| Abstract|| |
Background: Trauma is one of the leading causes of death and disability in Indian population. Aim: To correlate various variables like epidemiology, clinical status, severity of TBI & associated co-morbid conditions and its outcome. Settings and Design: This study involved retrospective collection, prospective management and follow up of 796 cases of TBI admitted to the neurosurgery department of a tertiary care hospital in New Delhi during one year study duration. Materials and Methods: All the relevant variables recorded and analyzed with Glasgow Outcome Scale (GOS) in 6 months into 3 groups i.e. group 1 (GOS-1/Dead), group 2 (GOS-2&3/Bad) and group 3- (GOS-3&4/good). Statistical Analysis: Compiled data collected, analyzed and difference between two proportions was analyzed using Chi Square test. Results: This study included 791 cases with 569 (72%) males and 222 (28%) females with average age of 24 years. Fall from height was the main cause of TBI (56%) followed by road traffic injury (RTI) (36%). Majority (61%) patients reached the hospital within 6 hours of injury out of which 27% patients were unconscious. As per Glasgow coma scale mild, moderate & severe grade of TBI was seen in 62%, 22% &16% cases respectively. Radiological examination of other body parts revealed injuries in 11% cases. Only 11% cases required surgical management, rest was managed conservatively. Good outcome noted in 80% cases and 20% cases expired. Average duration of hospital stay was 5 days. According to multivariate analysis, the factors which correlated with poor prognosis are presence of radiological injuries to other body parts, GCS, abnormal cranial nerve examination, abnormal plantar and abnormal pupillary reflex. (P < 0.05) Conclusion: TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Mortality increases with the severity of TBI and associated injuries therefore multimodality approach in polytrauma is essential.
Keywords: Epidemiology, traumatic brain injury, Glasgow outcome score, multimodality approach
Key Message: TBI is a significant public health problem worldwide and requires appropriate attention from researchers and policy makers regionally through the development of ongoing surveillance programs and the implementation of effective evidence - based interventions. By improving our system with better reporting and documentation of cases, we will be able to make a better plan to decrease the incidence of TBI and their timely appropriate multimodality approaches to achieve better outcome of these cases within our limited resources.
|How to cite this article:|
Shekhar C, Gupta LN, Premsagar IC, Sinha M, Kishore J. An epidemiological study of traumatic brain injury cases in a trauma centre of New Delhi (India). J Emerg Trauma Shock 2015;8:131-9
|How to cite this URL:|
Shekhar C, Gupta LN, Premsagar IC, Sinha M, Kishore J. An epidemiological study of traumatic brain injury cases in a trauma centre of New Delhi (India). J Emerg Trauma Shock [serial online] 2015 [cited 2019 Jul 19];8:131-9. Available from: http://www.onlinejets.org/text.asp?2015/8/3/131/160700
| Introduction|| |
Traumatic brain injury (TBI) is one of the most devastating types of injury. It affects all ages; however majority of road traffic injuries (RTI) occurs in young adults of productive age group. As per report by the ministry of road transport, Government of India (2007) 1.4 lakhs road accident happened in 2007 with 40,612 people killed and 1.5 lakhs people injured.  Hence, India is leading the world in fatalities due to road accidents. TBI is also associated with significant socioeconomic losses in India as well as in other developing countries. ,
Worldwide it is a major public health problem and is predicted to surpass many diseases as a major cause of death and disability by the year 2020.  The majority (60%) cases are due to road traffic injuries (RTI), followed by falls (20-25%) and violence (10%). 
Due to rapid surge in urbanization, motorization and economical liberation, many Asian countries have an increased risk for TBI.  Similarly in many low and middle income countries (LMIC), non-communicable disease including injuries are becoming a leading cause of mortality and morbidity. LMIC face a higher preponderance of risk factors for TBI yet often do not have the efficient health care capacity to deal with the associated health outcomes. The significant disabilities associated with TBI also places a considerable burden on health care system in these countries, therefore knowledge of the epidemiological profile of TBI and development of preventive measures to alleviate this burden are vital, particularly in the limited resources setting. 
