ORIGINAL ARTICLE Year : 2023  |  Volume : 12  |  Issue : 1  |  Page : 48-54

An epidemiologic study of traumatic brain injury in children, middle-aged patients, and elderly presenting to the emergency department

Farhad Heydari, Babak Masoumi, Alireza Abootalebi, Amir Bahador Boroumand, Reyhane Qasemi
Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission09-Jan-2023Date of Decision25-Mar-2023Date of Acceptance26-Mar-2023Date of Web Publication30-Apr-2023

Correspondence Address:
Reyhane Qasemi
Alzahra Hospital, Sofeh Ave., Keshvari Blvd., Isfahan
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/atr.atr_3_23

Background and Objectives: Traumatic brain injury (TBI) is one of the major health and socioeconomic problems in the world. How clinicopathological features of TBI differ by age is unclear. The present study evaluated the epidemiology of TBI and identified any variable that differs among pediatric, middle-aged, and elderly patients. Methods: The descriptive cross-sectional study was conducted on patients with TBI from April 2019 to April 2021. The study population consisted of all patients with TBI who were admitted to the Emergency Department. The inclusion criteria were all TBI patients who were a candidate for head computed tomography (CT) scans. The patients' clinicopathological parameters were recorded. Results: Among 3513 patients with TBI who underwent CT scans, 212 patients died (6.0%). The mean age of subjects was 30.67 ± 19.42, and 69.2% of the patients (2430 cases) were male. Motor vehicle accidents (48.4%) were the most prevalent mechanisms of injury. Intracranial lesions were seen on the head CT scan in 509 (14.5%) patients. The highest mortality rate was shown in elderly patients and the lowest in children (P < 0.001). Falls were the most common mechanism of injury in the elderly subjects (65.2%), while motor vehicle accidents were the most common in the children and middle-aged groups (40.9% and 54.0%). The incidence of intracranial lesions and moderate-to-severe head injuries was significantly higher in the elderly subjects (P < 0.001). Subdural hematoma and subarachnoid hemorrhage were the most common CT findings in elderly patients (13.3% and 11.3%). Brain contusion and skull fracture were the most common findings in the children (6.0% and 4.3%). Conclusions: The present study found that the clinicopathological parameters were significantly different among children, middle-aged patients, and elderly patients.

Keywords: Brain injury, emergency department, epidemiology, trauma

How to cite this article:
Heydari F, Masoumi B, Abootalebi A, Boroumand AB, Qasemi R. An epidemiologic study of traumatic brain injury in children, middle-aged patients, and elderly presenting to the emergency department. Arch Trauma Res 2023;12:48-54
How to cite this URL:
Heydari F, Masoumi B, Abootalebi A, Boroumand AB, Qasemi R. An epidemiologic study of traumatic brain injury in children, middle-aged patients, and elderly presenting to the emergency department. Arch Trauma Res [serial online] 2023 [cited 2023 Apr 30];12:48-54. Available from: https://www.archtrauma.com/text.asp?2023/12/1/48/375444   Introduction 

Traumatic brain injury (TBI) is one of the major health and socioeconomic problems in Iran and around the world.[1],[2] According to the World Health Organization, TBI is the third leading cause of death and disability in the world in 2020.[3] About 37% of all deaths following injuries are caused by TBI.[4] Each year about 50,000 deaths after TBI are reported in the United States.[5] In recent years, the number of people with TBI has increased steadily in developed and developing countries.[6] In Iran, head-and-neck trauma is one of the most common types of injuries, and the most common mechanism is motor vehicle accidents.[7]

TBI is more common in the middle-aged, followed by teenagers and the elderly.[6] However, with the increase in the age of the population, the proportion of the elderly with TBI has increased compared to young patients.[8] Mortality and morbidity after TBI vary by age. The mortality rate in the elderly is higher than that of teenagers and middle-aged people.[4],[5] This could be related to differences in brain anatomy, the presence of more comorbidities, and greater use of anticoagulants and antiplatelet drugs.[5],[8],[9] Older adults experienced more complications and had more injuries due to low-energy traumas such as falls, longer lengths of stay, higher triage levels, and lower discharge rates compared with younger adults.[5],[10] The mortality rate in middle-aged people is higher than in juveniles. It can be related to more occurrences of motor vehicle accidents in these ages which cause more serious injuries.[11]

Age and gender have a significant effect on TBI outcome, either alone or in combination with Glasgow Coma Score (GCS).[6],[11] GCS is the most common score used to describe the severity of brain injuries. GCS was developed to assess consciousness levels in patients with head trauma. Traditionally, mild head trauma is defined as a GCS = 14–15, moderate head trauma is defined as a GCS = 9–13, and severe head trauma is defined as a GCS ≤8.[12],[13]

