Injury Patterns in Patients With Traumatic Brain Injuries: Findings From a Traumatic Brain Injury Registry Initiative

INTRODUCTION

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide, particularly in young adults in their productive age group.^[1] Road traffic accidents (RTA) account for the majority of the cases of TBI (60%), followed by falls (20-25%) and assaults (10%).^[2-9] India is one of the leading countries in high fatalities due to road accidents.^[3,4,7,8]

Prevention of RTAs can be a major step in controlling the outcomes, but is influenced by resources governing protective transport gear, drunk-driving legislature, speeding by-laws, broken architecture, pre-hospital transport services, and overburdened small rural hospital centres, to name a few.^[10] India holds roughly 1% of the world’s vehicles but is responsible for 11% of the RTAs. According to the data from the NCRB, accident-related mortalities have been on a declining trend from 2016-2020, but observed 80.5% of the victims were males, majorly between 30-45 years, and that 11% were geriatric.^[11] However, given this recent data, information on TBI from India is scarce. A recent literature search yields a short repertoire of TBI datasets, even from national centres.^[11]

The significant disabilities associated with TBI place a considerable burden on the health care system in India with infrastructural and manpower related constraints. Knowledge of the epidemiological profile of TBI is essential in planning preventive and corrective measures to improve TBI-related outcomes.^[12] In India, however, the TBI statistics are not comprehensive and concise due to the absence of well-maintained registries and proper documentation. The present study shares the epidemiological profile of TBI patients in a tertiary care centre in coastal Karnataka to bridge this gap.

MATERIAL AND METHODS

This is a descriptive observational study based on 5-year hospital-based retrospective data maintained as an in-hospital trauma registry. Approval of the institute’s ethics committee was obtained prior to the conduct of the study (Kasturba Hospital, Ethics Committee, IEC no. 205/2015). The study included all patients of trauma with clinical/radiological evidence of head injury alone or in association with other injuries admitted to the neurosurgery department of a tertiary care centre in coastal Karnataka, India, during a 5-year period beginning January 2018. The tertiary centre is a 1500-bedded hospital having 24-hour facilities to manage TBI cases with a team comprising residents and faculty from emergency medicine and neurosurgery. Data were collected at the time of admission based on a standardised proforma. All patients having TBI (as per the criteria laid by International Classification of Disease (ICD) injury codes ICD 10) were included in this study. Data captured included patients’ demographic profiles, pre-hospital care, type of injury, radiological findings, clinical examination, neurological findings, and management details. Demographic data included age, sex, marital status, education, occupation, pre-existing co-morbidities, influence of alcohol, and mechanism of injury. The severity of the head injury was assessed by the Glasgow Coma Scale (GCS) and was graded as mild (13-15), moderate (9-12), and severe (≤8). GCS 3-4 is considered especially as ‘Critical GCS.’ A computed tomography (CT) scan of the brain was done as early as possible, and radiological findings and details of surgical intervention were also recorded. Outcome assessment was limited to current hospitalisation as follow-up data was not comprehensive and complete. Confidentiality of patient information was maintained.

Statistical analysis: The details were entered into Microsoft Excel 2007, exported to SPSS Version 16 (Chicago Inc.), and analysed. The statistical method was a descriptive analysis of the percentage of retrievable information on the clinic-demographic variables related to TBI. Inferences were made based on the descriptive analysis data. Statistical tests of significance were not employed as the study was of a descriptive observational design.

RESULTS

Our study cohort included 1934 TBI patients between January 1, 2018, to June 9, 2023. Of these, 1543 (79.79%) were males and 391 (20.21%) were females. The age of patients varied from 6 months to 102 years, with a mean age of 40.3 (SD 3.3) years. The majority of patients belonged to the 20–40-year age group (721 patients; 37.28%), followed by the 40-60-year age group (608; 31.43%) [Table 1]. Extremes of age (0-20 and 60-80 years) were represented almost equally (12-14%). The youngest patient was a 6-month-old child, and we had 29 patients above 80 years of age, including one centurion. RTA was the most common cause of TBI (1421; 73.47%) [Table 2]. TBI due to RTA was most common among males in the 20-40 years age group (608; 42.79%) [Table 3]. The second most common mechanism of injury was “fall from a height/building” (185; 9.56%), common in males but similarly distributed among all age groups [Table 4]. Analysing the severity of GCS with the mechanism of injury, we noted GCS (13-15) was predominantly seen 57-67% in all mechanisms, followed closely by GCS (9-12) at 17-18%, GCS (3-8) at 5-11%, and critical GCS (3-4) at 9-14% [Table 4].