Young male are commonly affected population in TBI. , In children younger than 15 years, head injury is the leading cause of mortality , but in elderly most frequent cause of TBI is fall. , 69% cases of injury were reported from age group 15-35. 
Most common clinical presentation in TBI patient is headache and vomiting followed by skull fracture with history of loss of consciousness (LOC). Associated clinical findings suggestive of basal skull fractures are nasal bleed, ear bleed, ecchymoses over mastoid (battle's sign) and CSF rhinorhea/otorrhoea. Neurological assessment for assessing severity of TBI is commonly done by Glasgow coma scale (GCS) but low score of GCS do not necessarily predict bad outcome. 
Since GCS do not follow a normal distribution, studies employing mean GCS values and standard statistical analysis are misleading. 
X-Ray skull can detect skull fracture that is an indicator for more severe internal brain injury and is frequently associated with development of intracranial hematoma. 
The computed tomography (CT) classification for TBI yields important prognostic information. It provides an objective assessment of the structural damage to brain following TBI. Individual CT characteristics are important predictors of outcome in TBI. Despite various advances in radiology, CT remains the investigation of choice in case of suspected TBI. Treatment plan and prognostication can also be done easily. Cases of head injury with fracture tend to have more complication and are more often fatal than those without fracture.
The quality of pre-hospital and emergency room care is an extremely important determinant of outcome in trauma patients. Trauma presents with variety of injuries and problems that demand rapid evaluations, discussion, improvisation and interventions to save life and prevent permanent disabilities.
There are numerous factors that determines the outcome in head injury patients namely age, sex, severity of injury, intracranial pathology, intracranial pressure and associated injuries. 
The objective of present study was to determine epidemiology of TBI, correlation of the clinical status, severity of head injury and the associated co morbid conditions with the final outcome and how a multimodality management can change the prognosis.
| Materials and Methods|| |
The approval of ethical committee of hospital was taken. The study included all the patients of trauma with clinical/radiological evidence of head injury alone or in association with other injuries admitted to neurosurgery department, Dr. R. M. L. Hospital, New Delhi during the period of one year of study.
A data capture form was filled for each of the patient, which included all the details about the case like patient profile, pre hospital care, type of injury, radiological findings, clinical examination, neurological findings and management details. TBI severity was scored according to GCS. CT scan of brain was done as early as possible. These data were transferred into the computer on MS office excel sheet. Weekly progress of the study was reviewed. The progress, follow up and their final outcome were recorded by neurology examination. GCS was used for age-group more than 5 years and Pediatric Coma Scale (by Simpson and Reilly) was used for pediatric age group less than 5 years cases. Based on GCS, TBI cases were graded as mild (13-15), moderate (9-12) and severe (<8). Glasgow Outcome Scale (GOS, Teasdale G et al.) was used to know the final outcome.
Glasgow Outcome Scale
(Teasdale G, Jennett B: Assessment of coma and impaired consciousness. Lancet 1974; 1:81-83) Glasgow.
To study final outcome, detailed assessment was done and recorded after 6 months from the date of injury.
Follow-up: Initially at weekly interval for first 2 weeks then 4 weekly for next 3 months and then 3 monthly or as per need. Clinical evaluations were recorded.
Data Analysis - Compiled data was collated and analyzed using Microsoft Excel and Epi info (CDC Atlanta and WHO software for statistical analysis). Data is presented in proportion and mean values. Differences between the two proportions were analyzed using Chi Square test with significant level which was set at <5% error.
At the end of the study all the data were analyzed/interpreted to derive all the important variables and their effect on the final outcome of the head injury cases in our hospital. These variables were presented by the descriptive statistical methods e.g. pie and in proportions. GCS scores were analyzed with GOS. Clinical status and outcome was also assessed. Outcome was measured by GOS scoring and comparison of the Good outcome (GOS-4 and 5) were compared with the GOS-1 (Dead) cases. Five cases of bad outcome (GOS-2 and 3) were excluded because of small sample size.
