 50 -
'0
~

.c 40
Q) ~

E
::J
z 30 f-
20 f--- - - f- - f-

10

0
f---

3
-
~

4
-

-
5
f-

Figure 3. Glasgow coma score at presentation.

6
-
'--
7
f-

'--
8
Ll=
9 10
La •
11 12 .------
13 14 15
 Akang et al.: Pattern of Fatal Head Injuries in Ibadan - A 10 Year Review 163

60 Table 11/. Central nervous system findings at

50 postmortem
CNS Findings Number %
(ij 40
> of cases
's
:; 30
en Subdural haemorrhage 330 62.4
~
0
20 Subarachnoid haemorrhage 130 24.6

10 Epidural haemorrhage 54 10.2

Intracerebral haemorrhage 51 9.6
o
1 3 5 7 9 11 14 16 18 3035 60 90 183 Intraventricular haemorrhage 18 3.4

Figure 4. Survival period of head injury cases Cerebral contusions 117 22.1
from time of incident to time of death. Cerebral oedema 272 51.4
Meningitis 9 1.7
More common manifestations included hemi-
Cerebral abscess 7 1.3
plegia, cranial nerve paralysis, quadriplegia
and seizures. Subdural empyema 1 0.2
Radiological investigations were obtained in Sinus thrombosis 2 0.4
60 (11.3%) ofthe cases, including computerized Hydrocephalus 4 0.8
axial tomography (CT) in 33 (55%) of these
Brain infarct 1 0.2
cases, and X-ray studies in 26 (49%). CT
findings included intracranial haemorrhages Skull fracture 202 38.2
in 12 (36.4%), contusions in 5 (15.2%), and Scalp haematoma 91 27.2
skull fractures in 3 cases (9.1 %). X-ray findings Scalp laceration 94 17.8
in our cases included skull fractures in
Scalp abrasion 75 14.2
6 (23.1 %) and long bone fractures in 3 (11.5%).
Cervical spine fracture 12 2.3
Fifty-seven (10.8%) ofthe patients had some
form of surgical intervention prior to their Spinal cord transection 8 1.5
death. These included 20 exploratory burr
holes, eight suturing of lacerations, eight
craniotomies, wound debridement in five Table III shows the major findings in the
cases, two laparatomies (splenectomy in one central nervous system (CNS) at postmortem.
case) and chest tube insertion in two cases. As may be seen, intracranial haemorrhage
Thirty-six patients (6.8%) were managed in played a major role in fatality from head
the intensive care unit. injury. The most common site was subdural
(62.4%), followed by subarachnoid (24.6%),
Figure 4 shows the survival period of head
epidural (10.2%), intracerebral (9.6%), and
injury cases from the time of incident to the
intraventricular (3.4%). Cerebral oedema was
time of death. The overall mean survival
recorded in 51.4% of postmortem cases. Skull
period was 4.9 ± 13.6 days. Fatality occurred
fractures were present in 38.2% of cases, while
within the first day in 52.2% of the cases,
cerebral contusions occurred in 22.1%. Table
within five days in 83.2%, and within ten days
IV shows the common sites of skull fractures.
in 92.3%. The mean survival period of female
As may be seen, the bones most frequently
patients (4.4 ± 13.3 days) was not significantly
affected were frontal, parietal and temporal in
less than that of males (5.0 ± 13.7 days)
declining order of frequency. Intracranial
(p=0.7). However, the survival period of chil-
infection was a relatively uncommon sequel
dren aged less than 15 years (2.0 ± 2.2 days)
in these patients.
was significantly less than that of adolescents
and adults aged 15 years and above (5.6 + 15.1 Prominent extra-cranial findings in our
days) (p=0.02). - cohort of cases were limb fractures, rib frac-
164 Med. Sci. Law (2002) Vol. 42, No.2

