Epidemiology and Outcomes of Traumatic Brain Injury in Elderly Population : A Multicenter Analysis Using Korean Neuro-Trauma Data Bank System 2010-2014

Integration of Palliative Care in Neurosurgical Critical Care : Insights from a Single-Center Perspective

OBJECTIVE

Palliative care is a specialized approach designed to enhance the quality of life for both patients and their families, offering patient-centered care through comprehensive assessment and care planning. However, the integration of palliative care within neurocritical care settings has been relatively understudied. This descriptive study aims to identify the characteristics, palliative care needs, and outcomes of patients referred to palliative care services during admission to the neurosurgical intensive care unit (NS-ICU).

METHODS

A retrospective analysis of adults admitted to the NS-ICU at a referral hospital between December 2019 and December 2021 was conducted. The study focused on those referred to the inpatient palliative care team with diagnoses of non-traumatic brain hemorrhage, traumatic brain injury, or brain neoplasm. Excluded were patients who died before palliative care consultation or lacked sufficient information. The investigation assessed demographic and clinical characteristics at consultation, along with post-consultation hospital outcomes derived from medical records and interview notes.

RESULTS

In this study involving 38 enrolled patients, the median age was 65, with 42.1% females. The most prevalent diagnosis was nontraumatic brain hemorrhage (47.4%). Reasons for palliative care consultation included psychosocial support (95%), goal-of-care discussions (68%), decision-making support (50%), and communication facilitation (39%). The median time from NS-ICU admission to consultation was 3.5 days (interquartile range, 1-8 days), and all interviews involved family members. Key decision topics encompassed mechanical ventilation (23.7%) and tracheostomy (21.1%). Patient preferences for life-sustaining treatment could be estimated in only 47.4% of cases, often resulting in treatment disagreement. Among the 38 patients, 26 (68.4%) died during admission. Before the consultation, full code status, partial code status, and comfort care alone were reported as 32%, 66%, and 2%, respectively; post-consultation, these figures shifted to 11%, 42%, and 47%, respectively.

CONCLUSION

Palliative care was predominantly sought for psychosocial support and discussions concerning goals of care. Despite challenges in ascertaining patient treatment preferences, palliative care consultations proved invaluable in aiding family members and facilitating treatment decision-making. Our study suggests the potential integration of palliative care within neuro-critical care, contributing to a heightened utilization of comfort care at the end-of-life.

Introduction to the Korean Neurotrauma Data Bank System and Report on the Results of the Second Project

OBJECTIVE

In 2006, the Korean Neurotraumatology Society (KNTS) established the 1st Korean Neurotrauma Data Bank Committee (KNTDBC) and developed the Korean Neurotrauma Data Bank System (KNTDBS). Full-scale registration of traumatic brain injury (TBI) patient data began in September 2010. Since then, KNTS has conducted two trauma-related data registration projects and is now in its 5th term of the KNTDBC. This study aimed to introduce the KNTDBS of the KNTS and report the results of the second project.

METHODS

Between January 2018 and June 2021, 1109 TBI patients were registered from 18 hospitals. The inclusion criteria were 1) patients who visited the hospital with TBI, 2) patients with severe TBI with a Glasgow coma scale (GCS) score of 8 or lower, and 3) adult patients aged 19 years or older. Exclusion criteria were 1) patients under 18 years of age, 2) patients with a GCS score of 9 or higher, and 3) patients with a history of previous craniotomy or craniectomy. Data from the second project were registered into seven major categories : patient registration, neuroimaging, neuromonitoring, hypothermia, surgical treatment, medical treatment, and patient evaluation.

