Injury patterns, severity and outcomes among older adults who sustained brain injury following a same level fall: a retrospective analysis

Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals

BACKGROUND

Traumatic brain injury (TBI) among elderly individuals poses a significant global health concern due to the increasing ageing population.

METHODS

We searched PubMed, Cochrane Library, and Embase from database inception to Feb 1, 2024. Studies performed in inpatient settings reporting in-hospital mortality of elderly people (≥60 years) with TBI and/or identifying risk factors predictive of such outcomes, were included. Data were extracted from published reports, in-hospital mortality as our main outcome was synthesized in the form of rates, and risk factors predicting in-hospital mortality was synthesized in the form of odds ratios. Subgroup analyses, meta-regression and dose-response meta-analysis were used in our analyses.

FINDINGS

We included 105 studies covering 2217,964 patients from 30 countries/regions. The overall in-hospital mortality of elderly patients with TBI was 16 % (95 % CI 15 %-17 %) from 70 studies. In-hospital mortality was 5 % (95 % CI, 3 %-7 %), 18 % (95 % CI, 12 %-24 %), 65 % (95 % CI, 59 %-70 %) for mild, moderate and severe subgroups from 10, 7, and 23 studies, respectively. A decrease in in-hospital mortality over years was observed in overall (1981-2022) and in severe (1986-2022) elderly patients with TBI. Older age 1.69 (95 % CI, 1.58-1.82, P < 0.001), male gender 1.34 (95 % CI, 1.25-1.42, P < 0.001), clinical conditions including traffic-related cause of injury 1.22 (95 % CI, 1.02-1.45, P = 0.029), GCS moderate (GCS 9-12 compared to GCS 13-15) 4.33 (95 % CI, 3.13-5.99, P < 0.001), GCS severe (GCS 3-8 compared to GCS 13-15) 23.09 (95 % CI, 13.80-38.63, P < 0.001), abnormal pupillary light reflex 3.22 (95 % CI, 2.09-4.96, P < 0.001), hypotension after injury 2.88 (95 % CI, 1.06-7.81, P = 0.038), polytrauma 2.31 (95 % CI, 2.03-2.62, P < 0.001), surgical intervention 2.21 (95 % CI, 1.22-4.01, P = 0.009), pre-injury health conditions including pre-injury comorbidity 1.52 (95 % CI, 1.24-1.86, P = 0.0020), and pre-injury anti-thrombotic therapy 1.51 (95 % CI, 1.23-1.84, P < 0.001) were related to higher in-hospital mortality in elderly patients with TBI. Subgroup analyses according to multiple types of anti-thrombotic drugs with at least two included studies showed that anticoagulant therapy 1.70 (95 % CI, 1.04-2.76, P = 0.032), Warfarin 2.26 (95 % CI, 2.05-2.51, P < 0.001), DOACs 1.99 (95 % CI, 1.43-2.76, P < 0.001) were related to elevated mortality. Dose-response meta-analysis of age found an odds ratio of 1.029 (95 % CI, 1.024-1.034, P < 0.001) for every 1-year increase in age on in-hospital mortality.

CONCLUSIONS

In the field of elderly patients with TBI, the overall in-hospital mortality and its temporal-spatial feature, the subgroup in-hospital mortalities according to injury severity, and dose-response meta-analysis of age were firstly comprehensively summarized. Substantial key risk factors, including the ones previously not elucidated, were identified. Our study is thus of help in underlining the importance of treating elderly TBI, providing useful information for healthcare providers, and initiating future management guidelines. This work underscores the necessity of integrating elderly TBI treatment and management into broader health strategies to address the challenges posed by the aging global population.

REVIEW REGISTRATION

PROSPERO CRD42022323231.

Racial differences in concussion diagnosis and mechanism of injury among adults presenting to emergency departments across the United States

OBJECTIVES

The purpose of this study was to examine the association between race and concussion diagnosis as well as the association between race and mechanism of injury (MOI) for concussion diagnoses in adult patients (>19 years old) visiting the emergency department (ED).

METHODS

A retrospective analysis of patient visits to the ED for concussion between 2010 and 2018, using the National Hospital Ambulatory Medical Care Survey, was conducted. Outcome measures included concussion diagnosis and MOI. Multivariable and multinomial logistic regression analyses were conducted to assess associations between race and outcome variables. The results were weighted to reflect population estimates with a significance set at p < 0.05.