All the demographic and other variables were computed in relation to outcome. For two proportions, chi-square test was used to find out differences. It was statistically significant only when an error is <5%.
All these variables which were significant in univariate analysis were put in unconditional logistic stepwise regression procedure to study the effect on outcome. Odds ratios were estimated from the P coefficients obtained with respective 95% confidence intervals (95% CI).
| Results|| |
The total numbers of patients of head injury admitted in neurosurgery department of Dr. Ram Manohar Lohia hospital during 2007-2008 were 796. The age of patients varied from 1 month to 92 years. In this study 45 cases of TBI were infants. The majority (34%) cases were of age up to 10 years; second highest (22%) were in age group 21-30 years followed by 14% cases of 30-40 years and 11% cases of 11-20 years respectively with P value <0.05. Younger the age of patient, better is the recovery [Figure 1]. Overall outcome was analyzed with Glasgow outcome scale (GOS) after 6 months of initial injury. Outcome was divide into 3 major groups for analysis that is group1/dead patients (GOS-1), group 2/Good outcome (GOS-4 and 5) and group 3/bad outcome (GOS-2 and 3).
|Figure 1: Number of patients admitted to hospital by age group and their outcome|
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Since number of patients (n = 5) with bad outcome/group 3 was very low, they all were excluded from the final analysis. Therefore total effective number of cases remained was 791 and finally these two groups (group 1 and group 2) were analyzed to look for meaningful correlation between various factors related to injury and the final outcome seen at 6 months of injury.
There were 569 (72%) males and 222 (28%) females with average age of 24 years. Majority (63%) cases were unmarried. As per literacy status of patients were 45% illiterate, 43% with school education and 12% were graduate and above.
Most of the patients were from poor socio-economic strata (57%). Urban population accounted for (78%) in this study [Table 1]. The patients were brought to hospital mainly by known to person or reached on their own (92%) and only few (7%) cases were accompanied by police man. Most of injury occurred while at home and were accidental. Predominant mode of TBI was fall from height (56%) and mostly seen in pediatric cases at home. Majority (96%) cases were accidental TBI cases. There were only 4% cases of assault related TBI. History of alcohol consumption was noted in 8% cases [Table 2], [Figure 2].
|Figure 2: Number of patients admitted by selected mode of injury, injury locale and their outcome|
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In case of road traffic injury significant number of two wheeler users (40%) and pedestrians (37%) were hit by some motorized vehicle on the road. Eighty six percent RTI were seen on city roads. Data not mention in table.
First aid was provided by trained person (doctors/paramedics) in 60% cases only and in rest 40% cases first aid was provided by general public/police man without any formal training to attend trauma cases.
Ambulance could reach the injured person in time only in 25% cases, in rest they used private vehicle and only 62% cases reached our hospital within 6 hours of sustaining injury. Only 16% cases reached after 24 hours of injury, among these mostly were from either from outside Delhi region or who were initially admitted in some small private hospitals [Table 3].
The event following the injury included episode of loss of consciousness (LOC) in 77% cases, vomiting in 55% cases and seizure following injury in 8% cases. On examination 14% cases had abnormal pupillary response, 10% had abnormal motor power, 17% had abnormal plantar response and cranial nerve examination was not normal in 22% cases. Findings like nose bleed, ear bleed, Raccoons eye sign, Battles sign and CSF leak of injured cases are depicted in bar diagram. [Figure 3] Of the patient who required resuscitation (6% of total admission) on reaching the hospital, among these 60% cases expired. On the basis of GCS score cases were characterized mild, moderate and severe grade in 63%, 22%, and 15% cases respectively. Among severe grade of TBI cases 73.5% cases died (P value < 0.05) [Figure 4].
|Figure 3: Number of patients admitted with clinical details and their outcome|
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|Figure 4: GCS score of patients at the time of admission and their outcome|
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Majority (66%) cases of TBI showed some form of local injury on head and neck region.