RESULTS

The characteristics of TBI patients in this study were not significantly different from those in previous studies, including the 1st project of KNTS. The GCS had a large number of severe patients with scores of 3 and 4, which was associated with the highest proportion of patients having bilateral pupils with unrecordable responses. Most TBI patients had severe or critical injuries (score 4 or 5) concentrated in the Abbreviated incentive scale head but had minor injuries to other regions of the body. Rotterdam computed tomography scores of 5 and 6 primarily indicated acute subdural hematomas. Surgical treatment was performed in 36.2% of all TBI cases. Most hospitals used levetiracetam and valproate as prophylactic antiepileptic drugs. Neuromonitoring, hypothermia, and coma therapy were not actively performed. The overall mortality rate was 33.3%, and among 740 survivors, 3.9% underwent shunt surgery.

CONCLUSION

The creation of a database for TBI patient data facilitated the collection of objective and valid information on trauma. Utilizing data from the KNTDBS will significantly aid in the treatment and prevention of TBI and contribute to the improvement of healthcare in the country.

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.

Outcome after decompressive craniectomy in older adults after traumatic brain injury

Objective

Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients.

Methods

A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05.

Results

A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429).

Conclusion

Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.

Association Between Social Determinants of Health and Traumatic Brain Injury: A Scoping Review

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Disparities exist in the populations that acquire TBIs, however, with a greater burden and poorer outcomes associated with communities of color and lower socioeconomic status. To combat health inequities such as these, institutions have begun to target social determinants of health (SDoH), which are environmental factors that affect health outcomes and risks. The SDoH may play a role in sustaining a TBI and provide modifiable targets for action to reduce the risk of TBI, especially in high-risk communities. In this study, we describe the existing literature regarding SDoH and their association with sustaining a TBI. We performed a scoping review with a comprehensive search of the Ovid MEDLINE/Embase databases. To summarize the literature, this review adapts the World Health Organization's Commission on SDoH's conceptual framework. Fifty-nine full-text articles, including five focusing on lower and middle-income countries, met our study criteria. Results of the scoping review indicate that several structural determinants of health were associated with TBI risk. Lower educational attainment and income levels were associated with higher odds of TBI. In addition, multiple studies highlight that minority populations were identified as having higher odds of TBI than their White counterparts. Literature highlighting intermediate determinants of health examined in this review describes associations between sustaining a TBI and rurality, work environment, medical conditions, medication/substance use, and adversity. Recommended exploration into lesser-researched SDoH is discussed, and the expansion of this review to other aspects of the TBI continuum is warranted.

[Emergency Treatment of Traumatic Brain Injury]

Traumatic brain injury (TBI) is a temporary or permanent damage to the cerebral functions caused by external force on the skull. TBI is one of the most common causes of death worldwide and has significant socioeconomic and health consequences. This article examines classification, clinical pictures and adequate emergency treatment with diagnostics, surgical therapy and prognosis.

[Traumatic brain injury]

Traumatic brain injury (TBI) describes parenchymal brain damage caused by external forces to the head. It has a massive personal and socioeconomic impact, as it is a disease with high morbidity and mortality. Both young and old people are affected, as a result of traffic or sports accidents as well as due to falls at home. The term TBI encompasses various clinical pictures, differing considerably in cause, prognosis and therapy. What they all have in common is the pathophysiological cascade that develops immediately after the initial trauma and which can persist for several days and weeks. In this phase, medical treatment, whether surgical or pharmacological, attempts to reduce the consequences of the primary damage. The aim is to maintain adequate cerebral perfusion pressure and to reduce intracranial pressure.

Current Status of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury in Korea : A Post Hoc Analysis of Korea Neurotrauma Databank Project with a Nationwide Survey

OBJECTIVE

This study aimed to investigate the current status of intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI) in Korea and the association between ICP monitoring and prognosis. In addition, a survey was administered to Korean neurosurgeons to investigate the perception of ICP monitoring in patients with sTBI.

METHODS

This study used data from the second Korea Neurotrauma Databank. Among the enrolled patients with sTBI, the following available clinical data were analyzed in 912 patients : Glasgow coma scale score on admission, ICP monitoring, mortality, and extended Glasgow outcome scale score at 6 months. In addition, we administered a survey, entitled "current status and perception of ICP monitoring in Korean patients with sTBI" to 399 neurosurgeons who were interested in traumatic brain injury.