RESULTS

Overall, 714 patient visits for concussions were identified, representing an estimated 4.3 million visits nationwide. Black adults had lower odds of receiving a concussion diagnosis [p < 0.05, Odds Ratio (OR), 0.54; 95% Confidence Interval (CI), 0.38-0.76] compared to White adults in the ED. There were no significant differences in MOI for a concussion diagnosis by race.

CONCLUSION

Racial differences were found in the ED for concussion diagnosis. Disparities in concussion diagnosis for Black or other minoritized racial groups could have significant repercussions that may prolong recovery or lead to long-term morbidity.

The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities

BACKGROUND

Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients.

METHODS

Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition.

RESULTS

We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001).

CONCLUSIONS

This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.

Care of the older trauma patient following low-energy transfer trauma-highlighting a research void

BACKGROUND

in high-income countries trauma patients are becoming older, more likely to have comorbidities, and are being injured by low-energy mechanisms. This systematic review investigates the association between higher-level trauma centre care and outcomes of adult patients who were admitted to hospital due to injuries sustained following low-energy trauma.

METHODS

a systematic review was conducted in January 2021. Studies were eligible if they reported outcomes in adults admitted to hospital due to low-energy trauma. In the presence of study heterogeneity, a narrative synthesis was pre-specified.

RESULTS

three studies were included from 2,898 unique records. The studies' risk of bias was moderate-to-serious. All studies compared outcomes in trauma centres verified by the American College of Surgeons in the USA. The mean/median ages of patients in the studies were 73.4, 74.5 and 80 years. The studies reported divergent results. One demonstrated improved outcomes in level 3 or 4 trauma centres (Observed: Expected Mortality 0.973, 95% CI: 0.971-0.975), one demonstrated improved outcomes in level 1 trauma centres (Adjusted Odds Ratio 0.71, 95% CI: 0.56-0.91), and one demonstrated no difference between level 1 or 2 and level 3 or 4 trauma centre care (adjusted odds ratio 0.91, 95% CI: 0.80-1.04).

CONCLUSIONS

the few relevant studies identified provided discordant evidence for the value of major trauma centre care following low-energy trauma. The main implication of this review is the paucity of high-quality research into the optimum care of patients injured in low-energy trauma. Further studies into triage, interventions and research methodology are required.

Injury Patterns after Falling down Stairs-High Ratio of Traumatic Brain Injury under Alcohol Influence

Falling down a staircase is a common mechanism of injury in patients with severe trauma, but the effect of varying fall height according to the number of steps on injury patterns in these patients has been little studied. In this retrospective study, prospectively collected data from a Level 1 Trauma Center in Germany were analyzed regarding the injury patterns of patients admitted through the trauma room with suspicion of multiple injuries following a fall down a flight of stairs between January 2016 and December 2019. In total 118 patients were examined which where consecutively included in this study. More than 80% of patients suffered a traumatic brain injury, which increased as a function of the number of stairs fallen. Therefore, the likelihood of intracranial hemorrhage increased with higher numbers of fallen stairs. Fall-associated bony injuries were predominantly to the face, skull and the spine. In addition, there was a high coincidence of staircase falls and alcohol intake. Due to a frequent coincidence of staircase falls and alcohol, the (pre-)clinical neurological assessment is complicated. As the height of the fall increases, severe traumatic brain injury should be anticipated and diagnostics to exclude intracranial hemorrhage and spinal injuries should be performed promptly to ensure the best possible patient outcome.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review

BACKGROUND

Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group.

METHODS AND FINDINGS

A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review.

CONCLUSIONS

Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Sex and age differences in isolated traumatic brain injury: a retrospective observational study

Background

Among the many factors that may influence traumatic brain injury (TBI) progression, sex is one of the most controversial. The objective of this study was to investigate sex differences in TBI-associated morbidity and mortality using data from the largest trauma registry in Japan.

Methods

This retrospective, population-based observational study included patients with isolated TBI, who were registered in a nationwide database between 2004 and 2018. We excluded patients with extracranial injury (Abbreviated Injury Scale score ≥ 3) and removed potential confounding factors, such as non-neurological causes of mortality. Patients were stratified by age and mortality and post-injury complications were compared between males and females.