In suspected polytrauma cases, radiological evaluation of other body parts were also done and evidence of injury was noted in 11% cases out of which 2% cases survived. On CT scan head 67% cases revealed abnormal findings; however most of these patients were given conservative treatment and only11% cases were operated. In 14% cases craniectomy along with duraplasty was done and bone pieces were put in subcutaneous space of lower abdomen, which was later repositioned depending on further response. Majority (43%) cases had duration of hospital stay between 2-7 days. Thirty seven percent cases were discharged same day with necessary advice of follow up within 2 days of injury as they had milder grades TBI. Complications like bed sore, meningitis etc were noted in 14% cases of TBI [Table 4].
As per univariate analysis many variables like age of patient, place of residence (urban/rural), person who brought the patient to hospital, place of injury, mode of injury, provision of first aid by trained personal, distance covered by patients to reach hospital, mode of patient transportation, presence of unconsciousness, history of LOC/vomiting/seizure, on examination-abnormal pupillary reflex/motor power/plantar reflex/cranial nerve dysfunction/ear bleed/raccoons eye sign, requirement of resuscitation, severity of TBI as per GCS, presence of local injury on head and face, evidence TBI on CT scan, other body parts radiological positive injuries and complications all were significantly related with outcome (P < 0.05).
Multivariate logistic regression analysis for various factors were done for the entire variables (having P value of <0.05 on univariate analysis) with dependent variables as good and bad outcome. Significant association was noted with radiological injuries of other body parts, GCS, abnormal planter response, abnormal pupillary response and cranial nerve dysfunction (P value < 0.05) [Table 5].
|Table 5: Logistic regression analysis of factors associated with bad outcome in TBI cases|
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| Discussion|| |
Similar to various other studies majority of our patients were males. No correlation was observed between the sex of patient and final outcome (P value > 0.05).
As per analysis sex distribution did not have any specific impact on outcome of TBI patients but it is important to note that majority of TBI affected population were male. TBI continues to be a nightmare for both the public as well as for the neurosurgeons due to associated high morbidity and mortality. It is also associated with significant socioeconomic losses in developing countries including India. , Road traffic injuries is an increasing health problem globally and especially in South-East Asia.  In India, the incidence is basically reported from metropolis and are based on medico legal reports which may not be absolutely correct. ,,
This study is a retrospective and prospective analysis of small number of patients seen in our institute.
Highest incidence of TBI has been reported in the age group of 2-10 years by most of the authors.  Whereas others have reported that 69% cases were in age group of 15-35 years. 
In a study from central India reported mean age of TBI cases were 32-64 years. 
In our study the age of the patients varied from 1 month to 92 years. Out of which 64% patients were found to be adults and age above 12 years, followed by 36% in pediatric age group (<12 years). Mean age noted was 24.57.
As per present study, analysis indicates all univariate factors like age of patient, place of residence (urban/rural), person who brought the patient to hospital, place of injury, mode of injury, provision of first aid by trained personal, distance covered by patients to reach hospital, mode of patient transportation, presence of unconsciousness, history of LOC/vomiting/seizure, on examination-abnormal pupillary reflex/motor power/plantar reflex/cranial nerve dysfunction/ear bleed/raccoons eye sign, requirement of resuscitation, severity of TBI as per GCS, presence of local injury on head and face, evidence TBI on CT scan, radiologically positive injuries on other body parts and complications were found to be significant (P value < 0.05).
The IMPACT study has concluded that outcome in TBI cases are dependent on age  , but in our study outcome remained to be closely related with the impact of primary injury as shown by the initial GCS.
Male:Female ratio was 2.56:1. Similar observation of male predominance was noted by many other authors also. , The probable reason may be that the male population move out of their home more frequently for work. No correlation of sex with treatment outcome is noted in present study (P value > 0.05).Our observation corresponds with those made by other studies. The reason is that the mobility of male population is higher than their female counter part and they are exposed to more accidental risk factors at various places. 45% cases were either preschool group or illiterate and 44% cases were from school going age group (P value was > 0.05).
