Next Article in Journal
Geochemical Modeling Source Provenance, Public Health Exposure, and Evaluating Potentially Harmful Elements in Groundwater: Statistical and Human Health Risk Assessment (HHRA)
Next Article in Special Issue
Prevalence and Disability-Adjusted Life Year Rates of Asthma in China: Findings from the GBD Study 2019 of the G20
Previous Article in Journal
Developing Students’ Emotional Competencies in English Language Classes: Reciprocal Benefits and Practical Implications
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia

Department of Public Health and Nursing, Norwegian University of Science and Technology, 7491 Trondheim, Norway
Military Region 5 Hospital, Battambang, Cambodia
Trauma Care Foundation Cambodia, Battambang, Cambodia
Tromsø Mine Victim Resource Center, University Hospital North Norway, 9038 Tromsø, Norway
Department of Community Medicine, UiT the Arctic University of Norway, 9019 Tromsø, Norway
Department of Neurosurgery, University Hospital of North Norway, 9038 Tromsø, Norway
Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, 5009 Bergen, Norway
Authors to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(11), 6471;
Original submission received: 17 March 2022 / Resubmission received: 4 May 2022 / Revised: 22 May 2022 / Accepted: 24 May 2022 / Published: 26 May 2022
(This article belongs to the Special Issue 5th Anniversary of Section Global Health)


To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.

1. Introduction

Cambodia is a Southeast Asian country with a total population of around 16.95 million in 2021 [1]. It is considered a lower-middle-income country, with a gross national income per capita in 2019 of 4320 USD [2]. According to the United Nations, 80% of Cambodians live in rural areas with a severe problem of generational poverty [1]. In 2015, the World Health Organization revealed that privately unqualified (nonmedical) providers dominate primary health care delivery in rural Cambodia at around 43% [3]. In recent years, the prevalence of traumatic brain injury (TBI) has increased in Cambodia [4], where the neurosurgical capacity is not up to international standard, with only 34 qualified neurosurgeons in the entire country in 2020 [5].
Most people in low- and middle-income countries, including Cambodia, are distributed in rural and remote areas with poor transportation, which result in extensive prehospital transit hours [6]. The long prehospital transport duration in turn leads to higher prehospital fatalities in rural settings [7,8]. As a solution to reduce trauma mortality, the University Hospital of Northern Norway (UNN) implemented medical training in remote areas where resources were scarce. Between 2002 and 2005, UNN initiated a training program in general trauma care in the Military Region 5 Hospital [9]. The Military Region 5 Hospital is a regional hospital in the most landmine-infested province in Cambodia; it acts as the main public referral trauma center for six provinces in the Northwest, with a catchments area of around 3 million people. Treatment at the hospital is open to all, and complete treatment for the poor population is granted free of charge.
After this training [9], two general surgeons from Military Region 5 Hospital began to carry out craniotomies on casualties with traumatic head injuries. To enhance the quality of the existing medical procedures in this regional hospital, UNN continued to provide training in emergency cranial neurosurgery, focusing on operative and postoperative care since September 2013. Box 1 describes the training in detail. The research team conducted a prospective, descriptive cohort study to examine the functional outcomes of patients treated by emergency trauma procedures at this hospital after the teaching intervention.
Box 1. Teaching model in emergency cranial neurosurgery.
  • Five 150-h training courses in primary trauma surgery
  • Instructors from UNN conducted five consecutive 150 h training courses in primary trauma surgery at six regional hospitals in rural Cambodia from 2002 to 2005. The teaching program proved successful, with a significant reduction in trauma morbidity in the study hospitals [9]. The intervention was built on the Mozambique experience [10] and the previous experience of UNN’s “village university” teaching model [7,11,12].
  • Cranial neurosurgical capacity-building program
  • The training included a four-week in-hospital skill training at the neurosurgery department at UNN for a selected surgeon followed by teaching and surgical supervision for the surgeon’s team.
  • In September 2013, senior surgeon Vannara Sokh from the Military Hospital underwent four weeks of in-hospital skill training at the neurosurgical department at UNN to enhance the quality of operative and postoperative care. Since October 2013, the hospital in Battambang had performed 14 craniotomies in TBI cases and 11 craniotomies in patients with cerebral hemorrhage. During this period, the neurosurgeon instructors at UNN guided the Cambodian surgical team online by evaluating CT scans and other patient information. They also made several visits to the study hospital, where they performed surgeries together with the local surgical team to provide hands-on teaching and supervision. The training program in emergency cranial neurosurgery did not introduce new techniques or procedures but controlled the quality of medical procedures already in use in the study hospital in Cambodia.

2. Materials and Methods

2.1. Eligibility Criteria for Intervention and Data Sources

All emergency procedures were performed by general surgeons Vannara Sokh (VS) and Sophy Nguon (SN) in the operating theatres of the study hospital. The study hospital had an intensive care unit (ICU) with basic equipment and drugs for postoperative care. The ICU had no ventilator service, and the researchers did not expect such service to be installed during the inclusion period. Therefore, patients with GCS < 7 were considered to have brain injuries that were too severe to profit from the craniotomy protocol applied at the study hospital.
The patients were included consecutively as they were admitted to the study hospital for emergency medical care after the injury/incident from January 2015 to December 2016. Computer tomography (CT) scans were performed on admission at a private clinic in Battambang. Photographs of the CT films were taken using a camera and sent to the clinical supervisors at UNN for evaluation. The Glasgow Coma Scale (GCS) was rated by one of the main investigators (VS or SN) on admission. The supervisors advised the surgical team in Cambodia and attended the decision to exclude cases from inclusion by two measures on admission: GCS < 7 and/or CT scans.
The endpoint was Glasgow Outcome Scale (GOS) three months after injury/incident. Study patients without full GOS ratings were excluded from the cohort study, resulting in anonymous data of 294 valid subjects being transferred to an Excel database for research analysis.