Results

A total of 51,726 patients with isolated TBI were included (16,901 females and 34,825 males). Mortality across all ages was documented in 12.01% (2030/16901) and 12.76% (4445/34825) of males and females, respectively. The adjusted odds ratio (OR) of TBI mortality for males compared to females was 1.32 (95% confidence interval [CI], 1.22–1.42]. Males aged 10–19 years and ≥ 60 years had a significantly higher mortality than females in the same age groups (10–19 years: adjusted OR, 1.97 [95% CI, 1.08–3.61]; 60–69 years: adjusted OR, 1.24 [95% CI, 1.02–1.50]; 70–79 years: adjusted OR, 1.20 [95% CI, 1.03–1.40]; 80–89 years: adjusted OR, 1.50 [95% CI, 1.31–1.73], and 90–99 years: adjusted OR, 1.72 [95% CI, 1.28–2.32]). In terms of the incidence of post-TBI neurologic and non-neurologic complications, the crude ORs were 1.29 (95% CI, 1.19–1.39) and 1.14 (95% CI, 1.07–1.22), respectively, for males versus females. This difference was especially evident among elderly patients (neurologic complications: OR, 1.27 [95% CI, 1.14–1.41]; non-neurologic complications: OR, 1.29 [95% CI, 1.19–1.39]).

Conclusions

In a nationwide sample of patients with TBI in Japan, males had a higher mortality than females. This disparity was particularly evident among younger and older generations. Furthermore, elderly males experienced more TBI complications than females of the same age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02305-6.

Acute and Delayed Intracranial Hemorrhage in Head-Injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy

INTRODUCTION

Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies.

METHODS

A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH.

RESULTS

Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56-1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84-5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10-2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27-3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention.

CONCLUSION

Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.

Low falls causing major injury: a retrospective study

BACKGROUND

Falling from a height of under 2 m (low fall) is the most common mechanism of injury causing major trauma in Ireland. This presentation encompasses a wide patient cohort, from paediatric sport injuries to elderly falls.

AIMS

Our aim is to characterise major trauma resulting from a low fall, and its various sub-populations, to identify preventative strategies and care pathways to improve outcomes for patients.

METHODS

The Trauma Audit and Research Network (TARN) which is used to provide Major Trauma Audit was used to retrospectively identify patients presenting to the Cork University Hospital Emergency Department with trauma resulting from a low fall from January 2015 to June 2018.

RESULTS

The database returned 1066 qualifying cases (49.3% of cases in the time period), with a mean age of 67.3 years (SD = 21) and a median age of 71.3 years (IQR = 23); 44% were male. 'Mechanical falls' accounted for n = 513 (48%) of low-fall injuries, followed by 'stationary falls' n = 265 (25%). Injuries occurred most often at home n = 515 (48%), followed by public places n = 208 (19.5%). The most severely injured body region was the limbs n = 526 (49.3%), followed by the head n = 253 (23.7%). A number of patients with Glasgow Outcome Scores of 4 (moderate disability) and 5 (good recovery) were n = 488 (45.8%) and n = 390 (36.6%).

CONCLUSIONS

Low falls occur in patients over 55 years of age; many do not return to independent living. Wait times to initial assessment, length of hospital stay and mortality increase with age. Mechanical falls at home are the most common cause of low-fall major trauma.

Comorbidity in adults with traumatic brain injury and all-cause mortality: a systematic review

OBJECTIVES

Comorbidity in traumatic brain injury (TBI) has been recognised to alter the clinical course of patients and influence short-term and long-term outcomes. We synthesised the evidence on the effects of different comorbid conditions on early and late mortality post-TBI in order to (1) examine the relationship between comorbid condition(s) and all-cause mortality in TBI and (2) determine the influence of sociodemographic and clinical characteristics of patients with a TBI at baseline on all-cause mortality.

DESIGN

Systematic review.

DATA SOURCES

Medline, Central, Embase, PsycINFO and bibliographies of identified articles were searched from May 1997 to January 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included studies met the following criteria: (1) focused on comorbidity as it related to our outcome of interest in adults (ie, ≥18 years of age) diagnosed with a TBI; (2) comorbidity was detected by any means excluding self-report; (3) reported the proportion of participants without comorbidity and (4) followed participants for any period of time.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and assessed risk of bias using the Quality in Prognosis Studies tool. Data were synthesised through tabulation and qualitative description.

RESULTS

A total of 27 cohort studies were included. Among the wide range of individual comorbid conditions studied, only low blood pressure was a consistent predictors of post-TBI mortality. Other consistent predictors were traditional sociodemographic risk factors. Higher comorbidity scale, scores and the number of comorbid conditions were not consistently associated with post-TBI mortality.

CONCLUSIONS

Given the high number of comorbid conditions that were examined by the single studies, research is required to further substantiate the evidence and address conflicting findings. Finally, an enhanced set of comorbidity measures that are suited for the TBI population will allow for better risk stratification to guide TBI management and treatment.

PROSPERO REGISTRATION NUMBER

CRD42017070033.

Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review

OBJECTIVE

To characterize racial/ethnic and insurance disparities in the utilization of healthcare services among US adults with traumatic brain injury (TBI).

METHODS

The PubMed database was used to search for articles that directly examined the association between race/ethnicity and insurance disparities and healthcare utilization among patients with TBI. Eleven articles that met the criteria and were published between June 2011 and June 2016 were finally included in the review.

RESULTS

Lack of insurance was significantly associated with decreased use of inhospital and posthospital healthcare services among patients with TBI. However, mixed results were reported for the associations between insurance types and healthcare utilization. The majority of studies reported that racial/ethnic minorities were less likely to use inhospital and posthospital healthcare services, while some studies did not indicate any significant relation between race/ethnicity and healthcare utilization among patients with TBI.

CONCLUSIONS

This review provides evidence of a relation between insurance status and healthcare utilization among US adults with TBI. Insurance status may also account for some portion of the relation between race/ethnicity and healthcare utilization.

Complications and Mortality Among Correctly Triaged and Undertriaged Severely Injured Older Adults With Traumatic Brain Injuries

Determining differences in clinical outcomes of older adults treated at trauma centers (TCs) and nontrauma centers (NTCs) is imperative considering their persistent undertriage and the projected costs of fixing the problem. This study compared the incidence and predictors of complications and mortality among brain-injured older adults treated at TCs and NTCs. This secondary analysis of New York inpatient data included patients aged 55+ years, primary brain injury diagnosis, and acute care hospital admission. Interfacility transfers and nontraumatic brain injuries were excluded. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes identified complications and mortality. Injury severity was determined by mapping ICD-9-CM diagnoses to Abbreviated Injury Scale 2005 Revision 2008 dictionary scores. A subgroup analysis of 1,594 patients with New Injury Severity Scores greater than 15 was performed to examine complications and mortality. This study included 7,138 patients who met inclusion criteria. Predictors of subgroup complications included chronic renal failure, odds ratio (OR) = 2.251 (confidence interval [CI] = 1.470-3.447), p < .001; major operating room procedure, OR = 2.349 (CI = 1.679-3.285), p < .001; number of diagnoses, OR = 1.201 (CI = 1.158-1.245), p < .001; and number of procedures, OR = 1.119 (CI = 1.077-1.162), p £ .001. Mortality predictors included age, OR = 1.031 (CI = 1.017-1.045), p < .001; preexisting coagulopathy, OR = 1.753 (C = 1.130-2.719), p = .012; number of procedures, OR = 1.122 (CI = 1.081-1.166), p < .001; acute renal failure, OR = 3.114 (CI = 1.672-5.797), p < .001; systemic inflammatory response syndrome, OR = 4.058 (CI = 1.463-11.258), p = .007; adult respiratory distress syndrome, OR = 3.179 (CI = 1.673-6.041), p < .001; and subarachnoid bleed, OR = 2.667 (CI = 1.415-5.029), p = .002. Nearly 23% of the severely/critically injured patients experienced 1 or more complications. Incidence of complications was low and comparable for TCs and NTCs. The proportion of deaths was slightly higher at TCs but not significant. The most prevalent complications carry a high mortality risk.

Investigation of risk factors of geriatric patients with significant brain injury from ground-level fall: A retrospective cohort study in a local Accident and Emergency Department setting

Background:

Trauma was the fifth leading cause of death in Hong Kong in 2013.4 Injuries caused by falls ranked first in traumatic brain injury (TBI) cases among older adults (51%).5 Elderly trauma patients face an increased risk of adverse consequences6 from trauma compared with their younger counterparts, as advanced age itself is already a well-recognized risk factor for less favorable outcomes following trauma. Therefore, identifying factors associated with significant brain injury in geriatric patients in A&E triage is crucial in providing timely care to these patients.

Objectives:

To identify the risk factors for geriatric patients with significant brain injury from ground-level falls and to formulate their association of risk factors with significant brain injury as a consequence from ground-level falls.

Methods:

This was a retrospective study with data collected from the Clinical Data Analysis and Reporting System of Queen Mary Hospital from 1 January 2013 to 31 December 2015. A total of 1101 cases were identified.

Results:

There were 76% of the recruited patients with a normal computed tomography scan. However, the remaining 24% had computed tomography scans indicative of brain injury. Severe head injuries were scored 3 -8 on the Glasgow Coma Scale and moderate head injuries were scored 9 -12. Respectively, these were 20 times (p = 0.005) and 5 times (p = 0.002) more likely to have positive computed tomography findings than patients with a Glasgow Coma Scale score from 13 to 15. Patients with loss of consciousness were two times more likely to have a positive computed tomography result than those without loss of consciousness (p = 0.001). Although warfarin use is a well-established risk factor for intracranial hemorrhage after head injury, in our dataset, the result was not statistically significant. However, the use of new oral anti-coagulants was associated with positive computed tomography findings with patients taking new oral anti-coagulants 2.3 times more likely to have positive computed tomography findings compared with those with no anticoagulant use (p = 0.033).

