Risk factors for intracranial lesions and mortality in older patients with mild traumatic brain injuries

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.

Concussion Management in Older People: A Scoping Review

OBJECTIVE

To map existing literature about concussion management in older people, identifying and analyzing gaps in our understanding.

CONTEXT

Concussion injuries affect older people, yet little guidance is available about how to approach concussion management with older people. Research does not always include older populations, and it is unclear to what extent standard concussion management is appropriate for older people.

DESIGN

Scoping review.

METHOD

A structured literature search was conducted using 4 databases to identify existing literature relating to concussion management in older people. Studies that assessed outcomes relating to the management of concussion/mild traumatic brain injury in those 65 years or older were included and mapped according to the main themes addressed.

RESULTS

The search yielded a total of 18 articles. Three themes related to early management (use of anticoagulants n = 6, intracranial lesions n = 3, and service delivery for older people n = 5), and 1 theme related to general management (cognitive issues n = 4). A lack of articles exploring general management in older people was observed.

CONCLUSION

Existing literature indicates that specific management strategies are needed for older people with concussion, especially in early management. This review highlights that good evidence is available about early management and this is reflected in some guidelines, yet little evidence about general management is available and this gap is not acknowledged in guidelines. Distinct approaches to early management in older people are clearly recommended to mitigate the risk of poor outcomes. In contrast, general concussion management for older people is poorly understood, with older people poorly represented in research. A better understanding is needed because-as observed in early management-older people have distinct characteristics that may render standard management approaches unsuitable.

Cutaneous Impact Location Predicts Intracranial Injury Among the Elderly Population with Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is one of the most common trauma-related diagnoses among the elderly population treated in emergency departments (ED). Identification of patients with increased or decreased risk of intracranial bleeding is of clinical importance. The objective of this study was to evaluate the implication of cutaneous impact location (CIL) on the prevalence of intracranial injury after suspected or confirmed TBI irrespective of its severity.

Methods

This was a retrospective, single-center, descriptive observational study of geriatric patients aged 65 years and older treated for suspected or confirmed TBI in a trauma surgery ED. The primary outcome of the study was the assessment of a CIL of the injury and its association with the prevalence of intracranial lesions found on a head computed tomography scan.

Results

Among 381 patients included in the analysis, the CIL of interest (temporo-parietal and occipital impacts) was present among 178 (46.7%) cases. Thirty-six (9.5%) patients were diagnosed with intracranial bleeding. The prevalence of intracranial bleeding was higher in the CIL of interest group compared with other locations outside (12.9% vs 6.4%; p = 0.030). CIL of interest was a predictor of intracranial bleeding (p = 0.033; OR: 2.17; 95% CI: 1.06 to 4.42).

Conclusion

The CIL of head injury is a predictor of intracranial lesions among geriatric patients with traumatic brain injury. Physicians should be aware of this association when assessing elderly patients with head injuries. More studies are needed to develop a clinical management tool incorporating CIL to guide the diagnosis of TBI in this population.

Risk for intracranial hemorrhage in individuals after mild traumatic brain injury who are taking serotonergic antidepressants

Background

Serotonergic antidepressants may predispose to bleeding, but little is known of the risk for traumatic intracranial bleeding.

Methods

This was a prospective case-control study of 218 patients with mild traumatic brain injuries (TBI) who were treated at a Finnish tertiary trauma hospital. Injury-related information and clinical findings were prospectively collected in the emergency department. Detailed pre-injury health history was collected from electronic medical records. Information on the use of serotonergic antidepressants was attained from the Finnish national prescription registry. All head CT scans were reviewed by a neuroradiologist based on the Common Data Elements. Cases were patients with traumatic intracranial hemorrhage on head CT. Controls were patients from the same cohort, but without traumatic intracranial lesions on CT. The proportion with traumatic intracranial bleeding for patients on serotonergic antidepressant medication was compared to the proportion for patients not on serotonergic medication.

Results

The study cohort consisted of 24 cases with traumatic intracranial bleeding and 194 injured controls. The median age of the sample was 70 years (interquartile range = 50-83). One fifth (21.6%) of all the patients were taking a serotonergic antidepressant. Of the patients on an antidepressant, 10.6% (5/47) had an acute hemorrhagic lesion compared to 11.1% (19/171) of those who were not on an antidepressant (p = 0.927). In the regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use.