2.2. Data Collection

Baseline characteristics were gathered on case record forms at admission. Specific trauma data collection included overall anatomical severity (rated by injury severity score), brain injury severity (rated by GCS), and other medical factors. The severity of the brain injury was defined by GCS score as severe head injury (GCS ≤ 8), moderate head injury (GCS 9–12), or mild head injury (GCS 13–15) [13]. The injury severity score (ISS) is calculated to depict the severity of traumatic extracranial injuries. The higher the ISS score, the more severe the injuries. Patients with an ISS > 15 are considered severely injured [14]. The primary outcome was GOS three months after injury/incident, which was collected by the two investigators (VS and SN) through mobile telephone interviews or home visits to the study patients. The GOS is widely used to measure and monitor a patient’s recovery following head and nervous system injuries. A higher GOS score indicates better functional performance and independence (Table 1) [15].

2.3. Statistical Analysis

IBM SPSS Statistics for Windows version 26 was used for statistical analyses. Continuous variables were presented using means and standard deviations (SDs). Categorical data were presented using percentages and frequencies. We examined the data distribution using the Shapiro-Wilk test and the Q-Q plot. The Mann-Whitney U-test or the Kruskal Wallis test was applied to compare the differences between groups. For categorical variables, the chi-square test or Fisher’s exact test were used.
The GOS score as an outcome variable was subdivided into unfavorable (GOS 1–3) or favorable (GOS 4–5). The associations between the variables and the outcome were measured by univariate regression analysis. As we had a small sample size and a low number of outcomes, we could not perform a multivariable model with logistic regression. Complete case analysis was used for handling missing data. A significance level of p < 0.05 (two-tailed) was used for all analyses.

3. Results

3.1. Data Inclusion/Exclusion for Statistical Analysis

A total of 294 consecutive patients were enrolled in the cohort study for emergency burr-hole trephination or emergence craniotomy, including a few patients with GCS < 7. Based on our aim of focusing on trauma, nontraumatic admissions were excluded from the analysis, resulting in 235 valid subjects included in this analysis. A table comparing the subsets is available in the Supplementary Materials. Figure 1 shows the process of data inclusion and exclusion for statistical analysis.

3.2. Patient Demographics and Clinical Status

The mean age at enrollment was 34 years, ranging from 12 to 84 years. Two hundred seven (88.1%) TBI patients underwent craniotomy. In the study, 83 (35.3%) patients presented a severe head injury (GCS ≤ 8), while 51 (21.7%) patients experienced a mild head injury (GCS 13–15). All patients had an ISS score of over 15.
In our study, 100 (42.5%) patients were diagnosed with an acute epidural hematoma (acute EDH), 74 (31.5%) with acute subdural hematoma (acute SDH), 35 (14.9%) with acute intracerebral hematoma (acute ICH), and 26 (11.1%) with chronic intracranial hematoma. Patients were predominantly males at 206 (87.7%), and this proportion ranged for the different trauma diagnoses from 82.4 to 94.3%. Patients with chronic intracranial hematoma were the eldest, with more than 85% of patients aged above 50 years. By contrast, patients with acute EDH were the youngest, with a mean age of 26 years. There was a difference in the time from injury to admission. The patient group with chronic intracranial hematoma experienced a delay between injury and admission, with an average duration from injury to admission of 484 ± 455 h, compared with an average duration of fewer than 60 h for each of the other trauma diagnoses. Before surgery, the patients with chronic intracranial hematoma had no polytrauma and almost no fractures. However, polytrauma was observed frequently in patients with acute intracranial hematoma (80%, 82.4%, and 74.3% for acute EDH, acute SDH, and acute ICH, respectively), and more than half of patients with acute intracranial hematoma had a fracture. Furthermore, all patients with acute EDH had fractures. No craniotomy was performed on patients with chronic intracranial hematoma, and almost no burr-hole trephination was performed on patients with acute intracranial hematoma (Table 2). Acute SDH and acute ICH mainly occurred after moderate or severe head trauma. In contrast, acute EDH mainly occurred after moderate head trauma, and chronic intracranial hematoma majorly occurred after mild head trauma (Table 2).

3.3. Outcome Measures

As shown in Table 3, a total of 218 (92.8%) patients experienced favorable outcomes. Favorable outcomes were achieved in 93 (93%) patients with acute EDH, compared with 66 (89.2%) with acute SDH, 34 (97.1%) with acute ICH, and 25 (96.2%) with chronic intracranial hematoma. All mortality rates reported were from the last follow-up, which was later than three months after injury, but the specific time was not recorded. All patients in a vegetative state (GOS = 2) on the fifth day after surgery and all patients with unfavorable outcomes at three months after the injury were deceased before the last follow-up (data not shown).