Due to the importance of head injury and its consequences, such as loss of consciousness and death, its costs in the health-care system, and disabilities caused by head trauma, an epidemiological study of this issue is necessary. Previous studies have reported the epidemiology of head trauma worldwide.[1],[3],[6] While, the different clinical and pathological characteristics of head trauma among pediatric, middle-aged, and elderly people are not well defined. Furthermore, the epidemiology of head trauma seems to be changing due to its increased incidence in the elderly.[1]

The present study was performed to evaluate the epidemiology of TBI and to identify any variable that differs among pediatric, middle-aged, and elderly patients.

  Materials and Methods 

Study design

The descriptive cross-sectional study was performed on patients with TBI from April 2019 to April 2021 in Alzahra and Kashani Hospitals, two university hospitals in Isfahan, Iran. The study protocol was approved by the Ethics Committee of the Isfahan University of Medical Sciences (IR.MUI.MED.REC.1400.135).

Study setting and population

The study population consisted of all patients with traumatic brain trauma who were admitted to the Emergency Department (ED) of Alzahra and Kashani Hospitals during the study period. The inclusion criteria were all patients with TBI who were a candidate for head computed tomography (CT) scans. Patients with trauma to other parts of their body, who had an abbreviated injury scale score of more than 2, were not included in the study.

Patients with a history of taking anticoagulant drugs, with a previous history of brain tumors or cerebrovascular diseases, pregnant women, and incomplete medical records were excluded from the study.

Data gathering

The data were obtained by reviewing the medical records of all patients, using a preestablished checklist. The data collected included demographic data (gender, age), triage level based on the Emergency Severity Index-version 4, mechanisms of injury, time of day and season of the event, the severity of trauma based on the GCS, head CT findings including subdural hematoma (SDH), epidural hematoma (EDH), subarachnoid hemorrhage (SAH), brain contusion, skull fracture, and others, scalp laceration, and outcomes (death or survived).

Patients were also classified into children (≤17 years), middle-aged patients (18–64 years), and elderly patients (≥65 years).[6],[9],[11],[13] The attending radiologists reported all head CT scans.

Statistical analysis

Results were reported as frequencies (%) for qualitative data and mean and standard deviation (SD) for descriptive variables. The Chi-squared test and Mann–Whitney U-test were used to compare the variables.

A multivariate logistic regression analysis was used to assess the independent risk factors of death. Stepwise logistic regression was performed for the occurrence of death, considering the variables associated with a higher univariate association with death (P < 0.1). All statistical analyses were performed using SPSS (ver. 25.0; IBM, Armonk, NY, USA). P < 0.05 was considered statistically significant.

  Results 

A total of 3513 patients with traumatic brain trauma underwent CT analyses in the present study. Of these, 881 patients were under 18 years old, 256 patients were over 64 years old, and 2376 patients were between 65 and 80 years old. The mean (SD) age of subjects was 30.67 (19.42), and 69.2% of the patients (2430 cases) were male. 6.0% (n = 212) of patients died. Motor vehicle accidents (48.4%) were the most prevalent mechanisms of injury. In most patients, the severity of the head injuries was mild (86.9%).

Intracranial lesions were seen on the head CT scan in 509 (14.5%) patients. Parenchymal contusion was the most common CT finding (7.0%), followed by diffuse axonal injury (4.7%) and skull fracture (4.3%). Between 18:00 and 24:00 (36.0%) and between 12:00 and 18:00 (31.5%) were the most common times of the day when patients were admitted to the ED, and spring (27.5%) was the most common season to present to the ED. The baseline characteristics are presented in [Table 1].

The associations of baseline characteristics with gender are reported in [Table 1]. The men were significantly younger than the women (27.59 ± 15.51 vs. 37.58 ± 24.79; P < 0.001). The prevalence of intracranial lesions between men and women had no significant difference (P = 0.099). There were significant differences in terms of the severity of trauma (P = 0.041), level of triage (P = 0.020), and mechanism of injury (P < 0.001). Moreover, the mortality of males and females had no significant difference (P = 0.718).