Table IV. Anatomical location of skull fractures. Table V. Extra-cranial postmortem findings in the
present study.
Location of skull fractures Number %
of cases Postmortem findings Number of %
cases
Frontal 25 12.4
Fronto-parietal 12 5.9 Limb fractures 38 7.2
Parietal 18 8.9 Splenic rupture 19 3.6
Parieto-temporal 12 5.9 Rib fracture 21 4
Parieto-occipital 11 5.4 Acute tubular necrosis 14 2.6
Temporal 19 9.4 Haemothorax 14 2.6
Occipital 16 7.9 Haemoperitoneum 17 3.2
Temporo-occipital 3 1.5 Pulmonary embolism 6 1.1
Base of skull 15 7.4 Acute pyelonephritis 6 1.1
Multiple sites 31 15.3 Bronchopneumonia 7 1.3
Not specified 35 17.3 Pulmonary oedema 5 0.9
TOTAL 202 100 Pulmonary haemorrhage 5 0.9
Aspiration 5 0.9
Multiple gunshot wounds 10 1.9
tures, splenic rupture, haemoperitoneum, hae- Liver laceration 8 1.5
mothorax and acute tubular necrosis (Table V). Pelvic fracture 4 0.8
Causes of death noted in the cases are
Pneumothorax 3 0.6
shown in Table VI. These included raised
intracranial pressure (76.5%), cerebral oedema
(16.1 %), and shock (15.8%). Death was as-
cases. Most of these patients were either
cribed to raised intracranial pressure in the
passengers or pedestrians. This is similar to
presence of postmortem findings of flattening
observations from other studies, where road
of the gyri with obliteration of the sulci, and
traffic accidents account for the majority of
uncal or tonsillar herniation. Less common
cases (Adesunkanmi et al., 1998; Ingebrigtsen
findings were aspiration, septicaemia, pul-
et al., 1998; Feickert et al., 1999). Other major
monary embolism, acute tubular necrosis,
aetiological factors of head injury in our study
and respiratory failure in patients with cervi-
included falls from a height, assault and
cal spine injuries.
gunshot injury in descending order of fre-
quency.
DISCUSSION
As shown in the present study, fatal head Intriguingly, only 7.6% of the casualties in
injury is commoner in male than female the present study were drivers. This contrasts
subjects. This has also been the experience of with findings in a previous prospective study
other workers from different centres, who from this environment where 19% of coroner's
report male to female ratios ranging from cases involved in road traffic accidents were
1.7:1 to 8:1 (Prat et al., 1998; Lai et al., 1998). drivers (Amakiri et al., 1995). A possible
The peak age was in the fourth decade, with explanation for this is that drivers involved
a mean of 33 years. Again, this is comparable in road traffic accidents sustained major
to the findings of others (Ng et al., 1998; Lai et complications other than head injury in a
al., 1998). We observed that females were on significant number of cases. In a prospective
average seven years younger than males. study of acute head injuries from Malawi,
Road traffic accident was the most impor- Adeloye and Ssembatya-Lule (1997) also ob-
tant predisposing factor to fatal head injury in served a similarly low frequency of drivers
the present study, accounting for 83.8% of (10.6%) among their subset of road traffic
 Akang et al.: Pattem of Fatal Head Injuries in Ibadan - A 10 Year Review 165