3.4. Risk Factors for Unfavorable Outcomes

As shown in Figure 2, the proportion of unfavorable outcomes (GOS = 1–3) at three months after injury was significantly higher in the group with a severe head injury than in the group with mild or moderate head injury (19.3% vs. 0% vs. 1%, p < 0.001). Univariate analysis using binary logistic regression showed that patients with moderate head injury were less likely to have an unfavorable outcome compared with those with severe head injury (OR 0.04, 95% CI 0.01–0.32). The preoperative GCS < 7 was associated with an unfavorable outcome at three months after injury (OR 26.3, 95% CI 7.9–87.1). In contrast, age, gender, type of fracture, trauma diagnosis, through referral hospital or not, surgery type, time from injury to admission, time from admission to surgery, and ISS score did not show significant associations with unfavorable outcomes (Table 4).

4. Discussion

In this study, we evaluated the surgical outcomes, patient characteristics, and prognosis predictors of emergency craniotomy and burr-hole trephination in a resource-constrained hospital in Cambodia.

4.1. Surgical Outcomes

The professionals at the hospital made the decisions regarding surgery type in the absence of clear guidelines for which surgical technique should proceed or which kind of patients should undergo neurosurgery. In the following sections, we compared the outcomes of surgical management by different trauma diagnoses with studies of high similarity (Table 5).
It is rare for epidural hematoma and intracerebral hematoma to become chronic [32,33,34]. Subdural hematoma is generated from the vein and has a slow and late onset, which is more likely to develop chronically [32]. Therefore, in the discussion section, the surgical outcomes of chronic intracranial hematoma in our study were compared with literature related to chronic subdural hematoma (CSDH).
Similar to other studies of CSDH patients [16,17,18,19,20], the surgical management for chronic intracranial hematoma in our study was burr-hole trephination. We observed a mortality rate of 3.8% in this patient group, which was notably lower than that in Singapore (in-hospital mortality rate of 13.3%) and in rural Kenya (30-day mortality rate of 6.7%) [16,19] but a bit higher than those in Taiwan (discharge mortality rate of 2.34%) and in China (mortality rate of 2% at six months after operation) [18,20]. In our study, the favorable outcome (GOS 4–5) was achieved in 96.2% of the patients with chronic intracranial hematoma, which was higher than that of surgically treated CSDH patients in Taiwan (83.3%) and in rural Kenya (90.8%) [16,20]. It is worth noting that more than half of CSDH cases were caused by head trauma [16,18,20]. However, most studies on the surgical management of CSDH included patients with injuries from all causes (both head injury and nontraumatic causes such as hypertension and alcohol consumption) [16,17,19,20]. It is interesting to note that surgical outcomes were similar in patients with nontraumatic CSDH and patients with traumatic CSDH [18]. In terms of mortality and favorable outcome, surgical outcomes in this study were acceptable compared with those in the published studies [16,17,18,19,20]. Therefore, we consider the surgical management of TBI patients with chronic intracranial hematoma at the Fifth Military Regional Hospital acceptable.
In our study, all patients with acute SDH underwent craniotomy as the surgical management. The postoperative mortality rate of 10.8% in the study hospital was very low compared with the mortality rate of 34.5% in Thailand (mortality at the last follow-up with a mean time of 6 months) and the 6-month mortality rate of 32–35.2% in the United Kingdom [21,22]. We observed a favorable outcome of 89.2% at three months, which seemed much better than 51% in Thailand and 42–45% in the United Kingdom [21,22]. It should be noted that the long-term results in our study were collected three months after the injury, while the long-term results of these two studies were collected six months after the injury [21,22]. The different time points of following up after the injury may explain the rate variations in favorable outcomes. Overall, we concluded that the surgical treatment of acute SDH patients at the Fifth Military Regional Hospital was of acceptable quality.
All acute EDH patients in our cohort underwent craniotomy except one patient who underwent burr-hole trephination. The surgical management in our study was similar to the published studies, which mainly involved craniotomy [24,26,27,28]. We observed mortality of 7%, which was slightly higher than the 2% across England and Wales [27] and the 3.3% in Hong Kong [24]. However, compared with studies in low-resource countries, the mortality rate in our study was lower than the 15.7% reported in Bangladesh [26] and similar to the 5.3% reported in Pakistan [28]. We found that the incidence of favorable outcomes three months after injury was 93%, which was much higher than the discharge outcomes in Japan (50%), Bangladesh (55.7%), and Hong Kong (76.7%) [24,25,26]. Therefore, we concluded that the surgical treatment of acute EDH patients in the Fifth Military Regional hospital was acceptable.
Almost all patients with acute ICH in our study received craniotomy. The practice was consistent with previous reports that craniotomy was the most used surgical method for traumatic intracerebral hematoma [29,30,35,36]. For surgically treated traumatic ICH patients, our favorable outcome of 97.1% was significantly higher than the 62% in the United Kingdom and the 63% reported in the first randomized trial (STITCH) for traumatic ICH patients in 31 centers from 13 countries [29,30]. Our mortality rate of 2.9% was prominently lower than the 10% in Brazil or the 15% reported in 31 centers from 13 countries [30,31]. Therefore, we concluded that the surgical treatment of traumatic ICH patients in the study hospital was acceptable.