RESULTS

Among the 912 patients, 79 patients (8.7%) underwent ICP monitoring. The mortality and favorable outcome were compared between the groups with and without ICP monitoring, and no statistically significant results were found. Regarding the survey, there were 61 respondents. Among them, 70.4% of neurosurgeons responded negatively to performing ICP monitoring after craniectomy/craniotomy, while 96.7% of neurosurgeons responded negatively to performing ICP monitoring when craniectomy/ craniotomy was not conducted. The reasons why ICP monitoring was not performed were investigated, and most respondents answered that there were no actual guidelines or experiences with post-operative ICP monitoring for craniectomy/craniotomy. However, in cases wherein craniectomy/craniotomy was not performed, most respondents answered that ICP monitoring was not helpful, as other signs were comparatively more important.

CONCLUSION

The proportion of performing ICP monitoring in patients with sTBI was low in Korea. The outcome and mortality were compared between the patient groups with and without ICP monitoring, and no statistically significant differences were noted in prognosis between these groups. Further, the survey showed that ICP monitoring in patients with sTBI was somewhat negatively recognized in Korea.

In-hospital mortality and risk factors among elderly patients with traumatic brain injury: protocol for a systematic review and meta-analysis

INTRODUCTION

The elderly population is more vulnerable to traumatic brain injury (TBI) compared with younger adults, and there is an increasing trend in TBI-related hospitalisations and deaths in the elderly due to the ageing global population. This is a thorough update to a previous meta-analysis on the mortality of elderly TBI patients. Our review will include more recent studies and provide a comprehensive analysis of risk factors.

METHODS AND ANALYSIS

The protocol of our systematic review and meta-analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. We will search the following databases: PubMed, Cochrane Library and Embase from inception to 1 February 2023 reporting in-hospital mortality and/or risk factors predicting in-hospital mortality among elderly patients with TBI. We will perform a quantitative synthesis for in-hospital mortality data combined with meta-regression and subgroup analysis to determine whether there is a trend or source of heterogeneity. Pooled estimates for risk factors will be presented in the form of ORs and 95% CIs. Examples of risk factors include age, gender, cause of injury, severity of injury, neurosurgical intervention and preinjury antithrombotic therapy. Dose-response meta-analysis for age and risk of in-hospital mortality will be performed if sufficient studies are included. We will perform a narrative analysis if quantitative synthesis is not appropriate.

ETHICS AND DISSEMINATION

Ethics approval is not required; we will publish findings from this study in a peer-reviewed journal and present results at national and international conferences. This study will promote a better understanding and management of elderly/geriatric TBI.

PROSPERO REGISTRATION NUMBER

CRD42022323231.

Prediction of Mortality in Geriatric Traumatic Brain Injury Patients Using Machine Learning Algorithms

Background: The number of geriatric traumatic brain injury (TBI) patients is increasing every year due to the population’s aging in most of the developed countries. Unfortunately, there is no widely recognized tool for specifically evaluating the prognosis of geriatric TBI patients. We designed this study to compare the prognostic value of different machine learning algorithm-based predictive models for geriatric TBI. Methods: TBI patients aged ≥65 from the Medical Information Mart for Intensive Care-III (MIMIC-III) database were eligible for this study. To develop and validate machine learning algorithm-based prognostic models, included patients were divided into a training set and a testing set, with a ratio of 7:3. The predictive value of different machine learning based models was evaluated by calculating the area under the receiver operating characteristic curve, sensitivity, specificity, accuracy and F score. Results: A total of 1123 geriatric TBI patients were included, with a mortality of 24.8%. Non-survivors had higher age (82.2 vs. 80.7, p = 0.010) and lower Glasgow Coma Scale (14 vs. 7, p < 0.001) than survivors. The rate of mechanical ventilation was significantly higher (67.6% vs. 25.9%, p < 0.001) in non-survivors while the rate of neurosurgical operation did not differ between survivors and non-survivors (24.3% vs. 23.0%, p = 0.735). Among different machine learning algorithms, Adaboost (AUC: 0.799) and Random Forest (AUC: 0.795) performed slightly better than the logistic regression (AUC: 0.792) on predicting mortality in geriatric TBI patients in the testing set. Conclusion: Adaboost, Random Forest and logistic regression all performed well in predicting mortality of geriatric TBI patients. Prognostication tools utilizing these algorithms are helpful for physicians to evaluate the risk of poor outcomes in geriatric TBI patients and adopt personalized therapeutic options for them.

