Traumatic Brain Injury: A Perspective on the Silent Epidemic

Background: Epidemiological data regarding the causes, patterns, severity, and outcomes of traumatic brain injury (TBI) are essential to plan for preventive strategies addressing this public health epidemic. The main aim of this study is to explore the patterns and causes of traumatic brain injury at two trauma centers. Methods: A retrospective cohort study was conducted using a pre-tested validated data collection sheet. Data were collected from the medical records and electronic database of patients who presented to the emergency department with head trauma. Variables including the mechanisms, patterns of the injury, accompanying injuries, level of consciousness, and hospitalization duration were investigated for any possible association. Results: A total of 269 patients (78% males, 22% females) who satisfied our study criteria were included in the final analysis. Motor vehicle collisions were the most common reason for traumatic brain injury (57.6%) followed by falls (28.3%). There was a statistically significant association observed between type of hemorrhage and Glasgow coma scale at initial presentation (P < 0.05). Conclusion: The most common cause of traumatic brain injury is motor vehicle collisions, followed by falls. The public should be made aware of the importance of using safety and precautionary measures to minimize the impact of traumatic brain injuries. Educational programs for neurotrauma prevention can be developed and utilized as a blueprint for local hospitals and officials in the country.


Introduction
Traumatic brain injury (TBI) is a silent public health epidemic and a major cause of disability, morbidity, and mortality worldwide [1]. TBI is characterized by a breakdown in the normal function of the brain caused by collision, blow, and jolt to the head-neck-spinal cord, possibly leading to temporary or permanent impairment [2]. Global epidemiological data show that approximately 69 million people suffer from TBI yearly. The highest incidence is reported in high-income countries compared to low-middle income countries [3].
Road traffic accidents are the leading cause of TBI. Higher rates of TBI in the United States are observed among older adults (2,232 per 100,000), followed by young children (1,591 per 100,000) [4]. Although there is scarcity in the data regarding TBI from the Kingdom of Saudi Arabia, the reported incidence is 116 per A retrospective cohort study was conducted using data collected from the medical records and electronic database of patients who presented to the emergency department with head trauma from April 2016 to April 2019. The study was conducted at two medical institutions, King Faisal Medical Complex and King Abdulaziz Specialized Hospital. These institutions provide medical care and advanced trauma care services to patients mainly from the Western region of Saudi Arabia. Data were collected and entered into a pre-designed and validated data collection sheet.

Patient eligibility
All patients who presented to the emergency department with traumatic head injuries during the study period were included. Initially, the records of 418 patients admitted to these two hospitals due to TBI were assessed. Patients with incomplete records and unsalvageable data were excluded from the analysis (35%). These included missing charts, unrecognizable radiological records, and incomplete documentation of posttraumatic symptomatology.

Data collection
The examined variables included socio-demographic details, mechanism of injury, accompanying injuries, Glasgow coma scale (GCS) on admission, radiological findings on brain CT, length of stay (LOS), and symptomatology. The severity of TBI was assessed using the GCS. TBI was classified into mild (GCS = 15-13), moderate (GCS = 12-9), and severe (GCS = 8-3). The association between the mechanism of injury and gender was analyzed.

Statistical analysis
Data were entered into Microsoft Excel by an investigator. Statistical analysis was performed using SPSS version 23 (IBM Corp., Armonk, NY, USA) by an independent biostatistician. Categorical variables were summarized as proportions and frequencies. Any possible association of the variables was analyzed using Pearson's Chi-square test. Continuous variables were expressed as mean and standard deviation. A P-value of ≤ 0.05 was considered statistically significant.

Ethical considerations
The ethical committees of the Research and Studies Department, Directorate of Health Affairs approved the current study. Prior to commencement of the study, permission was obtained from King Faisal Medical Complex and King Abdulaziz Specialized Hospital. Patient-related data were preserved and kept confidential. The identifying personal details were not included in the analysis. The assigned protocol number is HAP-02-T-067.

Baseline characteristics
After scrutinizing the data, a total of 269 patients were included in the final analysis. The analysis included 22% females and 78% males who had some degree of TBI. The age distribution of the patients is illustrated in Figure 1.

Co-existing injury vs. type of hemorrhage
When the co-existing injuries were assessed, it was found that 17.9% (n=10) of the patients with intra-axial hemorrhage had head and face injuries. Spinal cord injuries were noted in 5.7% (n=5) of the patients with extra-axial hemorrhage.

Mechanism of injury vs. gender
TBI was more common in males than females. Motor vehicle accidents in males accounted for 45.72% (n = 123) of trauma patients presenting to the emergency department. Table 2 outlines the mechanism of injury according to the gender of the patient.

Mechanism of injury vs. fracture type
It was observed that a fracture of the vertebrae was more prevalent in MVCs. Fractures involving the base of the skull were noted in those who had a fall. Fractures involving the vault of the skull were more prevalent in assault. Table 4 outlines the type of fracture and the reason for injury.

Type of fracture vs. hemorrhage
Fracture of the vault of the skull was noted in 17.2% (n=15) of the patients with extra-axial hemorrhage. It was observed that a fracture of the vertebrae was more prevalent in patients with simultaneous intra-and extra-axial hemorrhage.