Table VI. Causes of death. severe intracranial haematomas than those

with mid to lower cervical injuries.
Causes of death Number of %
cases Though documentation of radiological in-
vestigations carried out were scanty (11.3% of
Raised intracranial pressure 218 76.5 cases), CT scan was carried out in over half of
Cerebral oedema 46 16.1 the patients that had radiological studies.
Shock 45 15.8
Intracranial haemorrhage was the most com-
mon finding (36% of our cases), as noted by
Aspiration 11 3.9
other workers (Prat et al., 1998; Feickert et al.,
Septicaemia 11 3.9 1999; Stocchetti et al., 1999). In modern
Acute tubular necrosis 5 1.8 centres CT scan is an essential investigation,
Pulmonary embolism 4 1.4 which should be available for all cases of head
Respiratory failure 3 1.1 injury. The documentation and localization of
intracranial haemorrhage guides neurosurgi-
Pneumonia 2 0.7
cal intervention and is critical in management
Brainstem failure 1 0.4 of these patients. The relative unavailability of
Electrolyte imbalance 1 0.4 CT scan could have contributed to the low rate
Pulmonary oedema 1 0.4 of surgical intervention in the present study.
The mean survival period was 4.9 days, with
most deaths occurring within the first 24 hours
accident victims, although in their study, after the incident. Suominen et a1. (1998) from
pedestrians constituted the largest group of Helsinki observed that 77.1% of children with
road traffic accident victims. By contrast, severe and fatal childhood trauma, of which
Adeloye et a1. (1996) reporting from Kuwait 85.6% had head injury alone or combined with
observed that 32% of road traffic accident other injuries, died within the first 6 hours,
victims with acute head injuries were drivers. and all died within 9 days. A recent study by
It would appear that among Africans, passen- the European Brain Injury Consortium re-
gers and pedestrians rather than drivers are at ported that 31% of patients with head injury
relatively greater risk of sustaining severe died within 6 months (Graham et al., 2000). In
head injury following road traffic accidents our study we observed that the mean survival
(Adeloye and Ssembatya-Lule, 1997). period in children less than 15 years (2 days)
was significantly less than that of adults (5.6
Post-traumatic neurological manifestations
days). In contrast to our findings, Feickert et
such as hemiplegia, cranial nerve palsies,
a1. (1999), have noted that severe head injury
quadriplegia and seizures were documented
is more favourable in children than in adults.
in 9% of cases in our study. In clinical studies,
relatively higher figures for neurological in- Major postmortem findings include intra-
volvement ranging from 39-75% of cases, have cranial haemorrhage, cerebral oedema, skull
been noted (Shokunbi and Olurin, 1994; fractures and cerebral contusions, as observed
Mariak et al., 1997; Feickert et al., 1999). in the present study (Adams et al., 1989).
The lower figures in our study are due to Although we encounter clinical cases of diffuse
incomplete documentation because of the axonal injury in our routine autopsy cases, the
retrospective nature of the present study. frequency of diffuse axonal injury could not be
accurately ascertained because histological
Eight patients had quadriplegia or quad- examination was not done in all cases.
riparesis secondary to cervical spine injury. Extra-cranial postmortem findings in the
About one third of all patients with cervical present cohort of patients with head injury
spine and or spinal cord injuries have moder- included limb and rib fractures, splenic rup-
ate or severe head injury (Iida et al., 1999). ture, haemoperitoneum, haemothorax and
Those with upper cervical injury are at greater acute tubular necrosis, all of which contributed
risk of suffering from skull base fractures and significantly to mortality. Moreover, impor-
166 Med. Sci. Law (2002) Vol. 42, No.2

