Demographic Profile, Clinical Features, Imaging, and Outcomes in Patients with Traumatic Brain Injury Presenting in Garhwal Himalayas in Tertiary Care Hospital

Abstract Introduction  Traumatic brain injury (TBI) poses a significant global health challenge, accounting for over 50% of trauma-related deaths and emerging as a leading cause of mortality and disability. Objective  This article studies the demographic characteristics, clinical features, imaging findings, and outcomes of TBI patients. Materials and Methods  This was a retrospective observational study conducted on 490 patients with TBI. Data regarding age, gender, socioeconomic status, and residential location were extracted from medical records. Neuroimaging reports, including computed tomography (CT) scans results, were analyzed for structural and functional insights. Results  The majority of TBI cases involved individuals aged 21 to 40, with a higher incidence in males. Road traffic accidents were identified as the most common mode of injury, followed by falls. Most of the patients had moderate Glasgow Coma Scale scores at admission. CT scans indicated skull fractures, cerebral edema, and subdural hematomas as common findings. Most patients did not require ventilator support, and the majority had a hospital stay of less than 10 days. At discharge, 89.8% exhibited favorable outcomes, while 4.3% experienced mortality during treatment. Follow-up data demonstrated an overall mortality rate of 8.8%, with 89.2% achieving complete recovery within a month. Conclusion  The study underscores the importance of understanding the multifaceted aspects of TBI, emphasizing the need for integrated approaches in tertiary medical care to optimize patient outcomes and contribute to effective public health strategies.


Introduction
Traumatic brain injury (TBI) is a pervasive clinical issue that places a substantial financial burden on health care resources. 1More than 50% of trauma-related deaths result from head trauma, making it a major public health problem worldwide.Predictions indicate TBI is expected to surpass many diseases as a leading cause of death and disability. 2,3n India alone, an alarming 1.5 to 2 million individuals sustain injuries annually, with over a million succumbing to death.Road traffic accidents (RTAs) are the predominant cause of TBIs, accounting for 60% of cases, followed by falls (20-25%) and violence (10%).Alcohol involvement is identified as a confounding factor in 15 to 20% of TBI cases at the time of injury. 4,5BI is not only a significant health concern but also results in substantial socioeconomic losses in India and other developing nations.The majority of TBI cases (60%) are attributed to road traffic injuries, underscoring the urgent need for comprehensive strategies to address road safety. 5emographically, TBI exhibits a diverse profile influenced by age, gender, socioeconomic factors, and geographical location.Considering the demographic shift toward an aging population, it is anticipated that specific population patterns will emerge.These may include a rise in the incidence of TBIs resulting from falls among the elderly.Additionally, within the TBI patient demographic, an upward trend is expected in the utilization of antiplatelet and anticoagulation medications. 6imilarly, TBI presents a diverse range of clinical manifestations, from mild concussions to severe injuries, necessitating thorough evaluation of symptoms, neurological deficits, and comorbidities.Imaging techniques, including computed tomography (CT) scans and magnetic resonance imaging, are crucial for diagnosis and ongoing management, offering insights into structural and functional changes.Patient outcomes, spanning short-term recovery to long-term quality of life, require identification of predictive factors to tailor rehabilitation strategies.This concise overview highlights the multidimensional aspects of TBI, emphasizing the need for an integrated approach in tertiary medical care.

Objective
The objective is to analyze the demographic characteristics, clinical features, imaging findings, and outcomes of patients with TBI presenting in Garhwal Himalayas at a tertiary care hospital.

Material and Methods
Study design: This study employed a combined retrospective and prospective observational design to analyze demographic profiles, clinical features, imaging findings, and outcomes in patients with TBI presenting in Garhwal Himalayas at a tertiary care hospital.
Study setting: The study was conducted at Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India renowned for its specialized neurotrauma services.
Study period: The study was conducted between September 2022 and August 2023.
Sample size and sampling method: The study included a total of 490 patients diagnosed with TBI who presented to the emergency department of Shri Guru Ram Rai Institute of Medical and Health Sciences.The sample size was determined based on a systematic random sampling approach, ensuring a representative selection of cases during the specified timeframe.

Inclusion Criteria
1. Patients of all ages presenting to the emergency department with a confirmed diagnosis of TBI. 2. Cases with complete demographic, clinical, and imaging data available for analysis.

Exclusion Criteria
1. Patients with incomplete or insufficient medical records.
2. Individuals with preexisting neurological conditions affecting the interpretation of TBI outcomes.

Data Collection
Demographic characteristics: Data on age, gender, socioeconomic status, and residential location were extracted from medical records.Clinical features: Clinical manifestations, mode of injury, and comorbidities were documented.
Glasgow Coma Scale (GCS) score was noted at time of admission of patient.
Imaging findings: Neuroimaging reports, including CT scans results, were analyzed for structural and functional insights.
Outcomes: Short-term recovery, long-term functional status, and quality of life outcomes were assessed using standardized outcome measures.Glasgow Outcome Scale (GOS) is used to measure outcome.
Statistical analysis: Descriptive statistics were used to summarize demographic characteristics, clinical features, and imaging findings.Data analysis was performed using statistical software.