4.2. Patient Characteristics: Mainly Young Males, High Incidence of Acute EDH, Late Admission

Our findings revealed a phenomenon that young men contribute the most to the cranial neurosurgery burden caused by TBI in Cambodia, which was consistent with the opinion of M. Kim et al. [5]. The unbalanced gender and age distribution of the primary labor force, the high proportion of men among drivers, and the high ratio of men who engage in violence or fighting could explain the phenomena observed in our study patients [1,37,38,39].
Acute EDH was the most frequent diagnosis in our study (43%). Many authors reported that the patient population with acute EDH was the youngest among all trauma diagnoses [26,40,41]. The high incidence of acute EDH may be related to the demographic characteristic that more than half of Cambodia’s population was under the age of 22 [1]. Kim et al. in 2020 [5] also documented that EDH accounted for a slightly higher proportion than SDH in TBI patients admitted to a public hospital in Cambodia.
Late admissions were observed in our study, which may be due to the absence of either an ambulance system or a referral system in Cambodia. Consequently, many patients were admitted to emergency surgery many days and even weeks after the injury [5]. Delays may also be due to resource constraints, such as lack of appropriate beds in receiving hospitals, lack of vehicles, or lack of trained referral staff [42,43].

4.3. Risk Factors of Unfavorable Outcomes

Kulesza et al. and Hanif et al. suggested that age and preoperative GCS score could predict the outcome after TBI, but gender did not have predictive value [44,45]. In our study, the severity of head injury based on GCS score was the only factor that was associated with the surgical outcomes (long-term unfavorable outcomes). Age was repeatedly identified as a predictor of TBI prognosis, and older age was associated with unfavorable GOS outcomes [14,44,46]. Hanif et al. commented that the likelihood of poor outcomes following surgical intervention in older patients with TBI was even magnified [45]. They further concluded that prognosis was also associated with time from injury to treatment and surgery type [45]. Researchers have noted that for traumatic acute intracranial hematoma requiring surgical evacuation, the more expediently (less transfer time) the surgical intervention is performed, the better the outcome [47,48]. However, we did not find that factors such as age, time from injury to surgery (injury to admission, admission to surgery), or surgery type played a role in predicting postoperative outcome.

4.4. Strengths and Limitations

The reasons for the lower mortality rates we observed compared with those reported in other studies may relate to the fact that study patients who lost contact after discharge were not included in the data set (due to lack of endpoint data). Cambodian society is disorganized, with many migrant families, which may have influenced the dropout rate. Moreover, the patients in Cambodia may be generally younger, and the younger age group may carry a better prognosis. Furthermore, a greater proportion of severe patients were not enrolled in the intervention due to resource constraints in the study hospital.
To our knowledge, this is the first study to evaluate the teaching outcome of a neurosurgical capacity-building program in Cambodia. Two Cambodian investigators managed all the procedures in the study hospital. As such, we did not expect disagreements and variations between raters and performers in the study hospital. Additionally, ours was a prospective study design, which ensured the accuracy of data collection. There were several limitations related to our study. One was that all cranial cases were CT scanned outside the hospital due to the lack of CT capability at the study site. Therefore, underdiagnosis bias may exist. Another was that this was a single-center study, which may reflect only the experience of the study hospital, resulting in limited generalizability. The other limitation was that the outcome measurements were unblinded and performed by the surgeons themselves, which may have led to misclassified results and biased assessments. Despite these limitations, our findings demonstrate a complex treatment reality that could serve as a framework for future training programs.

5. Conclusions

We found that the emergency burr-hole trephinations and emergency craniotomies for TBI patients at the Fifth Military Regional Hospital resulted in acceptable outcomes and that severe traumatic brain injury was identified as a predictor of the study hospital’s long-term unfavorable outcomes.

Supplementary Materials

The following supporting information can be downloaded at:, Table S1: Baseline characteristics of the study population grouped by preoperative GCS score.

Author Contributions

J.H.: formal analysis, validation, visualization, writing—original draft; H.H. and R.K.: conceptualization, methodology, investigation, project administration; Y.V.H.: project administration, data curation; V.S. and S.N.: investigation, data curation; J.Ø.O., H.H. and S.X.: statistical advice, supervision, writing—review and editing. All authors have read and agreed to the published version of the manuscript.


This study was financed by the Norwegian Ministry of Foreign Affairs and was supported by the Trauma Care Foundation in Cambodia, the University Hospital of Northern Norway, and the Norwegian University of Science and Technology. The study was carried out in cooperation with the Military Region 5 Hospital, Battambang, Cambodia.

Institutional Review Board Statement

The prospective, descriptive cohort study was approved by the Board of Directors at Military Region 5 Hospital, Battambang (No.12/05/2014), and it was conducted per the Helsinki Declaration. The analysis of this study was conducted under the approval of the Norwegian Regional Committee for Medical Research Ethics (REK) (No. 172645).

Informed Consent Statement

Written informed consent was obtained from all participants for any use of data in the study.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to data privacy but are available from the corresponding author upon reasonable request.


We thank the research group who designed and conducted this study and the patients who participated in the study.

Conflicts of Interest

The authors declare no conflict of interest.