RTA occurred predominantly in two-wheeler riders (1139; 80.2%) followed by pedestrians (143; 10.1%), car drivers or passengers (104, 7.3%). Auto-rickshaw (31; 2.2%), bus, or train travellers were relatively less involved (19, 1.3 %). Among two-wheelers, drivers (69%) and pillion riders (22.8%) were vulnerable to TBIs and did not use helmets as per the history documented. Evidence of alcohol consumption was not forthcoming in 504 (26.06%) patients but was a potential cause for TBI in 12% for RTA and 3% with fall. Alcohol consumption-related TBI was more common among males (96%), especially between 20-40 years (90%). Associated orofacial injuries were seen in 557 (28.8%), and 260 patients (13.4%) had polytrauma. Nasal bleeding (364; 18.82%), ear bleeding (156; 8.07%), and oral bleeding (467; 24.15%) were a common association with TBI. Polytrauma included 144 (7.44%) patients with thoracic injures, 51 (2.63%) with abdominal trauma, and 25 (1.3%) with pelvic injuries. A total of 215 patients (11.11%) had associated spinal injuries, of which cervical spine injury occurred in 155 patients; thoracolumbar spine injuries occurred in 30 (1.55%) patients each. Upon presentation, 1116 (57.7%) patients had a GCS score between 13-15. Moderate, severe, and critical TBI constituted 309 (15.8%), 180 (9.3%), and 239 (12.36%), respectively [Table 5]. Comparing age groups (divided as 0-10 years, 11-20 years and so forth till 100 years) with GCS at the time of presentation, we noted that GCS (13-15) was present uniformly in all age groups, ranging from 57-83% of the cases, followed closely by GCS (9-12) ranging 10-30%, GCS (3-8) ranging 10-20%, and critical GCS (3-4) representing 5-8% of each age-related cohort. A history of loss of consciousness was noted in nearly 1143 (59.10%) patients with post-traumatic amnesia in 14.73%. Of the 728 patients with moderate, severe, and critical TBI, 419 (57.5%) underwent surgery. Craniotomy with evacuation of hematoma represented the most common surgery performed (155; 37%), followed by decompressive craniectomy in 101 (24%) cases. Emergency surgeries also included anterior cranial fossa repair (51; 12%) and depressed fracture elevation (30; 7%). Spine surgery as an emergency was done in 70 (17%) patients, of whom 30 (5%) had craniovertebral junction stabilisation procedures. Mortality was noted in 427 patients (22%), largely from the severe and critical GCS group.