Conclusion

Serotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage after a mild TBI. The patients in this relatively small cohort were mostly middle-aged and older adults. These factors limit the generalizability of the results in younger patients with mild TBI.

What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis

OBJECTIVES

This review aimed to identify the demographic and clinical differences between those older adults admitted directly under neurosurgical care and those that were not, and whether EMS clinicians could use these differences to improve patient triage.

METHODS

The authors searched for papers that included older adults who had suffered a TBI and were either admitted directly under neurosurgical care or were not. Titles and abstracts were screened, shortlisting potentially eligible papers before performing a full-text review. The Newcastle-Ottawa Scale was used to assess the risk of bias.

RESULTS

A total of nine studies were eligible for inclusion. A high abbreviated injury score head, Marshall score or subdural hematoma greater than 10 mm were associated with neurosurgical care. There were few differences between those patients who did and did not receive neurosurgical intervention.

CONCLUSIONS

Absence of guidelines and clinician bias means that differences between those treated aggressively and conservatively observed in the literature are fraught with bias. Further work is required to understand which patients would benefit from an escalation of care and whether EMS can identify these patients so they are transported directly to a hospital with the appropriate services on-site.

Serotonergic Antidepressants and Risk for Traumatic Intracranial Bleeding

Background: Serotonergic antidepressants may predispose to bleeding but the effect on traumatic intracranial bleeding is unknown. Methods: The rate of intracranial bleeding in patients with antidepressant medication was compared to patients not antidepressants in a cohort of patients with acute head injury. This association was examined by using a consecutive cohort of head trauma patients from a Finnish tertiary center emergency department (Tampere University Hospital, Tampere, Finland). All consecutive (2010-2012) adult patients (n = 2,890; median age = 58; male = 56%, CT-positive = 22%, antithrombotic medication users = 25%, antidepressant users = 10%) who underwent head CT due to head trauma in the emergency department were included. Results: Male gender, GCS <15, older age, and anticoagulation were associated with an increased risk for traumatic intracranial bleeding. There were 17.8% of patients not taking antidepressants and 18.3% of patients on an antidepressant who had traumatic intracranial bleeding (p = 0.830). Among patients who were taking antithrombotic medication, 16.6% of the patients not taking antidepressant medication, and 22.5% of the patients taking antidepressant medication, had bleeding (p = 0.239). In a regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use. Conclusions: Serotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage.

Cognitive Impairment Following Acute Mild Traumatic Brain Injury

Patients with mild traumatic brain injury (mTBI) may present cognitive deficits within the first 24 h after trauma, herein called "acute phase," which in turn may lead to long-term functional impairment and decrease in quality of life. Few studies investigated cognition in mTBI patients during the acute phase. The objectives of this study were to investigate the cognitive profile of patients with mTBI during the acute phase, compared to controls and normative data, and whether loss of consciousness (LOC), previous TBI and level of education influence cognition at this stage. Fifty-three patients with mTBI (aged 19-64 years) and 28 healthy controls participated in the study. All patients were evaluated at bedside within 24 h post-injury. Demographic and clinical data were registered. Cognitive function was assessed with the Mini-mental state examination (MMSE), the Frontal Assessment Battery (FAB), Digit Span (working memory), and the Visual Memory Test/Brief Cognitive Battery (for episodic memory). The clinical sample was composed mainly by men (58.5%). The mean age was 39 years-old and 64.3% of the patients had more than 8 years of education. The most common causes of mTBI were fall from own height (28.3%), aggression (24.5%), and fall from variable heights (24.5%). Compared to controls, mTBI patients exhibited significantly worse performance on MMSE, FAB, naming, incidental memory, immediate memory, learning, and delayed recall. Compared to normative data, 26.4% of patients had reduced global cognition as measured by the MMSE. Episodic memory impairment (13.2%) was more frequent than executive dysfunction (9.4%). No significant differences were found in cognitive performance when comparing patients with or without LOC or those with or without history of previous TBI. Patients with lower educational level had higher rates of cognitive impairment (VMT naming-28.6 vs. 4.2%; VMT immediate memory-32 vs. 4.2%; VMT learning-39.3 vs. 4.2%, all p < 0.05). In sum, we found significant cognitive impairment in the acute phase of mTBI, which was not associated with LOC or history of TBI, but appeared more frequently in patients with lower educational level.