tant causes of death identified in the present and World Health Organization, Switzerland.
study included raised intracranial pressure, Epi-Info 6: (Oct 1994) A word-processing, data-
base and statistics programme for public health,
cerebral oedema, and shock. This suggests that Version 6.02.
a large proportion of the deaths were preven- Elmes B.G.T. (1957) Forensic medicine in Uganda. A
table if the underlying lesion or sequelae of five years survey. East Afr. Med. J. 34(2), 41-5.
injury had been promptly addressed. Clinical Feickert H.J., Drommer S. and Heyer R (1999)
awareness and early diagnosis are the keys to Severe head injury in children: impact of risk
factors on outcome. J. Trauma Injury Infect. Grit.
successful management of patients with head Care 47, 33---8.
injury. Graham D.L, McIntosh T.K, Maxwell W.L. and
In conclusion, the present study has shown Nicoll J.A.R (2000) Recent advances in neuro-
that young adults, predominantly males in the trauma. J. Neuropathol. Exp. Neural. 59,641-51.
most productive years of life, are those most Iida H., Tachibana S., Kitahara T., Horiike S.,
prone to fatal head injury, most commonly the Ohwada T. and Fujii K (1999) Association of
head trauma with cervical spine injury, spinal
result of road traffic accidents. Suggestions to cord injury, or both. J. Trauma-Injury Infect. Crit.
improve prognosis include appropriate radi- Care 46, 450-2.
ological evaluation, early and adequate surgi- Ingebrigtsen T., Mortensen K and Romner B. (1998)
cal intervention so as to treat other associated The epidemiology of hospital-referred head injury
severe injuries, intensive unit care and prompt in Northern Norway. Neuroepidemiology 17,
139-46.
referral of severely head injured patients for
Lai YC., Chen F.G., Goh M.H. and Koh KF. (1998)
early neurosurgical evaluation. Predictors of long term outcome in severe head
injury. Annals Acad. Med. Singapore 27, 326-31.
REFERENCES Mariak Z., Mariak Z. and Stankiewicz A. (1997)
Adams J.H., Doyle D., Ford 1., Graham D.L, McGee Cranial nerve II-VII injuries in fatal head
M. and McLellan D.R (1989) Brain damage in trauma. Eur. J. Ophihalmol. 7,68-72.
fatal head injury in relation to age and type of NgL, LewT.W., YeoT.T., SeowW.T., Tan KK, Ong
injury. Scott. Med. J. 34,399-401. P.L. and San W.M. (1998) Outcome of patients
Adeloye A, al-Kuoka N. and Ssembatya-Lule G.C. with traumatic brain injury managed on a
(1996) Pattern of acute head injuries in Kuwait. standardised head injury protocol. Annals Acad.
East Afr. Med. J. 73, 235---8. Med. Singapore 27, 332-9.
Adeloye A and Ssembatya-Lule G.C. (1997) Aetiolo- Odesanmi W.O. (1982) Forensic pathology in Niger-
gical and epidemiological aspects of acute head ia: the Ife experience. Med. Sci. Law 22, 269-74.
injury in Malawi. East Afr. Med. J. 74, 822---8. Olumide AA. and Adeloye A. (1978) Pattern of skull
Adesunkanmi AR, Oginni L.N., Oyelami AO. and fractures in Ibadan. Ghana Med. J. 79-83.
Badru O.S. (1998) Epidemiology of childhood
Prat Rand Calatayud-Maldonado V. (1998) Prog-
injury. J. Trauma Injury Infect. Crit. Care 44,
nostic factors in post-traumatic severe diffuse
506-12.
brain injury. Acta Neurochirurgica 140, 1257--61.
Amakiri C.N.T., Akang E.E.U., Aghadiuno P.U. and
Odesanmi W.O. (1997) Prospective study of Shokunbi M.T. and Olurin O. (1994) Childhood head
coroner's autopsies in the University College injury in Ibadan. West Afr. J. Med. 13, 38-42.
Hospital, Ibadan, Nigeria. Med. Sci. Law 37, Silvestri S. and Aronson S. '(1997) Severe head
69-75 injury: prehospital and emergency department
Baethmann A, Lehr D. and Wirth A. (1998) management. Mount Sinai J. Med. 64, 329-38.
Prospective analysis of patient management in Stocchetti N., Rossi S., Buzzi F., Mattioli C.,
severe head injury. Acta Neurochirurgica 718, Paparella A. and Colombo A. (1999) Intracranial
107-10. hypertension in head injury. Intensive Care Med.
Caird J., Brett F.N. and Phillips J.P. (1999) Extra- 25,371--6.
dural haematoma- a preventable cause of death. Suominen P., Kivioja J., Ohman J., Korpela R,
Ir. Med. J. 92,270-1. Rintala R. and Olkkola KT. Severe and fatal
Centres for Disease Control and Prevention (USA) childhood trauma. Injury 29, 425-30.