Evaluation of the clinical utility of advanced brain imaging by computed tomography and challenges around its feasibility in Internal Medicine in Rwanda

Abstract

Background: Imaging is one of the important diagnostic tools to practicing physicians worldwide. Brain imaging by computed tomography has gained a place in Rwandan medical practice over several decades ago and it is increasing over the years. However, little is known about how useful and to which extent this imaging modality helps physicians who practice in Rwanda. Objective: The aim of this study was to determine the clinical utility of brain imaging by computed tomography and the challenges around getting results in an optimal time. Methods: This was a cross-sectional study on 150 patients aged ≥ 16 years. It was conducted in two referral hospitals, CHUB and CHUK. Once a doctor in the department of internal medicine ordered a brain imaging by brain CT scan for medical reason(s); a questionnaire was filled after obtaining informed consent of the patient alongside his/her treating doctor. We recorded the times of ordering the brain CT-scan, that one of doing it and the other one of getting result. Thereafter diagnosis/diagnoses was/were recorded and the primary investigator recorded the way the treating team used the results of imaging to deliver the best care possible to the patient. Finally the challenges that caused brain imaging not to be available within the first 24 hours were recorded as well. Results: The mean age was 55 ± 22 years. The symptom that prompted the most a physician to order a brain imaging was hemibody weakness followed by alteration in mental status. HIV and hypertension were the leading associated co-morbidities that could influence the results of brain CT scan. Brain CT scan with contrast was ordered the most at 63%. The pre-scan diagnoses in the category of vascular conditions were dominating the figures and were led by 49.3 % ischemic strokes, infectious conditions being suspected by physicians; cumulatively at 61.2%, while malignant conditions were suspected at less than 50 %. Brain CT scan confirmed ischemic and hemorrhagic strokes at 28% and 17.3% respectively. Other conditions brain CT scan was able to diagnose or suspect were at lower percents. The general diagnostic exactness of brain CT scan was 34.56% which is a satisfactory number though not sufficient. In general on average 3 days were delayed to conduct brain CT scan with contrast as opposed to non contrast brain CT scan that required 2 days on average, with a p value 0.016, and no difference delay in interpretation was observed as to whether contrast was or was not used as roughly 7 days average were required to complete interpretation by a radiologist with a p value 0.057. Many challenges to perform brain CT scan as quick as possible were identified but unavailability of radiological report was by far the most cause of delaying results at 62%. Results of brain CT scan led to direct counseling of patients by the physician up to 50%, led to additional tests up to 29.3%, brain CT scan confirmed diagnosis at 36.7%, led to seek consults cumulatively at 32%, led physicians to new prescriptions at 16%. Conclusion: This study demonstrated that brain CT scan is an important tool for investigation mostly for vascular conditions suspected by a physician. The challenges around its promptness affect its utility and are reflected in a low general diagnostic exactness but satisfactory in limited resource settings and delay in getting the diagnosis.