Conclusions:

Early detection of patients with significant brain injury and aggressive management may prevent secondary injury from the complications of brain injury, hence improving patient mortality and morbidity, and reducing hospital stay and health care costs.

Treatment Charges for Traumatic Brain Injury Among Older Adults at a Trauma Center

OBJECTIVE

To provide charge estimates of treatment for traumatic brain injury (TBI), including both hospital and physician charges, among adults 65 years and older treated at a trauma center.

METHODS

We identified older adults treated for TBI during 2008-2012 (n = 1843) at Maryland's Primary Adult Resource Center and obtained hospital and physician charges separately. Analyses were stratified by sex and all charges were inflated to 2012 dollars. Total TBI charges were modeled as a function of covariates using a generalized linear model.

RESULTS

Women comprised 48% of the sample. The mean unadjusted total TBI hospitalization charge for adults 65 years and older was $36 075 (standard deviation, $63 073). Physician charges comprised 15% of total charges. Adjusted mean charges were lower in women than in men (adjusted difference, -$894; 95% confidence interval, -$277 to -$1512). Length of hospital and intensive care unit stay were associated with the highest charges.

CONCLUSIONS

This study provides the first estimates of hospital and physician charges associated with hospitalization for TBI among older adults at a trauma center that will aid in resource allocation, triage decisions, and healthcare policy.

Sex differences in mortality following isolated traumatic brain injury among older adults

BACKGROUND

Older adults have the highest rates of hospitalization and mortality from traumatic brain injury (TBI), yet outcomes in this population are not well studied. In particular, contradictory reports on the protective effect of female sex on mortality following TBI may have been related to age differences in TBI and other injury severity and mechanism. The objective of this study was to determine if there are sex differences in mortality following isolated TBI among older adults and compare with findings using all TBI. A secondary objective was to characterize TBI severity and mechanism by sex in this population.

METHODS

This was a retrospective cohort study conducted among adults aged 65 and older treated for TBI at a single large Level I trauma center from 1996 to 2012 (n = 4,854). Individuals treated for TBI were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Isolated TBI was defined as an Abbreviated Injury Scale score of 0 for other body regions. Our primary outcome was mortality at discharge.

RESULTS

Among those with isolated TBI (n = 1,320), women (45% of sample) were older (mean [SD], 78.9 [7.7] years) than men (76.8 [7.5] years) (p < 0.001). Women were more likely to have been injured in a fall (91% vs. 84%; p < 0.001). Adjusting for multiple injury severity measures, female sex was not significantly associated with decreased odds of mortality following isolated TBI (odds ratio, 1.01; 95% confidence interval, 0.66-1.54). Using all TBI cases, adjusted analysis found that female sex was significantly associated with decreased odd of mortality (odds ratio, 0.73; 95% confidence interval, 0.59-0.89).

CONCLUSION

We found no sex differences in mortality following isolated TBI among older adults, in contrast with other studies and our own analyses using all TBI cases. Researchers should consider isolated TBI in outcome studies to prevent residual confounding by severity of other injuries.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level IV.

Adaptation of Traumatic Brain Injury Guidelines in Iran

CONTEXT

The National institute for health and care excellence (NICE) and scottish intercollegiate guidelines network (SIGN) are two well-known sources of clinical guideline development. In the past years, they have developed clinical guidelines for the management of head injury. In this report, we will highlight our modifications to these guidelines according to the domestic situation in a developing country.

EVIDENCE ACQUISITION

The guidelines were appraised using the appraisal of guidelines for research and evaluation (AGREE) instrument. All key recommendations were reviewed by 14 prominent Iranian neurosurgeons; levels of evidence were evaluated and items with limited evidence were determined. Available evidence for selected items were reviewed and discussed.

RESULTS

The following items were the most challenging when accounting for the domestic situation in Iran: age as a risk factor for referral, computed tomography scan, the impact of medical comorbidities, pregnancy, consultation, referral to a neurosurgical unit, and teleconsulting and observation before discharge.

CONCLUSIONS

The evidence in the discussed topics was limited and controversial. This report is important because it exposes the current knowledge gap in head trauma studies in Iran.