Comparison of Outcomes at Trauma Centers versus Non-Trauma Centers for Severe Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury (TBI) is one of the most common injuries in patients with multiple trauma, and it associates with high post-traumatic mortality and morbidity. A trauma center was established to provide optimal treatment for patients with severe trauma. This study aimed to compare the treatment outcomes of patients with severe TBI between non-trauma and trauma centers based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS).

METHODS

From January 2018 to June 2021, 1122 patients were enrolled in the KNTDBS study. Among them, 253 patients from non-traumatic centers and 253 from trauma centers were matched using propensity score analysis. We evaluated baseline characteristics, the time required from injury to hospital arrival, surgery-related factors, neuromonitoring, and outcomes.

RESULTS

The time from injury to hospital arrival was shorter in the non-trauma centers (110.2 vs. 176.1 minutes, p=0.012). The operation time was shorter in the trauma centers (156.7 vs. 128.1 minutes, p0.003). Neuromonitoring was performed in nine patients (3.6%) in the non-trauma centers and 67 patients (26.5%) in the trauma centers (p<0.001). Mortality rates were lower in trauma centers than in non-trauma centers (58.5% vs. 47.0%, p=0.014). The average Glasgow coma scale (GCS) at discharge was higher in the trauma centers (4.3 vs. 5.7, p=0.011). For the Glasgow outcome scale-extended (GOSE) at discharge, the favorable outcome (GOSE 5-8) was 17.4% in the non-trauma centers and 27.3% in the trauma centers (p=0.014).

CONCLUSION

This study showed lower mortality rates, higher GCS scores at discharge, and higher rates of favorable outcomes in trauma centers than in non-trauma centers. The regional trauma medical system seems to have a positive impact in treating patients with severe TBI.

Subdural hematoma expansion in relation to measured mean and peak systolic blood pressure: A retrospective analysis

Objective

Subdural hematomas (SDH) account for an estimated 5 to 25% of intracranial hemorrhages. Acute SDH occur secondary to rupture of the bridging veins leading to blood collecting within the dural space. Risk factors associated with SDH expansion are well documented, however, there are no established guidelines regarding blood pressure goals in the management of acute SDH. This study aims to retrospectively evaluate if uncontrolled blood pressure within the first 24 h of hospitalization in patients with acute SDH is linked to hematoma expansion as determined by serial CT imaging.

Methods

A single center, retrospective study looked at 1,083 patients with acute SDH, predominantly above age 65. Of these, 469 patients met the inclusion criteria. Blood pressure was measured during the first 24 h of admission along with PT, INR, platelets, blood alcohol level, anticoagulation use and antiplatelet use. Follow-up CT performed within the first 24 h was compared to the initial CT to determine the presence of hematoma expansion. Mean systolic blood pressure (SBP), peak SBP, discharge disposition, length of stay and in hospital mortality were evaluated.

Results

We found that patients with mean SBP <140 in the first 24 h of admission had a lower rate of hematoma expansion than those with SBP > 140. Patients with peak SBP > 200 had an increased frequency of hematoma expansion with the largest effect seen in patients with SBP > 220. Other risk factors did not contribute to hematoma expansion.