There were significant differences between the survived and death groups in age and mechanism of injury (P < 0.001). The frequencies of intracranial lesions, level 1 of triage, and moderate-to-severe head injuries were significantly higher in the death group (P < 0.001). The findings demonstrated a higher prevalence of death in the summer and fall (P = 0.004) [Table 2]. The logistic regression results for the death are shown in [Table 3]. The multivariate analysis resulted in older patients (odds ratio [OR] = 1.043, 95% confidence interval [CI]: 1.026–10.60, P = 0.006), who had intracranial lesions (OR = 7.940, 95% CI: 2.981–21.146, P < 0.001), low triage level (OR = 0.195, 95% CI: 0.089–0.430, P < 0.001), and severe head trauma (OR = 19.470, 95% CI: 5.491–66.582, P < 0.001) as predictors of mortality.

Table 3: Logistic regression models for risk factors for death in head trauma patients

Click here to view

The associations of baseline characteristics with the age group (children, middle-aged patients, and elderly patients) are demonstrated in [Table 4]. The highest mortality rate was shown in elderly patients and the lowest in children (P < 0.001). Falls were the most common mechanism of injury in the elderly subjects (65.2%), while motor vehicle accidents were the most common in the children and middle-aged groups (40.9% and 54.0%). The prevalence of intracranial lesions and moderate-to-severe head injuries was significantly higher in the elderly subjects (P < 0.001). SDH and SAH were the most common CT findings in elderly patients (13.3% and 11.3%). Brain contusion and skull fracture were the most common findings in the children (6.0% and 4.3%). The findings showed a higher incidence of SDH, SAH, and diffuse axonal injury in the elderly group (P < 0.001).

  Discussion 

The present study is a population-based study assessing TBI that included both clinical and pathological characteristics. Most of the previous studies showed the epidemiology of TBI in young and elderly people, while in this study, we have assayed three age groups including juvenile, middle-aged, and elderly people.

The total number of TBI-related hospitalization and deaths has increased over time.[8],[14] However, improvements in the care of patients with TBI have led to reduced mortality and improved outcomes. In this regard, a study conducted by Martins et al.[15] reported that mortality from TBI decreased over time.

In this study, the majority of hospitalized patients had a mild injury (86.9%), which was consistent with previous studies that reported mild injury in 39%–85.3% of TBI patients.[3],[5] In another study, Peeters et al.[1] show that mild brain injuries vary between 71% and 97.5%. Furthermore, in the present study, head injury was more common in middle-aged people, followed by children and the elderly. These results were consistent with those reported by Wang et al.[6] and Onwuchekwa and Echem.[3]

The mean age of subjects was 30.67 years. Similarly, in another study conducted in Iran, it was 30.78 years.[2] In a systematic review, the mean age of patients varied from 22 to 49 years.[1] Similar to previous studies, the majority of patients were male (69.2%).[2],[4],[6],[11] The male-to-female ratio ranged from 1.2:1.0 to 4.6:1.0.[1] In line with previous studies, in the elderly group, the number of women increased slightly and the ratio of men to women decreased.[14],[16],[17]

Motor vehicle accidents were the most prevalent mechanisms of injury in the present study (48.4%). It was consistent with some studies[3],[16] and in contrast with other studies.[1],[17] In a systematic review of 26 studies, falls were found as the most frequent cause of TBI in 13 studies and motor vehicle accidents were the most frequent mechanisms of injury in 11 studies.[1] In previous studies conducted in Iran, motor vehicle accidents have always been the most common injury mechanism.[2],[7],[18],[19],[20]

In the present study, parenchymal contusion was the most common CT finding (7.0%), followed by diffuse axonal injury (4.7%) and skull fracture (4.3%). Mebrahtu-Ghebrehiwet et al.[21] demonstrated that cerebral contusion or laceration was the most common CT finding followed by SDH and then skull fracture. Adeleye and Ogun[22] found that the occurrence of brain contusions was 18.8%, the EDH was 4.1%, and the SDH was 3.8%. Heydari et al.[5] reported that SDH was the most common injury (27.6%). Forouzan et al.[20] showed that EDH was the most common CT finding followed by parenchymal contusion and skull fracture. Asadian et al.[19] found that skull fracture was the most common CT finding followed by EDH and parenchymal contusion. The reason for the difference in the CT scan findings can be considered to be the difference in age, gender, the severity of the trauma, and the mechanism of trauma in different studies.