  1. United Nations. World Population Review. Available online: (accessed on 14 May 2021).
  2. World Bank. Cambodia GNI (Current US$). 2019. Available online: (accessed on 9 May 2021).
  3. WHO. The Kingdom of Cambodia Health System Review; WHO Regional Office for the Western Pacific: Manila, Philippines, 2015. [Google Scholar]
  4. WHO. Road Safety in Cambodia. Available online: (accessed on 8 May 2021).
  5. Kim, M.; Yoo, C.B.; Lee-Park, O.; Nang, S.; Vuthy, D.; Park, K.B.; Vycheth, I. Patterns of neurosurgical conditions at a major government hospital in Cambodia. Asian J. Neurosurg. 2020, 15, 952. [Google Scholar] [CrossRef] [PubMed]
  6. Rubiano, A.M.; Carney, N.; Chesnut, R.; Puyana, J.C. Global neurotrauma research challenges and opportunities. Nature 2015, 527, S193–S197. [Google Scholar] [CrossRef] [PubMed]
  7. Husum, H.; Gilbert, M.; Wisborg, T. Save lives, save limbs. In Life Support to Victims of Mines, Wars, and Accidents; Third World Network: Penang, Malaysia, 2000. [Google Scholar]
  8. Murad, M.K.; Issa, D.B.; Mustafa, F.M.; Hassan, H.O.; Husum, H. Prehospital trauma system reduces mortality in severe trauma: A controlled study of road traffic casualties in Iraq. Prehospital Disaster Med. 2012, 27, 36–41. [Google Scholar] [CrossRef][Green Version]
  9. Van Heng, Y.; Davoung, C.; Husum, H. Non-doctors as trauma surgeons? A controlled study of trauma training for non-graduate surgeons in rural Cambodia. Prehospital Disaster Med. 2008, 23, 483–489. [Google Scholar] [CrossRef][Green Version]
  10. Pereira, C.; Bugalho, A.; Bergström, S.; Vaz, F.; Cotiro, M. A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique. BJOG Int. J. Obstet. Gynaecol. 1996, 103, 508–512. [Google Scholar] [CrossRef]
  11. Husum, H.; Gilbert, M.; Wisborg, T. Training pre-hospital trauma care in low-income countries: The Village University experience. Med. Teach. 2003, 25, 142–148. [Google Scholar] [CrossRef] [PubMed]
  12. Husum, H.; Gilbert, M.; Wisborg, T.; Van Heng, Y.; Murad, M. Rural prehospital trauma systems improve trauma outcome in low-income countries: A prospective study from North Iraq and Cambodia. J. Trauma Acute Care Surg. 2003, 54, 1188–1196. [Google Scholar] [CrossRef]
  13. Ślusarz, R.; Jabłońska, R.; Królikowska, A.; Haor, B.; Barczykowska, E.; Biercewicz, M.; Głowacka, M.; Szrajda, J. Measuring scales used for assessment of patients with traumatic brain injury: Multicenter studies. Patient Prefer. Adherence 2015, 9, 869. [Google Scholar] [CrossRef][Green Version]
  14. Lingsma, H.F.; Roozenbeek, B.; Steyerberg, E.W.; Murray, G.D.; Maas, A.I. Early prognosis in traumatic brain injury: From prophecies to predictions. Lancet Neurol. 2010, 9, 543–554. [Google Scholar] [CrossRef]
  15. Jennett, B.; Bond, M. Assessment of outcome after severe brain damage: A practical scale. Lancet 1975, 305, 480–484. [Google Scholar] [CrossRef]
  16. Kanyi, J.K.; Ogada, T.V.; Oloo, M.J.; Parker, R.K. Burr-hole craniostomy for chronic subdural hematomas by general surgeons in rural Kenya. World J. Surg. 2018, 42, 40–45. [Google Scholar] [CrossRef] [PubMed]
  17. Weigel, R.; Schmiedek, P.; Krauss, J. Outcome of contemporary surgery for chronic subdural haematoma: Evidence based review. J. Neurol. Neurosurg. Psychiatry 2003, 74, 937–943. [Google Scholar] [CrossRef] [PubMed]
  18. Ou, Y.; Yu, X.; Liu, X.; Jing, Q.; Liu, B.; Liu, W. A Comparative Study of Chronic Subdural Hematoma in Patients With and Without Head Trauma: A Retrospective Cross Sectional Study. Front. Neurol. 2020, 11, 1538. [Google Scholar] [CrossRef] [PubMed]
  19. Rohde, V.; Graf, G.; Hassler, W. Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: A retrospective analysis of 376 patients. Neurosurg. Rev. 2002, 25, 89–94. [Google Scholar] [CrossRef]
  20. Cheng, S.-Y.; Chang, C.-K.; Chen, S.-J.; Lin, J.-F.; Tsai, C.-C. Chronic subdural hematoma in elderly Taiwan patients: A retrospective analysis of 342 surgical cases. Int. J. Gerontol. 2014, 8, 37–41. [Google Scholar] [CrossRef][Green Version]
  21. Karnjanasavitree, W.; Phuenpathom, N.; Tunthanathip, T. The optimal operative timing of traumatic intracranial acute subdural hematoma correlated with outcome. Asian J. Neurosurg. 2018, 13, 1158. [Google Scholar]
