Demographics and injury factors
The prevalence of PCCI in our study was 9.1% and deemed to be very low, especially due to the survival rate of the victims who reached the facility on time, and the weakness of health-related events reporting systems in a conflict region. Indeed, there are no emergency medical mobile services that can collect and take to the hospital trauma patients to facilities for appropriate care [6]. Most of our patients were young adults, as reported to other literature with an average age of 30 years [8, 12, 13]. In our study, injuries were caused in the majority by gunshot head injury as frequently it is the case in war conflict zones, whereas non-missile low-velocity weapons are mostly reported in another African study [14].
More than half of patients were coming from rural areas, mostly due to the scarcity of the surgical workforce in the Eastern region of the DRC; Kong et al. found that in South Africa more than of half patients with PCCIs were urban, and due to criminalities in the cities [15].
Clinical presentations and imaging
Patients in our study were admitted with a delay as compared to other studies, but 82.1% were operated in a record time of 24 h following trauma; Aziz et al. reported that the average time from admission to surgery average was 57 h [6]. There were not any differences between these demographic parameters in terms of outcomes as found also by Jamous et al. [9].
On the other hand, Paradot et al. [7], Aarabi et al. [5], and Wei et al. [16] found respectively that the age (< 15 years vs > 16 years) of patients, the time between injury and admission (< 8 h vs > 8 h) were differently distributed in terms of outcomes. This may be explained by the difference of distribution of age and time from injury to the hospital between our study and theirs [5, 16]. Literature has documented that patients victims of PCCI had most of the time a low GCS and unstable hemodynamic state [4, 17, 18]. But in LMICs, different results are found because patients with low GCS die at the injury place or before admission. An important proportion of them was admitted with hemodynamic instability and neurologic deficit (especially hemiplegia in 23.6%) in our study. As found in our study and as already found in previous ones, patients with hemodynamic instability and low GCS had poorer outcomes than patients without these characteristics [8, 12, 19, 20]. In our study, criteria found in the ATLS® protocol 9th edition were used to classify patients as hemodynamically stable or unstable, but mainly the systolic blood pressure and the level of consciousness were consistently captured. Only half of the patients had done a Brain CT scan because of a lack of financial resources and poor clinical status at admission as compared to the study done by Wakrim et al. in which 100% of patients were diagnosed by a Brain CT scan [21]. Eight patients had an intracerebral hemorrhage and they had poorer outcomes than patients who had not such lesion contrarily to Petridis et al. who found did not find the same results [22]. Such findings can be explained by the fact that in our study half of the patients did not have brain CT scanning. Other important factors such as pupil response to light and midline shift in the brain CT were found in other studies to be differently distributed [18, 22] but were not looked at in our study due to the inconstant medical records.
Management and outcomes
The medical treatment consists of antibiotics and anti-comitial treatment to which we can add other treatments according to the patient’s state. That is why in our series all patients were treated with antibiotics and analgesics but only 62.3% were treated with anti-epileptic drugs for seizure treatment or prophylaxis like done by Thiam et al. [14]. This rate of duroplasty is high compared to the rate found by Thiam et al. and it may be explained by the high number of penetrating wounds in need of such procedures. The length of hospital stay in our study was longer as compared to other studies [12, 23]. It may be explained by the high number of postoperative complications and re-operation dominated by infections in most cases as found in other studies [24, 25]. Mortality and poor outcomes were observed to be lower in our study as compared to others. This may be a masked feature of the high mortality of patients who die within the golden hours before reaching the hospital due to the lack of emergency medical mobile services [6, 7, 14]. In HICs with a well-organized Health System, such emergency services allow most of the victims with PCCI to reach the specialized hospital for appropriate management. This fact seems to reveal the high rate of real-life in-hospital mortality and poor outcomes related to PCCI [17, 23, 26].
Factors associated with outcomes
on univariate analysis, poor outcomes were found, as in other studies, among patients with low admission GCS score [3, 5, 12] and with the presence of intracranial hemorrhage [5]. However, Khan et al. [12] did not find that dural tear in PCCI to be associated with poorer outcomes as found in our study. Many other factors have been described in different studies to be associated with poor outcomes on univariate analysis: bilateral mydriasis, bi-hemispheric lesion [12, 23, 27, 28], trans-ventricular penetrating agent trajectory, high intracranial pressure, [3], cistern obliteration [5] but not found in our study because they were not evaluated on admission and a low rate of accessibility to brain CT scan. Hemodynamic instability is well-known to be associated with poor outcomes in trauma patients as reported in our study [23]. Four factors were associated with poorer outcomes in the multivariate logistic regression model: GCS < 13, hemodynamic instability, intracranial hemorrhage, and hemiplegia. Our finding comforts those of Gressot et al. [3] in terms of GCS; he found that having a GCS between 9 and 15 on admission was statistically associated with favorable outcomes. However, other factors associated with poor outcomes in a multivariate regression model have been found (patency of basal cisterns, nonreactive pupil reaction, and midline shift) by Aarabi et al. whereas Gressot et al. found that younger age and uni-hemispheric or bi-frontal lesion are associated with favorable outcomes [3, 5]. These findings are emphasized by a literature review on PCCIs done by Aarabi et al. in 2015 based on old studies and his personal experience [29].
Limitations
Our study had several limitations, as per nature to be a retrospective series. The dynamics of the surgical workforce and skills over 10 years period could have contributed to the surgical outcomes. There was a relatively big number of patients with PCCI who unluckily did not reach the tertiary hospital alive or who died at the injury site. The low number of our cases does not allow us to extrapolate our findings in case they are different from pre-existing ones in the literature. Some important clinical factors (pupil response to light, intracranial pressure, midline shift in the brain CT scan, and type of intracranial hemorrhage) which could probably be associated with poor outcomes were not routinely documented on the medical records. The other limitation of this study is the fact that some of the patients from our series have done only from head X-ray examination because of financial accessibility, several breakdowns of the CT scan services in the hospital during the study period; this could have unveiled other intracranial lesions associated to poor prognosis. In addition, our setting does not perform advanced ICP monitoring and relies mainly on clinical findings to monitor patients.