DISCUSSION

Optimal management of traumatic brain injuries requires a multidisciplinary approach between hospitals, the police force, adequate road transport, engineering, media, health education, and health care personnel. Strategic reforms should be made on the basis of thorough knowledge of the epidemiology of trauma specific to a particular geographical area.^[12-19] TBI epidemiological data from India is scarce due to the lack of well-established systems for collecting information and the failure to analyse and quantify the burden of TBI.^[6,12-16,19]Lack of trauma registries, data sharing across centres and government agencies compounds the drawbacks of an existing emergency care system. An urgent need for collecting epidemiological data on TBI to guide policy changes to optimise care is of critical importance.^[6] Our study aims to bridge this gap by analysing TBI data from an in-hospital trauma registry maintained in a tertiary referral care centre that caters to a semi-urban population in south and coastal Karnataka, India. Roadways constitute the most common area for TBI, accounting for over 40 % of cases in most studies from India and abroad.^{[2-9,13-17,20]} Major factors lead to TBI - poor maintenance of roads, insufficient lighting, mixed traffic density, huge vehicle population, fast life style, inadequate infrastructure, lack of road safety measures, non-adherence to safety precautions of use of seat belt, helmets. Our study reflects a rural/semi-urban setting with a similar observation, except for the nature of vehicles involved. RTA was the most common mechanism of TBI (73.47%) predominant in 20-40 years (42.79%) with definite male preponderance. Two-wheeler riders (80.2%) were most vulnerable to TBI, followed by pedestrians. Among two-wheelers, pillion riders were more likely to sustain injuries. A similar observation has been reported by other studies where they relate the increased incidence to an inherent instability of two-wheelers and reluctance to use helmets.^[2,4,21,22] Car, bus, and truck passengers are susceptible to high-velocity injuries leading to polytrauma or death. However, high-speed accidents due to heavy vehicles were relatively uncommon in our series in contrast to most reported series from developed nations. Provision of requisite road infrastructure, dedicated cycle paths, lanes (for cyclists), sidewalks (for pedestrians), enforcement of traffic laws, helmet use, avoiding speeding and alcohol use, and education on road safety measures are critical in reducing RTA-related TBI. Falls from height, assault, and workplace injuries can also cause TBI. Sogut et al., in their series report, falls from the heights as a second most common cause of trauma while Byun et al. found blunt trauma related to work-place or domestic injuries as the second main cause in Korea.^[9,23] In our study, “fall from a height/building” (9.56%) was the second most common mode of injury, more in males but was similarly distributed among all age groups (Table 4). Interestingly, we had 64 patients with head injury secondary to falling from bed, of whom half were >60 years of age.^[24,25] In contrast, TBI due to assault/blunt trauma constituted <1% in our series. Productive aged males dominate most of the reported series of traumatic brain injuries, and similar to our study.^{[3,5,17,26-30]} More than two-thirds of our study population were 20–60 years old, with the majority belonging to the 20-40 years. A similar observation by Fararoei et al. notes the 20-40 years age group as the most vulnerable group to suffer TBI through a survey in Delhi.^[16,31] This may be because young adults have easy opportunities to drive, engage in outdoor activities and are susceptible to rage and rashness. In most parts of India, males have preferential access to driving, more vulnerable to workplace injuries and physical assaults. Alcohol consumption and driving under the influence are also more prevalent in males. Nearly one-tenth of our RTA cohort were found to be under the influence of alcohol, with 96% males in the 20-40-year group. This could reflect negligent behaviour, indifference to adhere to civic rules, accompanied by poor law enforcement.^[30] We noted our cohort had extremes of ages (6 months, 102 years) with 29 patients above 80 years of age. The effect of TBI is disproportionately severe in the elderly for a given severity of head injury.^[32] The International Mission for Prognosis and Clinical Trial (IMPACT) database on TBI observed that increasing age was strongly related to worse outcomes in a continuous linear trend.^[33] Patients over 60 years constituted nearly 16% of our cohort and, as reported in other series, had a poor outcome compared to their younger counterparts. Battered baby syndrome was relatively uncommon in our setting, and none of our paediatric patients had evidence of the same. TBI is commonly associated with polytrauma and other organ injuries. The Berlin Polytrauma Definition describes polytrauma as injuries with an Abbreviated Injury Scale score of ≥ 3 in ≥ 2 body regions (2AIS ≥ 3) combined with the presence of ≥ 1 physiological risk factor.^[34] A retrospective review of motorcycle trauma in Pakistan reported that 19.5% of all victims had polytrauma, and in an Indian hospital-based study, two-thirds of TBI cases had evidence of polytrauma.^[35,36] The most common regions of involvement were limbs, chest, and abdomen.^[37] Harna et al noted 11% sustained chest, 9% had abdomen and 3% had face and neck injuries.^[4] For us, orofacial injuries were common (28.8%). TBI is often associated with spinal injuries, especially involving the cervical spine. We noted similar findings with 12% of spinal injuries, majorly involving the cervical spine. Victims of two-wheeler accidents with severe TBI are vulnerable to suffer polytrauma.^[38] The probable reasons combine the inherent unsafety of the vehicle, increased usage by risk-taking young adults, and non-helmet use.^[39] The outcome following TBI is directly related to admission GCS, severity of TBI, and other secondary injuries.^[5,32] Nearly 45% of our cohort had an admission GCS of 12 or less, and nearly one-fifth had severe to critical TBI (GCS less than 8). The need for surgical intervention implies a severe injury and is a poor prognosticator. In Bhole et al. a series of 200 patients, surgical intervention was required in 19% of patients.^[5] We noted that one-fifth of our cohort required emergency brain surgery, and 3% required spine surgery. Proportionately, our mortality rates were high at 22%, representing the severe and critical TBI group. High mortality can be attributed to increased risk of secondary brain damage due to delayed, improper transportation techniques. TBI is a major public health concern due to high morbidity and mortality with a valuable socioeconomic impact. Along with the patient’s, the caregiver’s quality of life is compromised.^[39,40] The development of an electronic TBI data registry with centralised linking of multiple hospital-based registries can provide valuable epidemiological data,^[40-42] which can assist the administration in introducing and enhancing progressive reforms and corrective steps.

Limitations and strengths: Demographic details like marital status, education, occupation, income, addiction, and prehospital details were not captured accurately and, hence, not analysed. Follow-up of the cohort was till discharge. Our referral tertiary centre caters to three major adjoining districts, population of over 5 million, with a demographic profile of southern coastal India, though with a poor retrieval and emergency service care; is unlikely to reflect the exact situation of other hospitals in India. We hope this study can guide future comparative multicentre studies to be relevant for TBI policymaking in India.

CONCLUSION

TBI, secondary to RTA, is a major public health hazard in developing countries like India. This study is the first of its kind in coastal Karnataka, highlighting the importance of maintaining a proper trauma-based electronic registry. We noted TBI commonly in males in the productive ages, secondary to RTA due to two-wheeler driving. Nearly one-third of our patients had moderate, severe, or critical TBI, and one-fifth of them succumbed to the injury. We hope the study can help in formulating and implementing surveillance programs and effective evidence-based interventions to prevent, limit TBI-associated disabilities.