The present study indicated that the men were significantly younger than women (27.59 ± 15.51 vs. 37.58 ± 24.79; P < 0.001). It was consistent with previous studies.[1],[3],[11] Similar to previous studies, the incidence of intracranial lesions between men and women had no significant difference (P = 0.099).[2],[11]

In the current study, there was a significant difference in the mechanism of injury between men and women (P < 0.001). The most frequent mechanism of injury was motor vehicle accident in both groups but followed by assaults in men and fall in women. It was in contrast with previous studies that found no significant difference.[3],[11],[18]

In the present study, the associations of baseline characteristics with the age group (children, middle-aged patients, and elderly patients) were analyzed. The highest mortality rate was in elderly patients and the lowest was in children (P < 0.001). Previous studies showed that with increasing age, the OR of mortality was also increasing.[7],[8] In another study, the mortality rate was 2.5% for children and 10.4% for adults.[22] Ogolo and Ibe[23] reported that older adults were 4.6 times more likely to die from TBI than other age groups. In line with the present study, Munivenkatappa et al.[11] demonstrated that the highest and lowest mortality rates were in the elderly (>61 years) and pediatric (<18 years) groups. Furthermore, Wang et al.[6] reported that the elderly (≥65 years) had the highest mortality rates and the juvenile (≤17 years) had the lowest mortality rates.

In the present study, motor vehicle accidents were the most common mechanisms of injury in children and middle-aged individuals and falls were more common in older people. It was similar to the study conducted by Munivenkatappa et al.,[11] whereas other studies found that the rate of falls was highest in the juvenile and elderly groups and motor vehicle accidents were the most common cause in the middle-aged group.[1],[6] In the United States, Taylor et al.[14] showed that hospitalizations due to TBI from motor vehicle accidents decreased over time. Other studies reported that falls were the leading cause of TBI in older adults, followed by traffic accidents.[1],[5],[24] The reason can be that older adults are more prone to falls.

Consistent with previous studies, the incidence of intracranial lesions was significantly higher in elderly subjects.[6],[11],[24] Studies have shown that the probability of intracranial hemorrhage in older patients is higher due to the presence of comorbidities and the frequent use of anticoagulants and antiplatelets.[14],[24],[25]

SDH and SAH were the most common CT findings in elderly patients (13.3% and 11.3%). Aligned with the present study, previous studies showed that the incidence of SDH in adults increased with age, and the highest incidence of SDH was in the elderly.[6],[11],[24] Similarly, Heydari et al.[5] found that SDH was the most common CT finding in elderly TBI followed by SAH. The current study demonstrated that brain contusion and skull fracture were the most common findings in the children (6.0% and 4.3%) which was consistent with Wang et al.[6]

The present study showed that there was a significant difference between the survived and death groups in the mechanism of injury (P < 0.001). Motor vehicle accident was the main mechanism of injury in the death group (63.7%), which is consistent with previous studies that reported motor vehicle accidents in 77.7%[3],[7] and 75%[23] of the death group.

In the present study, the most admission hours of patients in the ED were between 18:00 and 24:00 (36.0%) and then between 12:00 and 18:00 (31.5%), which was consistent with the other studies conducted in Iran.[5],[18],[19] Therefore, it is necessary to increase the number of personnel and provide the necessary facilities in the emergency room to manage TBI patients during these hours.

Due to the difference in the severity of the injury, the type of intracranial injury, and the mortality rate at different ages, each ED must provide the necessary facilities and equipment according to the age of its patients. Furthermore, this point should be considered in the design of the ED. The study findings can provide new insights into the epidemiological characteristics of TBI in different age groups, leading to improved diagnosis and clinical treatment of patients with head trauma.

Limitations

The main limitation of the present study was its retrospective nature. Patients with incomplete medical records were excluded from the study, and this may affect the results of the study. Patients with severe and multiple trauma were not included in this study, which may lead to selection bias, as their mortality was not considered.

  Conclusions 

This population-based study evaluated TBI among three age groups. The result of the study demonstrated that the clinicopathological parameters were significantly different among children, middle-aged patients, and elderly patients. The highest mortality rate was shown in elderly patients and the lowest in children. The incidence of intracranial lesions and moderate-to-severe head injuries were significantly higher in the elderly subjects

Acknowledgments

The authors would like to express their gratitude to the staff of the ED of Al-Zahra and Kashani Hospital, Isfahan, Iran.