Length of stay vs. type of hemorrhage
The analysis of CT scan findings showed that 20.8% of the patients had intra-axial hemorrhage, 32.3%% (n=87) had extra-axial hemorrhage, and 12.6% had simultaneous intra-and extra-axial hemorrhage. When the association between the type of hemorrhage and the length of stay was assessed, it was found that most patients (n = 196; 66.2%) were hospitalized for less than one week (P = 0.007). Table 6 outlines the association between type of hemorrhage and the length of stay during hospitalization.

Discussion
Reports regarding TBI vary widely between and within countries due to the lack of data regarding the types, causes, and outcomes of TBI. The present study is a hospital-based, retrospective cohort analysis conducted at two medical institutions in Saudi Arabia. The findings of the study demonstrated that motor vehicle collisions (MVCs) were the leading cause of TBI. This concurs with other studies conducted in Middle Eastern countries, i.e. the United Arab Emirates and Qatar [7][8].
In contrast, a study in the United States reported that falls from heights and assault were the leading causes of TBI. However, MVCs remained the leading cause of death, followed by falls from heights [9]. In the present study, most patients with TBI were males and the leading cause of TBI in males was MVCs, although there was no significant association. This could be due to the fact that females were not allowed to drive during the major period of our study compared to other countries [7][8][9].

Associated injuries
Brain injuries resulting from MVCs, assault, or falls from heights frequently cause concurrent injuries to other body regions, including the spine, vertebrae, and extremities, the leading cause of death and disability [10]. The findings of the present study showed that head and spine injuries were commonly noted in MVCs and physical assaults. Studies show that one-third to one-half of the patients with severe extra-cranial injuries with associated brain injury have high mortality rates [11][12][13]. The reason for this could be explained on the basis that patients with injury at the extra-cranial sites could have massive hemorrhage, which could result in coagulopathy or decreased cerebral blood flow, causing secondary brain damage [14][15].

Severity of brain injury
The GCS is commonly recorded soon after arrival or within less than one hour after arrival to the hospital [16]. In our study, 15.2% of patients had severe brain injury whereas 14.1% had moderate brain injury. It was found that the severe brain injuries were noted in patients who had fractures of the vault of the skull, base of the skull, and vertebrae compared to other types of fracture. This finding was in accordance with the findings of Meng and Shi [17].
In another study conducted in the United States, it was reported that 14.5% of the patients who had severe brain injury had achieved good outcome at six months [18]. Studies also reported that 100% of mortality was observed in cases with fixed and dilated pupils who had severe brain injury [19][20].

Hospitalization
It is reported that patients with intracerebral hemorrhage (ICH) due to trauma suffer from long and uncertain hospitalization [21]. Therefore, it is important to take this into consideration to predict the outcomes and help healthcare providers take precautionary measures when managing patients with TBI. Studies report that various injury preventive programs were effective in reducing mortality and disability in patients who had road traffic accidents [22][23].

Age at risk
In the present study, the majority of victims with TBI (47%) were 20 years of age and younger. This emphasizes the issue within the affected demographic. Similarly, El-Matbouly et al. conducted a retrospective study on TBI across age groups in Qatar. Their findings showed that the majority of victims were young adults (34%) and middle-aged (21%). This concurs with the findings of the present study. Therefore, young adolescents should be properly made aware of traumatic brain injury and how it can be a silent epidemic [24].

Concurrent maxillofacial injury
Aldwsari et al. prospectively explored maxillofacial traumas in patients who sustained road traffic accidents from 2013 to 2018. The authors highlighted the important association of maxillofacial traumas with traumatic brain injuries. Of note, the face is the most susceptible area to trauma by road traffic accidents, being the most exposed area of the body. In the study of Aldawsari et al. approximately 60% of the cohort who sustained maxillofacial trauma suffered from concomitant brain damage [25].

Initial assessment
TBI could be associated with loss of cognitive, physical, or psychosocial functions leading to decreased level of consciousness, memory impairment, neurologic deficits, and alteration in the mental state of the individual [26]. Most of the MVCs are considered emergency cases and the first and foremost protocol in management is the maintenance of airway, breathing, circulation, stabilization of the disability, and prevention of secondary brain injury. In this situation, the initial assessment includes resuscitation and neurological examination [27].

Prognosis
The management of severe TBI is complex and overwhelming. Although several prognostic models have been developed and tested, the accurate assessment of short and long-term prognosis remains poorly validated. There is a need to properly understand the molecular mechanisms of TBI, which would help healthcare providers to accurately predict the outcomes [28].

Limitations
Our study was retrospective and hospital-based, hence could have some limitations of its own. There is a chance of selection bias and misclassification that could arise while retrospectively processing the data. Second, the type of management the patient received during hospitalization was not detailed, which might influence recovery. Despite these limitations, the present study highlighted that motor vehicle accidents and falls were the leading causes of TBI, thus emphasizing the importance of considering the implementation of preventive measures and appropriate public health programs including traffic safety rules. This helps to develop educational programs for neurotrauma prevention to be utilized as a blueprint for local hospitals and officials in Saudi Arabia.

Conclusions
The leading cause of traumatic brain injury in Saudi Arabia is motor vehicle accidents, followed by falls. The public should be made aware of road traffic rules and safety practices in motor vehicle accidents. People working at heights, such as building construction workers, have a high potential for falls and should be properly instructed to take precautionary and safety measures, i.e., protective equipment, in order to reduce the impact of traumatic brain injury.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.