Results
A total of 490 patients with TBI were included in the study.Majority of the patients were in the age group of 21 to 40 years (30%).Males were more inflicted with TBI as compared with females.Majority of the participants did not have past history of any other disease and 70% of them did not have history of alcohol intake (►Table 1).
On investigating the mode of injury in patients presenting with TBI, RTAs were found to be the most common mode of injury followed by fall.Other modes of injury included getting hit be heavy objects or physical assault.The most common presenting symptom was vomiting followed by bleeding from any site like nose, ear, or oral bleed.Central nervous system (CNS) symptoms like seizures or weakness in upper or lower limbs were observed in 63 patients at the time of presentation to the hospital (►Table 2).
At the time of presentation, maximum number of patients had moderate GCS score, that is, between 9 and 12. CTscan was done for all the 490 study participants.On CT, the most common finding was fracture of the skull bones (64.5%) followed by cerebral edema (26.9%) and subdural hemorrhage/hematoma (23.9%).Extradural hemorrhage/ hematoma was observed only in 1.4% patients (►Fig.1, ►Table 3).
In the present study, 311 patients (63.5%) were managed conservatively while 179 patients (36.5) were managed by surgery either with burr hole surgery, craniotomy, or decompressive craniectomy.Majority of our patients (79.6%) did not require any ventilator support during their stay in the hospital.Most of the patients stayed in the hospital for < 10 days (87.6%) with a median stay of 5 days.At the time of discharge, majority of the patients were conscious and active with GOS score of favorable outcome (89.8%), while 21 patients (4.3%) had mortality during the treatment.Among the patients with severe TBI, the mortality rate was 9% and only 67.1% patients had good recovery (►Table 4).
Note that 456 patients with TBI who were discharged were followed up till 1 month after discharge from the hospital.Seventeen patients were lost to follow-up during the study.Of the remaining patients, 407 patients (92.7%) had complete recovery, 7 patients (1.6%) had partial recovery, 2 patients (0.5%) were readmitted, and 2 patients (0.5%) had no recovery.Of the total patients who were followed up, 22 patients (5%) had mortality during the follow up period.Hence, the overall mortality rate in our study was 8.8%.

Discussion
Our study comprised 490 TBI patients, predominantly aged 21 to 40, with a higher incidence observed in males compared with females (3.1:1).Whereas in the study conducted by Sachan et al 7 most of the patients affected were in the range of 21 to 30 years with a sex ratio of 2.2:1.
In our study, among TBI patients, RTAs (43.9%) were the most common mode of injury, followed by falls (40.6%) and other causes like being hit by heavy objects or physical assault.Whereas in a study conducted by Chaitanya et al, 8 RTA (40.8%) was the most common mode of injury followed by fall from height (30.2%) and slippage in and around home (26.4%).
The prevalent presenting symptoms were vomiting, bleeding from various sites, and CNS symptoms such as seizures or limb weakness in 63 patients upon hospital presentation.
In our study, at the time of presentation, maximum number of patients had moderate GCS score, that is, between 9 and 12. CT scan was done for all the 490 study participants.In the study by Sachan et al, 7 most patients (49.10) had a mild GCS score, 13 to 15.
Whereas in the study conducted by Sachan et al, 7 69.78% were treated conservatively and 30.22% underwent surgery.In another study conducted by Kirankumar et al, 9 79% were treated conservatively and only 21% were managed surgically.
The majority (79.6%) did not require ventilator support, and most stayed in the hospital for < 10 days (87.6%, median stay: 5 days).At discharge, the majority were conscious with favorable outcome (89.8%), and 4.3% experienced mortality during treatment.While in the study by Huijben et al 10 313 of 758 patients from 52 European centers (41%) received at least one high therapy intensity level (TIL) treatment with significant variation between centers (median odds ratio ¼ 2.26).Patients often transiently received high TIL therapies without escalation from lower tier treatments.Thirty-eight percent of patients with high TIL treatment had favorable outcomes (Glasgow Outcome Scale-Extended 5).

Fig. 1
Fig. 1 Glasgow Coma Scale (GCS) score at the time of presentation in patients presenting with traumatic brain injury (TBI).

Table 1
Baseline characteristics of patients presenting with TBI Abbreviations: CAD, coronary artery disease; TBI, traumatic brain injury.a Multiple response.

Table 2
Mode of injury and clinical presentation of patients with TBI Abbreviation: TBI, traumatic brain injury.a Multiple response.

Table 3
Findings in CT scan of patients presenting with TBI Abbreviations: CT, computed tomography; TBI, traumatic brain injury.a Multiple response.

Table 4
Course of patients with TBI during their hospital stay and status at the time of discharge Abbreviations: GOS, Glasgow Outcome Scale; LAMA, Leave Against Medical Advice; TBI, traumatic brain injury.a Multiple response.