Conclusions

These results suggest that blood pressure is an important factor to consider when treating patients with SDH with medical management. Blood pressure management should be considered in addition to serial neurological exams, repeat radiological imaging, seizure prophylaxis and reversal of anticoagulation.

Understanding Acquired Brain Injury: A Review

Any type of brain injury that transpires post-birth is referred to as Acquired Brain Injury (ABI). In general, ABI does not result from congenital disorders, degenerative diseases, or by brain trauma at birth. Although the human brain is protected from the external world by layers of tissues and bone, floating in nutrient-rich cerebrospinal fluid (CSF); it remains susceptible to harm and impairment. Brain damage resulting from ABI leads to changes in the normal neuronal tissue activity and/or structure in one or multiple areas of the brain, which can often affect normal brain functions. Impairment sustained from an ABI can last anywhere from days to a lifetime depending on the severity of the injury; however, many patients face trouble integrating themselves back into the community due to possible psychological and physiological outcomes. In this review, we discuss ABI pathologies, their types, and cellular mechanisms and summarize the therapeutic approaches for a better understanding of the subject and to create awareness among the public.

Gender differences in adult traumatic brain injury according to the Glasgow coma scale: A multicenter descriptive study

PURPOSE

Patients' gender, which can be one of the most important determinants of traumatic brain injury (TBI) outcomes, is also likely to interact with many other outcome variables of TBI. This multicenter descriptive study investigated gender differences in epidemiological, clinical, treatment, mortality, and variable characteristics in adult TBI patients.

METHODS

The selection criteria were defined as patients who had been diagnosed with TBI and were admitted to the hospital between January 1, 2016 and December 31, 2018. A total of 4468 adult TBI patients were enrolled at eight University Hospitals. Based on the list of enrolled patients, the medical records of the patients were reviewed and they were registered online at each hospital. The registered patients were classified into three groups according to the Glasgow coma scale (GCS) score: mild (13-15), moderate (9-12), and severe (3-8), and the differences between men and women in each group were investigated. The risk factors of moderated and severe TBI compared to mild TBI were also investigated.

RESULTS

The study included 3075 men and 1393 women and the proportion of total males was 68.8%. Among all the TBI patients, there were significant differences between men and women in age, past history, and GCS score. While the mild and severe TBI groups showed significant differences in age, past history, and clinical symptoms, the moderate TBI group showed significant differences in age, past history, cause of justice, and diagnosis.

CONCLUSION

To the best of our knowledge, this multicenter study is the first to focus on gender differences of adult patients with TBI in Korea. This study shows significant differences between men and women in many aspects of adult TBI. Therefore, gender differences should be strongly considered in TBI studies.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Neurocritical Management of Traumatic Acute Subdural Hematomas

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Decreasing Incidence and Mortality in Traumatic Brain Injury in Korea, 2008-2017: A Population-Based Longitudinal Study

Traumatic brain injury (TBI), a global public health concern, may lead to death and major disability. While various short-term, small-sample, and cross-sectional studies on TBI have been conducted in South Korea, there is a lack of clarity on the nationwide longitudinal TBI trends in the country. This retrospective study investigated the epidemiological TBI trends in South Korea, using a population-based dataset of the National Health Insurance (2008–2017). The crude and age adjusted TBI incidence and mortality values were calculated and stratified by age, sex, and TBI diagnosis. The age-adjusted incidence per 100,000 people increased until 2010 and showed a decreasing trend (475.8 cases in 2017) thereafter; however, a continuously decreasing age-adjusted mortality trend was observed (42.9 cases in 2008, 11.3 in 2017). The crude incidence rate increased continually in those aged >70 years across all the TBI diagnostic categories. The mortality per 100,000 people was significantly higher among participants aged ≥70 years than in the other age groups. We observed changing trends in the TBI incidence, with a continuously decreasing overall incidence and a rapidly increasing incidence and high mortality values in older adults. Our findings highlight the importance of active TBI prevention in elderly people.