Forty four percent cases were married patients and it was seen that there was no correlation with marital status and the outcome (P value was > 0.05).
Ninety two percent cases were of poor and lower middle class (P value > 0.05). Though it does not show any impact on outcome but it is clear that they are not able to afford safe housing and transportation which make them more prone to various types of injury including TBI.
Gabela B, et al., used a state surveillance system to identify cases of TBI.  The study showed higher rates of severe TBI in rural as compared to urban areas. In our study predominant (78%) cases were from the urban areas and rest 22% cases were from rural background. Densely populated urban areas out number TBI cases compared with rural background due to better facilities for basic amenities like jobs, educational institutes and better residential facilities etc.
Urban population has higher mobility hence increased risk for RTI and other work related injuries. People who live in substandard living conditions in slums and unauthorized/illegal housing, lacking safety features which put pediatric population at risk of fall related TBI.
We received 14% cases from outside Delhi region, mostly from rural areas. Development of trauma services is a challenge in rural areas. The number and distribution of these facilities are not proportionate to the injured patient. 
Majority (92%) cases were brought to the hospital by some known to person or reached on their own. Police brought 7% cases and these were mainly RTI or assault cases. About 1 % cases were brought by people who were present at the spot of injury (P value < 0.05). Timely arrival in hospital helps in providing prompt management and good outcome.
On analysis of places where injury occurred we noted that majority of cases were at home (51%), predominantly involving fall related injury in pediatric population, followed by RTI cases (P value < 0.05). It showed positive correlation with outcome. Mortality was lower at home in comparison to TBI on roads.
Based on analysis of intention behind injury only 4% cases were assault cases and rest (96%) were accidental injuries. Every injury due to assault remains under reported in our setup due to legal hurdles.
Eight percent cases of TBI had consumed alcohol before sustaining the injury (P value > 0.05) as it hampers patient's reflex while on road making them prone to accidents. Most studies noted that most common cause of injury was motor vehicular accidents followed by fall from height and assault cases. But in children fall is the most frequent cause of TBI. It stresses the need of preventive aspect to be dealt properly by the parents/ family members whereas in adult falls are more commonly noted in association with alcohol consumption. ,
As per cause of injury we noted significant relation with outcome (P value < 0.05). Most common mode of injury was RTI and fall. Injuries other than RTI and fall showed good outcome as they have different mechanism of action.
Place of RTI was significant with P value 0.004. Highway contributed only 5% of cases and outcome was good in 90% of cases. May be it is because that city roads have more mixed variety of traffic and total length of highway is less in comparison to city roads in Delhi. Also there are other hospitals near the highways where other TBI patients might have been taken for treatment.
RTI constituted 36% cases of head injury. Maximum cases of RTI (85%) were from city roads. Major factors responsible for these accidents were poor maintenance of roads, poor lighting, mixed traffic population and dense vehicle population. Alcohol related injuries have increased recently due to lack of implication of safety rules and very low prosecution rates of such cases.
Sixty-one percent cases were given first aid treatment among this 60% care provider were trained persons. Majority (61%) cases reached hospital within 3 hours of injury.
Only 25% cases used ambulances to reach the hospital. Next popular mode of transportation was the auto rickshaw in 35% cases, which may be due to its cheap fare system, widespread availability and easy maneuverability in busy/congested city roads. All had P value < 0.05.
Pre-hospital care is very necessary for the stabilization of trauma cases in term of adequate airway protection, prevention of excess blood loss and subsequent trauma during transportation to proper hospital setup for definitive care. There is need to create awareness among public regarding how to provide initial care to a trauma patient and need of well trained paramedics on ambulances placed at various strategic location in the city for swift action.
Mock et al., (2003)  concluded in their study that good outcome is seen, if a victim of trauma receives proper life saving care within a few minutes of injury.