  22. Li, L.M.; Kolias, A.G.; Guilfoyle, M.R.; Timofeev, I.; Corteen, E.A.; Pickard, J.D.; Menon, D.K.; Kirkpatrick, P.J.; Hutchinson, P.J. Outcome following evacuation of acute subdural haematomas: A comparison of craniotomy with decompressive craniectomy. Acta Neurochir. 2012, 154, 1555–1561. [Google Scholar] [CrossRef]
  23. Kotwica, Z.; Brzeziński, J. Acute subdural haematoma in adults: An analysis of outcome in comatose patients. Acta Neurochir. 1993, 121, 95–99. [Google Scholar] [CrossRef]
  24. Cheung, P.S.; Lam, J.M.; Yeung, J.H.; Graham, C.A.; Rainer, T.H. Outcome of traumatic extradural haematoma in Hong Kong. Injury 2007, 38, 76–80. [Google Scholar] [CrossRef]
  25. Onodera, K.; Kamide, T.; Kimura, T.; Tabata, S.; Ikeda, T.; Kikkawa, Y.; Kurita, H. Identification of prognostic factors in surgically treated patients with acute epidural hematoma. Asian J. Neurosurg. 2020, 15, 532. [Google Scholar] [PubMed]
  26. Islam, M.; Saha, S.; Elahy, M.; Islam, K.; Ahamed, S. Factors influencing the outcome of patients with acute extradural haematomas undergoing surgery. Bangladesh J. Med. Sci. 2011, 10, 112–120. [Google Scholar] [CrossRef][Green Version]
  27. Ruff, L.M.; Mendelow, A.D.; Lecky, F.E. Improving mortality after extradural haematoma in England and Wales. Br. J. Neurosurg. 2013, 27, 19–23. [Google Scholar] [CrossRef] [PubMed]
  28. Rehman, L.; Karachi, N.J. Association of outcome of traumatic extradural hematoma with Glasgow Coma Scale and hematoma size. Ann. Pak. Inst. Med. Sci. 2010, 6, 133–138. [Google Scholar]
  29. Siddique, M.S.; Gregson, B.A.; Fernandes, H.M.; Barnes, J.; Treadwell, L.; Wooldridge, T.D.; Mendelow, A.D. Comparative study of traumatic and spontaneous intracerebral hemorrhage. J. Neurosurg. 2002, 96, 86–89. [Google Scholar] [CrossRef]
  30. Mendelow, A.D.; Gregson, B.A.; Rowan, E.N.; Francis, R.; McColl, E.; McNamee, P.; Chambers, I.R.; Unterberg, A.; Boyers, D.; Mitchell, P.M. Early surgery versus initial conservative treatment in patients with traumatic intracerebral hemorrhage (STITCH [Trauma]): The first randomized trial. J. Neurotrauma 2015, 32, 1312–1323. [Google Scholar] [CrossRef][Green Version]
  31. Fernandes, Y.; Borges, G.; Ramina, R.; Carvalho, F.; Cançado, B.; Morais, J. Minimally invasive approach to traumatic intracerebral hematomas. Min-Minim. Invasive Neurosurg. 2001, 44, 221–225. [Google Scholar] [CrossRef]
  32. Aromatario, M.; Torsello, A.; D’Errico, S.; Bertozzi, G.; Sessa, F.; Cipolloni, L.; Baldari, B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. Medicina 2021, 57, 125. [Google Scholar] [CrossRef]
  33. Lin, C.-Y.; Chen, Y.; Tseng, S.-H. Chronic encapsulated intracerebral haematoma. J. Clin. Neurosci. 2007, 14, 58–61. [Google Scholar] [CrossRef]
  34. Nomura, M.; Miyashita, K.; Tamase, A.; Kamide, T.; Mori, K.; Kitamura, Y.; Seki, S.; Shima, H.; Yanagimoto, K. A chronic intracerebral fluid hematoma. Neuroradiol. J. 2014, 27, 191–194. [Google Scholar] [CrossRef][Green Version]
  35. Cepeda, S.; Gómez, P.A.; Castaño-Leon, A.M.; Martínez-Pérez, R.; Munarriz, P.M.; Lagares, A. Traumatic intracerebral hemorrhage: Risk factors associated with progression. J. Neurotrauma 2015, 32, 1246–1253. [Google Scholar] [CrossRef]
  36. Sturiale, C.L.; De Bonis, P.; Rigante, L.; Calandrelli, R.; D’Arrigo, S.; Pompucci, A.; Mangiola, A.; D’Apolito, G.; Colosimo, C.; Anile, C. Do traumatic brain contusions increase in size after decompressive craniectomy? J. Neurotrauma 2012, 29, 2723–2726. [Google Scholar] [CrossRef] [PubMed]
  37. World Bank. Labor Force Participation Rate by Sex; World Bank: Washington, DC, USA, 2019. [Google Scholar]
  38. Peeters, S.; Blaine, C.; Vycheth, I.; Nang, S.; Vuthy, D.; Park, K.B. Epidemiology of Traumatic Brain Injuries at a Major Government Hospital in Cambodia. World Neurosurg. 2017, 97, 580–589. [Google Scholar] [CrossRef] [PubMed]
  39. Kulesza, B.; Mazurek, M.; Rams, Ł.; Nogalski, A. Acute epidural and subdural hematomas after head injury: Clinical distinguishing features. Indian J. Surg. 2020, 83, 96–104. [Google Scholar] [CrossRef]
  40. Bir, S.C.; Maiti, T.K.; Ambekar, S.; Nanda, A. Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States. Clin. Neurol. Neurosurg. 2015, 138, 99–103. [Google Scholar] [CrossRef] [PubMed]
  41. Rosyidi, R.M.; Priyanto, B.; Al Fauzi, A.; Sutiono, A.B. Toward zero mortality in acute epidural hematoma: A review in 268 cases problems and challenges in the developing country. Interdiscip. Neurosurg. 2019, 17, 12–18. [Google Scholar] [CrossRef]