Financial support and sponsorship

This study was funded by the Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Peeters W, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF, et al. Epidemiology of traumatic brain injury in Europe. Acta Neurochir (Wien) 2015;157:1683-96.  
    2.Hamrah H, Mehrvarz S, Mirghassemi AM. The frequency of brain CT-scan findings in patients with scalp lacerations following mild traumatic brain injury; a cross-sectional study. Bull Emerg Trauma 2018;6:54-8.  
    3.Onwuchekwa RC, Echem RC. An epidemiologic study of traumatic head injuries in the emergency department of a tertiary health institution. J Med Trop 2018;20:24.  
  [Full text]  4.Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V, et al. Epidemiology of traumatic brain injuries in Europe: A cross-sectional analysis. Lancet Public Health 2016;1:e76-83.  
    5.Heydari F, Golban M, Majidinejad S. Traumatic brain injury in older adults presenting to the emergency department: Epidemiology, outcomes and risk factors predicting the prognosis. Adv J Emerg Med 2020;4:e19.  
    6.Wang J, Han F, Zhao Q, Xia B, Dai J, Wang Q, et al. Clinicopathological characteristics of traumatic head injury in juvenile, middle-aged and elderly individuals. Med Sci Monit 2018;24:3256-64.  
    7.Saatian M, Ahmadpoor J, Mohammadi Y, Mazloumi E. Epidemiology and pattern of traumatic brain injury in a developing country regional trauma center. Bull Emerg Trauma 2018;6:45-53.  
    8.Bhullar IS, Roberts EE, Brown L, Lipei H. The effect of age on blunt traumatic brain-injured patients. Am Surg 2010;76:966-8.  
    9.Hawley C, Sakr M, Scapinello S, Salvo J, Wrenn P. Traumatic brain injuries in older adults-6 years of data for one UK trauma centre: Retrospective analysis of prospectively collected data. Emerg Med J 2017;34:509-16.  
    10.Lutze M, Fry M, Gallagher R. Minor injuries in older adults have different characteristics, injury patterns, and outcomes when compared with younger adults: An emergency department correlation study. Int Emerg Nurs 2015;23:168-73.  
    11.Munivenkatappa A, Agrawal A, Shukla DP, Kumaraswamy D, Devi BI. Traumatic brain injury: Does gender influence outcomes? Int J Crit Illn Inj Sci 2016;6:70-3.  
[PUBMED]  [Full text]  12.Mena JH, Sanchez AI, Rubiano AM, Peitzman AB, Sperry JL, Gutierrez MI, et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: Comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma 2011;71:1185-92.  
    13.Masoumi B, Heydari F, Hatamabadi H, Azizkhani R, Yoosefian Z, Zamani M. The relationship between risk factors of head trauma with CT scan findings in children with minor head trauma admitted to hospital. Open Access Maced J Med Sci 2017;5:319-23.  
    14.Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths – United States, 2007 and 2013. MMWR Surveill Summ 2017;66:1-16.  
    15.Martins ET, Linhares MN, Sousa DS, Schroeder HK, Meinerz J, Rigo LA, et al. Mortality in severe traumatic brain injury: A multivariated analysis of 748 Brazilian patients from Florianópolis City. J Trauma 2009;67:85-90.  
    16.Peeters S, Blaine C, Vycheth I, Nang S, Vuthy D, Park KB. Epidemiology of traumatic brain injuries at a major government hospital in Cambodia. World Neurosurg 2017;97:580-9.  
    17.Steyerberg EW, Wiegers E, Sewalt C, Buki A, Citerio G, De Keyser V, et al. Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: A European prospective, multicentre, longitudinal, cohort study. Lancet Neurol 2019;18:923-34.  
    18.Farzaneh E, Fattahzadeh-Ardalani G, Abbasi V, Kahnamouei-Aghdam F, Molaei B, Iziy E, et al. The epidemiology of hospital-referred head injury in Ardabil City. Emerg Med Int 2017;2017:1439486.  
    19.Asadian L, Hadadi K, Montaza SH, Khademloo M, Mirzaii N. An epidemiological study of head injuries in patients attending Sari Imam Khomeini Hospital, 2013-2014. J Mazandaran Univ Med Sci 2015;24:207-16.  
    20.Forouzan A, Masoumi K, Motamed H, Teimouri A, Barzegari H, Zohrevandi B, et al. Head trauma patients presented to emergency department; an epidemiologic study. Iran J Emerg Med 2015;2:134-8.  
    21.Mebrahtu-Ghebrehiwet M, Quan L, Andebirhan T. The profile of CT scan findings in acute head trauma in Orotta Hospital, Asmara, Eritrea. J Eritrean Med Assoc 2009;4:5-8.  
    22.Adeleye AO, Ogun MI. Clinical epidemiology of head injury from road-traffic trauma in a developing country in the current era. Front Neurol 2017;8:695.  
    23.Ogolo DE, Ibe MO. Determinants of outcome in traumatic head injuries: A South East Nigeria experience. World Neurosurg 2021;149:e386-91.  
    24.Mak CH, Wong SK, Wong GK, Ng S, Wang KK, Lam PK, et al. Traumatic brain injury in the elderly: Is it as bad as we think? Curr Transl Geriatr Exp Gerontol Rep 2012;1:171-8.  
    25.Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.e1.  
    

 
 

  [Table 1], [Table 2], [Table 3], [Table 4]