In 1978 it was suggested that the GCS be used to assess the seriousness of head injury. A total GSC score of 8 or less for 6 hours be used to set the boundaries of patient study groups and that the GCS be used as the initial end point at a specified time from injury for measuring morbidity and mortality. 
In the present study good outcome was noted in 97% mild, 93% moderate and 50% cases of severe grades of TBI. Therefore it becomes clear that there is a progressive decrease in good outcome as severity of TBI increases based on GCS.
On CT scan, brain contusion and subdural hematoma (SDH) was noted in 26% cases, contusion and SDH in 15% cases, Skull fracture in 13% cases, brain contusion in 10% and pneumocephalous in 3% cases of TBI.
Among CT positive cases 94% abnormality/lesion was not sizeable.
For any hospital with neurosurgeons, CT scan is an important diagnostic tool in planning the management, which dramatically improves outcome of head injury patients.
In present study, overall 89% cases were managed conservatively and rest 11% cases were managed surgically. The decision to operate depends on various factors mainly the patient's neurological status, imaging findings and extent of extra cranial injury.
About one third of patients who sustain severe head injuries are candidates for craniotomy. Hence majority of patients are managed by conservative means, usually directed at reducing intra cranial pressure. Bhole Anil M et al.,  in their study managed 81% cases conservatively and only 19% cases required surgical intervention mainly for significant intracranial hematomas and compound fractures.
In the present study, 89% cases had good outcome. Out of all 90 (11%) operated cases life of 17 (18.89%) cases could not be saved. Bhole Anil M et al.,  based on GOS at 6 months reported improved outcome in 87% cases and mortality was mainly from severe head injuries. However severe brain injury is major predictor of unfavorable outcome in patient with multiple injuries.
In our study majority of cases 708 (89%) showed good outcome (GOS-4&5) 1% cases had bad outcome (GOS-2&3) and 83 (10%) cases expired (GOS-I).
Complications (P value < 0.01), was more common in patients who expired. So various types of complications directly affects the outcome.
As per duration of hospital stay we found that 40% of total deaths occurred within 48 hours of injury and other 37% deaths were reported between 2-7 days. So first 48 hours are very crucial for TBI cases and majority of severe TBI cases die during this period. Later due to various complications next significant period is 1 week.
On logistic regression analysis for various factors with dependent outcome only one factor that is radiological injury to other body parts was significant. This indicates that other factors affect the outcome in a combined way rather than individually.
Predicting outcome in patients of severe TBI is a challenging task and generates abundant controversy. Apart from clinical parameters at the time of admission, it requires frequent revisits and clinical re-assessment to know about the early deterioration and prompt action with multimodality approach.
TBI is possible through environmental improvements and legislative changes. TBI is a significant public health problem worldwide and requires appropriate attention from researchers and policy makers regionally through the development of ongoing surveillance programs and the implementation of effective evidence-based interventions.
TBI in children and adolescents is a problem of enormous magnitude and because of improving survival rate, these people later face physical disabilities as well as neurobehavioral problems.
In India injury patterns/modes are different from the developed nations. We are in a fast transient phase of development with a wide gap between large poor population and rich people. The present health infrastructure is not able to meet the demand of common people, further aggravated with the ever expanding slum population in urban areas. Prevention of Prevention and care of injury is a multidisciplinary area and requires inter-sectoral coordination for planning.
Prompt treatment of head injuries involves immediate GCS, radiological evaluation, surgical intervention and intensive care in all appropriate cases, as the first few minutes are crucial for the final outcome. Surgeons should follow the general management plan - Resuscitation, Review and then Repair. The Advanced Trauma Life Support (ATLS) guidelines should be adhered to, while treating all cases of suspected head injury.
By improving our system with better reporting and documentation of cases, we will be able to make a better plan to decrease the incidence of TBI and their timely appropriate multimodality approaches to achieve better outcome of these cases within our limited resources.
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Department of Neurosurgery, Post Graduate Institute of Medical Education and Research and Dr. Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]