  42. Crimmins, D.W.; Palmer, J.D. Snapshot view of emergency neurosurgical head injury care in Great Britain and Ireland. J. Neurol. Neurosurg. Psychiatry 2000, 68, 8–13. [Google Scholar] [CrossRef][Green Version]
  43. Vyvyan, H.; Kee, S.; Bristow, A. A survey of secondary transfers of head injured patients in the south of England. Anaesthesia 1991, 46, 728–731. [Google Scholar] [CrossRef]
  44. Kulesza, B.; Nogalski, A.; Kulesza, T.; Prystupa, A. Prognostic factors in traumatic brain injury and their association with outcome. J. Pre-Clin. Clin. Res. 2015, 9, 163–166. [Google Scholar] [CrossRef][Green Version]
  45. Hanif, S.; Abodunde, O.; Ali, Z.; Pidgeon, C. Age related outcome in acute subdural haematoma following traumatic head injury. Ir. Med. J. 2009, 102, 255. [Google Scholar]
  46. Kulesza, B.; Litak, J.; Mazurek, M.; Nogalski, A. Initial Factors Affecting 6-month Outcome of Patients Undergoing Surgery for Acute Post-traumatic Subdural and Epidural Hematoma. Folia Med. 2020, 62, 94. [Google Scholar] [CrossRef]
  47. Deverill, J.; Aitken, L.M. Treatment of extradural haemorrhage in Queensland: Interhospital transfer, preoperative delay and clinical outcome. Emerg. Med. Australas. 2007, 19, 325–332. [Google Scholar] [CrossRef] [PubMed]
  48. Leach, P.; Childs, C.; Evans, J.; Johnston, N.; Protheroe, R.; King, A. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester. Br. J. Neurosurg. 2007, 21, 11–15. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Flowchart of the process of data inclusion and exclusion for statistical analysis. Overview of the process of extracting data for the study patient of interest. Abbreviations: GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale; ISS, Injury Severity Score.
Figure 1. Flowchart of the process of data inclusion and exclusion for statistical analysis. Overview of the process of extracting data for the study patient of interest. Abbreviations: GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale; ISS, Injury Severity Score.
Ijerph 19 06471 g001
Figure 2. The number of patients with a favorable outcome at three months after injury in the different preoperative GCS groups.
Figure 2. The number of patients with a favorable outcome at three months after injury in the different preoperative GCS groups.
Ijerph 19 06471 g002
Table 1. The Glasgow Outcome Scale.
Table 1. The Glasgow Outcome Scale.
2No response, but alive
3Severe disability, conscious but needs support for all daily activities
4Patient is independent but has some disability
5Full recovery, no disability
Table 2. Baseline characteristics of the study population grouped by trauma diagnosis.
Table 2. Baseline characteristics of the study population grouped by trauma diagnosis.
OverallTrauma Diagnosis
CharacteristicN = 235Epidural
n = 100n = 74n = 35n = 26
Age34.9 ± 17.326.3 ± 11.337.2 ± 16.836.2 ± 15.359.7 ± 13.7<0.001 a
Time from injury to admission (h)83 ± 213.525.3 ± 33.337.1 ± 9958.5 ± 91.3484.2 ± 455.6<0.001 a
Time from admission to surgery (h)21.4 ± 36.417.2 ± 25.119.3 ± 2824.5 ± 29.639.3 ± 77.50.7 a
Injury Severity Score23.2 ± 3.623.5 ± 3.423.5 ± 3.322.7 ± 422.2 ± 4.20.279 a
Head injury severity <0.001 b
  Severe (GCS 3–8)83 (35.3%)29 (29%)33 (44.6%)15 (42.9%)6 (23.1%)
  Moderate (GCS 9–12)101 (43.0%)50 (50%)33 (44.6%)12 (32.3%)6 (23.1%)
  Mild (GCS 13–15)51 (21.7%)21 (21%)8 (10.8%)8 (22.9%)14 (53.8%)
Gender 0.353 c
  Female29 (12.3%)11 (11%)13 (17.6%)2 (5.7%)3 (11.5%)
  Male206 (87.7%)89 (89%)61 (82.4%)33 (94.3%)23 (88.5%)
Age groups <0.001 c
  <20 y41 (17.4%)31 (31%)5 (6.8%)5 (14.3%)0 (0%)
  20–34 y105 (44.7%)53 (53%)38 (51.4%)12 (34.3%)2 (7.7%)
  35–49 y29 (12.3%)8 (8%)9 (12.2%)10 (28.6%)2 (7.7%)
  50–64 y40 (17%)7 (7%)15 (20.3%)7 (20%)11 (42.3%)
  > or =65 y20 (8.5%)1 (1%)7 (9.5%)1 (2.9%)11 (42.3%)
Type of fracture <0.001 c
  Close fracture130 (55.3%)98 (98%)16 (21.6%)15 (42.9%)1 (3.8%)
  Open fracture8 (3.4%)2 (2%)3 (4.1%)3 (8.6%)0 (0%)
  Without fracture97 (41.3%)0 (0%)55 (74.3%)17 (48.6%)25 (96.2%)
Polytrauma <0.001 b
  No other injuries68 (28.9%)20 (20%)13 (17.6%)9 (25.7%)26 (100%)
  Other moderate injury no need for surgery162 (68.9%)77 (77%)60 (81.1%)25 (71.4%)0 (0%)
  Other injury in need for surgery5 (2.1%)3 (3%)1 (1.4%)1 (2.9%)0 (0%)
Type of operation <0.001 c
  Burr-hole trephination28 (11.9%)1 (1%)0 (0%)1 (2.9%)26 (100%)
  Craniotomy207 (88.1%)99 (99%)74 (100%)34 (97.1%)0 (0%)
Abbreviations: GCS, Glasgow Coma Scale. a. Kruskal Wallis test; b. Chi-square test; c. Fisher’s exact test if more than 20% of cells have an expected count of less than 5 on the chi-square test.
Table 3. Trauma Diagnoses and Outcome Measures.
Table 3. Trauma Diagnoses and Outcome Measures.
OverallTrauma Diagnosis
CharacteristicN = 235Epidural
Chronicp-Value a
n = 100n = 74n = 35n = 26
Dead 0.540
  Yes17 (7.2%)7 (7%)8 (10.8%)1 (2.9%)1 (3.8%)
  No218 (92.8%)93 (93%)66 (89.2%)34 (97.1%)25 (96.2%)
Postoperative GOS (3 months post-injury) 0.540
  Unfavorable (GOS 1–3)17 (7.2%)7 (7%)8 (10.8%)1 (2.9%)1 (3.8%)
  Favorable (GOS 4–5)218 (92.8%)93 (93%)66 (89.2%)34 (97.1%)25 (96.2%)
Abbreviations: GOS, Glasgow Outcome Scale. a. Fisher’s exact test if more than 20% cells have expected count less than 5 on the chi-square test.
Table 4. The risk of unfavorable outcome three months after injury: univariate analysis by binary logistic regression.
Table 4. The risk of unfavorable outcome three months after injury: univariate analysis by binary logistic regression.
Unfavorable Outcome (GOS 1–3) at 3 Months after Injury
Variablep-ValueOR95% CI for OR
Moderate head injury (GCS 9–12)-ref--
Severe head injury (GCS 3–8)0.00223.883.09184.36
Mild head injury (GCS 13–15)0.9980 a0-
Type of fracture (Close fracture)-ref--
Type of fracture (Open fracture)0.761.410.1612.4
Type of fracture (No fracture)0.1470.420.131.35
Trauma diagnosis (Epidural hematoma)----
Trauma diagnosis (Subdural hematoma)0.3791.610.564.66
Trauma diagnosis (Intracerebral hematoma)0.3880.390.053.29
Trauma diagnosis (Chronic) 0.5630.530.064.52
Referral admission (No)-ref--
Referral admission (Yes)0.8491.110.393.1
Polytrauma (No)-ref--
Polytrauma (Yes)0.2951.980.557.13
Age group (<20 y)-ref--
Age group (20–34 y)0.1774.210.5233.99
Age group (35–49 y)0.3852.960.2634.32
Age group (> or =50 y)0.3562.860.3126.53
Surgery type (Burr-hole trephination) -ref--
Surgery type (Craniotomy) 0.4372.260.2917.75
ISS groups (ISS < 25) -ref--
ISS groups (ISS ≥ 25) 0.1724.160.5432.22
Time from injury to admission (Hours)0.589111
Time from admission to surgery (Hours)0.4530.990.971.02
Abbreviations: GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale; ISS, Injury Severity Score; OR, Odds ratio; CI, Confidence interval; Findings with p-value ≤ 0.1 are highlighted in bold; a For mild head injury, there was no case suffered unfavorable outcome.
Table 5. Summary of the literature comparisons of the surgical outcomes.
Table 5. Summary of the literature comparisons of the surgical outcomes.
Trauma DiagnosisSurgical Outcomes in the Study HospitalSurgical Outcomes * in the
Literature on the General
Surgical Outcomes * in the
Literature on a Specific
Chronic subdural hematomaFavorable outcome at 3 months 96.2%
Mortality 3.8%
Favorable outcome 90.8% [16]
Mortality 0–32% [16,17,18,19]
Age ≥ 65 years [20]:
Favorable outcome 83.3%
Mortality 2.34%
Traumatic acute subdural hematomaFavorable outcome at 3 months 89.2%
Mortality 10.8%
Favorable outcome 42–51% [21,22]
Mortality 32–35.2% [21,22]
Comatose patients (GCS < 10) [23]:
Favorable outcome 23%
Mortality 57%
Traumatic acute epidural hematomaFavorable outcome at 3 months 93%
Mortality 7%
Favorable outcome 50–76.7% [24,25,26]
Mortality 2–15.7% [24,26,27,28]
Not available
Traumatic intracerebral hematomaFavorable outcome at 3 months 97.1%
Mortality 2.9%
Favorable outcome 62–63% [29,30]
Mortality 10–15% [30,31]
Not available
* Surgical results at discharge, or surgical results at follow-up within 30 days after surgery, or 3 months after trauma, or at 6 months after trauma.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Hu, J.; Sokh, V.; Nguon, S.; Heng, Y.V.; Husum, H.; Kloster, R.; Odland, J.Ø.; Xu, S. Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia. Int. J. Environ. Res. Public Health 2022, 19, 6471.

AMA Style

Hu J, Sokh V, Nguon S, Heng YV, Husum H, Kloster R, Odland JØ, Xu S. Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia. International Journal of Environmental Research and Public Health. 2022; 19(11):6471.

Chicago/Turabian Style

Hu, Jingjing, Vannara Sokh, Sophy Nguon, Yang Van Heng, Hans Husum, Roar Kloster, Jon Øyvind Odland, and Shanshan Xu. 2022. "Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia" International Journal of Environmental Research and Public Health 19, no. 11: 6471.

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop