Pediatric Traumatic Brain Injury in the Middle East and North Africa Region: A Systematic Review and Meta-Analysis to Assess Characteristics, Mechanisms, and Risk Factors

Abstract
 Pediatric traumatic brain injury (pTBI) represents a major cause of child injuries in the Middle East and North Africa (MENA) region. This review aims to assess pTBIs in the MENA region and reports their clinical severity and outcomes. A search was conducted using major electronic databases, including Medline/Ovid, PubMed, EMBASE, Web of Science, and SCOPUS. Abstracts were screened independently and in duplicate to detect original research. The objective and study findings for each article were recorded, along with the mechanism of pTBI, patient age and sex, injury assessment tool(s) used, and outcome. A total of 1345 articles were retrieved, of which 152 met the criteria for full-text review, and 32 were included in this review. Males predominantly suffered from pTBIs (78%). Motor vehicle accidents, followed by child abuse, were the leading causes of pTBI. Overall, 0.39% of cases were mild, 0.58% moderate, 16.25% severe, and 82.27% unclassified. The mortality rate was 13.11%. Most studies used the computed tomography scan, Glasgow Coma Scale, Abbreviated Injury Scale, and Injury Severity Score as investigation methods. This review reports on the alarming rate of child-abuse–related pTBI and offers further understanding of pTBI-associated risk factors and insight into the development of strategies to reduce their occurrence, as well as policies to promote child well-being.


Introduction
][3] Traumatic brain injury (TBI) is defined as damage to the brain after a head trauma (e.g., violent hit to the head, penetrating object to skull/brain tissues). 4hereas all age groups suffer adversely from TBIs, children are at an increased risk for TBI-related hospitalization, disability, and death because of their physiological and anatomical vulnerability and propensity to sustain major injuries. 1,2,4Children have relatively weaker necks and torsos compared to adults; thus, any minor force may result in a serious injury, especially if inflicted in the head region and affecting the brain at its early developmental stages. 5Besides, a child's developing brain is smaller and more pliable with higher water content compared to the adult brain, which might lead to greater vulnerability to injury and different patterns of child injuries.Children have softer skulls than adults, with a thinner layer of protective fluid making them more susceptible to damage from even minor impacts.Myelination, the process by which nerve fibers are coated with myelin to increase the speed of electrical impulses, is incomplete in a child's developing brain, which can affect the severity and long-term effects of pTBI. 6he global burden of TBI is growing substantially.Further evidence is shown in low-and middle-income countries (LMICs), which suffer 3 times more TBI incidences compared to high-income countries (HICs). 1,2he United States reported >145,000 annual cases of children and adolescents (ages 0-19) suffering from long-term cognitive, physical, and behavioral effects attributable to TBI. 7 In the Middle East region, the median TBI incidence rate per capita is *45 per 100,000 population, which is *3 times higher than that in HICs. 8According to the Global Burden of Disease Study 2016, there were 27 million new cases of TBI globally in 2016. 9BI severity classification ranges from mild, moderate to severe and incorporates several parameters, including the Glasgow Coma Scale (GCS), level of consciousness, anatomical injuries on computed tomography (CT) scan with the Abbreviated Injury Scale (AIS), International Classification of Diseases, or Marshall classification of structural imaging, and occurrence of post-traumatic amnesia. 3Acute TBI symptoms largely depend on TBI severity and include loss of consciousness or other neurological deficits, headache, and vomiting.Patients may be left with long-term physical, cognitive, or emotional impairments. 4The reported etiology of pTBI varies from road traffic injuries to sports injuries to violence and child abuse.The Eastern Mediterranean Region sustains-in addition to routine TBIs caused by falls, car crashes, sports, and work-related injuries-a series of violence-related injuries because of ongoing violence, wars, and regional conflicts.The region's long history of violence and wars has also taken its toll on the pediatric population.A retrospective review of the Joint Theater Trauma Registry revealed that between 2004 and 2012, a total of 647 children were treated for severe isolated TBIs at a combat support hospital in Iraq and Afghanistan, of which 51% underwent a craniotomy or a craniectomy. 10revious regional studies have examined the epidemiology of TBI in the Middle East and North African (MENA) region. 11,12These existing studies were limited in their scope and approach, focusing on a broad population, district, or TBI type. 11Incidence and distribution of pTBI by age, sex, and region in the Middle East remain understudied, with several gaps in basic, epidemiological, clinical, and translational TBI-related research.Research in the field of pTBI is crucial to provide awareness and inform policies for age-appropriate interventions to decrease pTBI rates and improve its long-term outcomes.This study aims to conduct a systematic review of the literature and a meta-analysis to assess the epidemiological patterns, common mechanisms, types, and clinical outcomes of pTBI in the MENA region.This meta-analysis will be the first to assess, across all study designs, the characteristics, mechanisms, severity, and clinical outcomes among the TBI pediatric population in the MENA region.

Methods
We prepared and reported the present study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Meta-analysis of Observational Studies in Epidemiology (MOOSE), and Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines.

Search strategy and information sources
A systematic research was conducted using the following databases: Medline by way of Ovid, PubMed, EMBASE, Web of Science (WOS), SCOPUS, Current Index to Nursing & Allied Health Literature (CINHAL), Cochrane, and Global Health Library (search protocol available in Supplementary Appendix SA).Studies were retrieved from the inception of databases until March 2022, with no restriction on language or publication type.Key index and MeSH/EMTREE terms to search for TBI included: ''Brain trauma''; ''Brain injuries;'' and ''Brain concussion.''Key terms for literature published from the MENA region included ''Middle East,'' ''Northern Africa,'' and a list of all Arabic-speaking countries.Our search was narrowed to the pediatric age group (<18 years), which we defined by terms such as ''child,'' ''infant,'' ''adolescent,'' ''pediatric,'' and several more.The complete search strategy used to generate the results is presented in the Supplementary Material.

Inclusion/exclusion criteria
Retrieved studies were eligible if they 1) investigated patients (outpatient or inpatient) with an admission diagnosis of pTBI confirmed by an attending physician and 2) were unpublished or published cross-sectional, case-control, prospective, retrospective, and clinical trial studies.Articles were excluded if they were abstractonly reports, case series, or conference lectures and if they recruited patients from outside the MENA region.
Studies investigating non-Arabic-speaking countries-such as Turkey, Iran, and Israel-were excluded.The decision to exclude non-Arabic-speaking countries was based on cultural and social differences among these Arabic and non-Arabic-speaking countries.The included Arabic-speaking countries are all governed by the regulations of the Council of the League of Arab States, which comprises 22 Arabicspeaking countries that share similar educational and medical programs.Therefore, it was assumed that the response to national health issues such as TBI would be homogenous among these countries.Moreover, the decision to use the same exclusion/inclusion criteria as our previous study published in the Journal of Neuroepidemiology was made to ensure the consistency and comparability of the results between the adult and pediatric TBI studies. 11Additionally, several studies have been conducted in the MENA region with a specific focus on Arab countries, supporting the rationale for the exclusion of non-Arabic-speaking countries.
Further, we excluded studies that did not characterize the mechanism of injury, such as motor vehicle crashes, falls, military, assault/violence, and sports.Two co-authors (S.A. and L.H.) independently screened the recruited titles and abstracts based on a pre-defined protocol.Discrepancies were resolved by a discussion with a third investigator (F.K.).

Data abstraction and analysis
Two co-authors (S.F. and B.D.) independently abstracted the study variables and key findings onto a customized data extraction sheet in Excel.Details abstracted from each article include title, author, publication year, country, source population, sample size, study objective, key findings, age groups, sex, outcome measures reported (incidence, prevalence, severity, mortality, case fatality, morbidity, disability, recovery status, etc.), anatomical location of the injury, mechanism of the injury, the abuser (if child abuse), injury classification (open, penetrating, blunt, etc.), severity (documented severity, GCS, Functional Independence Measurement [FIM], Disability Rating Scale [DRS], cerebral CT scan, Injury Severity Score [ISS], AIS score, and Revised Trauma Score), case ascertainment method, surgical intervention performed, complications (intracranial hemorrhage, infections, death, etc.), long-term outcomes, length of hospital stay, intensive care unit (ICU) admissions, rehabilitation, and costs.

Synthesis of the evidence
Because of the scarcity of available TBI studies in the MENA region, all existing TBI studies were included in this review.We carried out a descriptive summary of the findings (Table 1).Where appropriate, we calculated the mean or proportion of the variable of interest using the combined sample.We analyzed the quality of the selected articles using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology), which assesses 22 key items that should be present in the titles, abstracts, introductions, methodologies, results, and discussions of a cross-sectional survey or case-control and cohort observational studies.From this analysis, we obtained the STROBE results for each study, displayed in Table 2, where the articles that included 0-7 items were considered low quality, 8-14 items were intermediate quality, and 15-22 items were high quality.

Study appraisal
Meta-analysis.In this meta-analysis, summary estimates for mortality rates were generated using the meta-analysis approach.Sources of heterogeneity were explored using subgroup analyses.Subgroup analyses were considered according to the cause of injuries and country's income level.No transformations for prevalence rates were done.We used the random-effects model to report pooled prevalence rates.A random intercept model was used to account for heterogeneity.

Statistical analysis
To report pooled prevalence rates, a random-effects model was used in this meta-analysis.The random-effects variable in this meta-analysis is the variation in prevalence rates across studies.The fixed-effects included in the model were cause of injuries and the country's income level, which were used to explore sources of heterogeneity and conduct subgroup analyses.No interactions were considered, and a random intercept model was used.

Results
The search strategy resulted in 1345 references, of which 152 met the criteria for full-text review.Based on the eligibility criteria, 117 were excluded and the remaining 32 articles were used to review and synthesize findings (refer to PRISMA; Fig. 1). 8, Age istribution and hospital length of stay (day) of pediatric traumatic brain injury are shown in Figures 2 and 3.

Regional distribution
As reported in Table 3, studies were distributed across the MENA region, with most findings originating from Iraq for a total of six articles (two of which also included Afghanistan), followed by the United Arab Emirates (UAE) and Kingdom of Saudi Arabia (KSA), with four each.Qatar, Bahrain, and Oman presented three studies each, whereas two were respectively found for Syria, Jordan, and Tunisia.The remaining MENA countries reported one or no studies (Tables 2 and 3).

Sex distribution
Among the 21 articles that reported sex distribution in the pediatric population, most had a higher proportion of male TBI cases.The mean proportion of males was 71.3%, with the median proportion of males being 71.7%.Among the total sample size for studies included in the review, males predominantly suffered from TBIs and accounted for 75.0%(n = 2458) of cases (Fig. 4).In Lebanon, the age distribution of TBI victims revealed two peaks-young adults between 18 and 40 years and older adults ‡60 years of agewhere males constituted the majority of cases. 13aumatic brain injury mechanisms or external causes TBIs resulted from several mechanisms.Seven studies indicated multiple causes of TBI; falls were the leading cause in three studies, motor vehicle accidents (MVAs) in another three, and undefined in the last one. 2,8,11,14,18,37,4027]39 Three studies looked at recreational and sports activities (including camel racing), 22,41,43 and one study investigated metallic ceiling-fan injuries. 33tor vehicle accidents A total of 15 studies reported MVA-related TBI among children with clinical presentations ranging from mild to severe. 2,8,11,14,18,20,21,24,28,29,32,37,40,44Sex-based differences in incidence were observed; in one study, males represented 86% of cases. 4Many cases required surgical interventions, such as urgent surgical repair for acute brain herniation and craniotomies.Cerebrospinal fluid otorrhoea and endaural herniation were also repaired using a transcranial, transmastoid, or combined surgical approach.The percentage of TBI mortality attributable to MVAs ranged between 8% and 24%. 3,8One article reported 132 pTBI cases and found that only 2% used seatbelts in the vehicle whereas 13% and 0% wore helmets when riding motorcycles and bicycles, respectively. 294][5]39 In Oman, TBIs attributable to falls or MVAs were the most commonly recorded injuries among hospitalized children. 43MVAs were further indicated as the leading cause of TBIs in Qatar, accounting for 77.3% of cases among 15-to 18-year-old adolescents. 39In the same study, underutilization of seatbelts among young vehicle occupants was associated with higher morbidity and mortality, and seatbelt compliance was estimated to reduce severe injuries by 2-fold and mortalities by 4-fold. 39ild abuse and homicide Child abuse was the second-leading injury mechanism resulting in pTBI.Eight studies included abuse-related pTBI.[15][16][17]19,27,30,35,42 Assaults represented 0.4-1.4% of pTBI cases.3,5 Among most victims, the abuser was known to the child in 89% of cases and was a parent in 64% of cases.2,8 Fall-related pTBI was reported in two articles as a mechanism of child abuse and accounted for nearly 55% of pTBI causes in neglected children. 28,29 Abusive TBI wa also reported in two studies, commonly in children <9 months.30 In Saudi Arabia, abusive TBI was the most reported cause of pTBI, accounting for 61% of cases.35 Approximately two thirds of pTBI hospital admissions were   attributable to caregiver abuse, of which 40% were under intensive care.28 Low socioeconomic status (SES) was reported in 53% of cases in one article. 27 n two studies, most abused victims were boys (60% and 70%), 22,30 whereas another study found that most homicide victims were mainly girls (53% across all ages and 89% for adolescents 12-18 years).22 Two studies reported TBIs as severe.27,34 Mortality was an outcome in three studies, ranging from 5.4% to as high as 20%.0 TBI clinical presentations were, namely, contusion and skeletal fractures indicative of structural damage to be considered when diagnosing TBI, in addition to brain injuries and intracranial bleed.45 Tools used for TBI screening included x-rays, skeletal films, CT scans, and magnetic resonance images.Some of the complications associated with TBI were subdural hemorrhage, cerebral hemorrhage, retinal hemorrhage, evidence of bruises, skull fractures, localized scalp swelling, subgaleal hematoma, and coma.Surgical interventions were needed in many cases, as mentioned in two studies.23,[25][26][27]39 TBI clinical presentations were mainly penetrating in nature, and the majority were severe in type.42 Death was an outcome in four studies, with mortality rates of 11.3%, 22%, 23%, and 25.7%.3,12,26,42 Cause of death was mainly intracranial bleeding and cerebral parenchymal injury.10 Tools used for severity assessment were CT, AIS, ISS, and GCS.3,10,14,26,27,44 Many cases underwent surgical interventions, such as skeletal fixation, oral/facial operation, soft tissue repair, ocular operation, craniotomy, and decompressive craniectomy, and many children had an intracranial pressure monitor placed.

Recreational injuries
Two studies reported camel-related TBI, 22,41 and one reported recreational TBI, 43 with clinical presentation ranging from mild to severe TBI.Overall, 11% of patients with recreational-related injury and 1 patient (1%) with camel-related injury required a craniotomy.The mortality rate was 3% attributable to camel-related injury and 5% after recreational injury.Approximately 90% of recreational-related TBIs were associated with all-terrain vehicles.Tools used for TBI assessment were CT and AIS, in addition to the GCS. 20,21,25lls Fall-related TBIs were reportedly a mechanism in eight articles. 2,8,11,13,14,18,37,40In five articles, fall was the primary mechanism and a secondary cause in the remaining three articles. 2,3,5,39,43There were no studies exclusively based on falls, and the clinical presentations were unstated.TBI assessment tools included radiography CT scan, x-rays, ISS, AIS, GCS, and PTS. 2,3,5,28,29,393,44 The most commonly reported injuries were subdural hematomas and intracranial hemorrhage in eight studies each. 15,20,21,30,34,35,41,43Of all diagnosed injuries, contusions had the highest mean reported proportion, at 41.3% overall, and a median of 48.3.Table 4 shows the detailed distribution of diagnosed TBI characteristics across all 12 studies.Traumatic brain injury outcomes TBI outcomes were evaluated in terms of mortality, severity, and long-term outcomes.
Mortality.Mortality refers to the number of TBIrelated deaths within a population, and the case-fatality proportion quantifies the number of TBI patients who died because of a sustained brain injury.
Twenty studies reported on the pediatric death rate attributable to TBI-which varied widely across studies-ranging between 1.4% and 30%, yielding a grand total for the mortality rate of 16.3%.Leading causes included child abuse, MVAs, military injuries, and camel and other recreational injuries.In studies including multiple injury types, TBI was frequently reported as a leading cause of death.We report an overall pTBI pooled prevalence estimate of 12% (95% confidence interval [CI], 8-17; I 2 = 95%; p < 0.01; Fig. 5).Subgroup analyses by the mechanism of TBI indicated a high heterogeneity as well, with pooled estimates of 20% for war injuries, 10% for road crashes, and 13% related to abuse (Fig. 6).When subgroup analysis is stratified by country income, a wide variation is noted with pooled estimates of 6% (95% CI, 3-11) in HICs, 26% (95% CI, 16-37) in LMICs, and 27% (95% CI, 13-43) in upper-middle-income countries (UMICs; Fig. 7).For this subgroup (i.e., by country income), we did not have enough studies from low-income countries; therefore, only one estimate is reported.
Long-term outcomes.Eleven studies provided information on recovery and long-term outcomes among patients who survived. 17,18,20,21,24,30,31,33,34,38,42Five studies reported full recovery and return to baseline for the majority of patients. 20,21,33,34,42Three studies found severe disability in TBI pediatric patients (Glasgow Outcome Scale [GOS] = 3). 33,34,38Among these studies, Bahloul and colleagues found that whereas half of the patients (53%) had a good recovery, the other half sustained moderate severity and poor longterm outcomes, including epilepsy, motor weakness or paralysis, oculomotor problems, and sensorineural and language deficits, with few patients suffering from severe disability and coma. 21Hoz and colleagues reported moderate disability in 3.5% of cases (GOS = 4). 33Crankson reported neurological impairment in 9.3 of cases, including weakness, paralysis, cranial nerve palsies, and a vegetative state. 24One study found that the majority of TBI patients had a loss of urine and stool control (mean FIM = 2.7), on average, 9 months after TBI.Six studies reported observing patients in a vegetative state after the TBI. 20,21,24,33

Discussion
This meta-analysis is the first to gather literature across the Arab-speaking MENA region on pTBI and evaluate epidemiological trends, mechanisms, severity, sex distribution, and management.pTBI imposes a substantial human and economic burden on children, families, and healthcare systems.Accurate diagnosis and recognition of pTBI cases are critical for an accurate assessment of the true population burden.Though the knowledge surrounding the mechanisms and risk factors of pTBI is well established in many parts of the world, limited data exist in MENA countries.This review provides a deeper understanding of common risk factors and outcomes to gain perspective on the scope of the problem.Investigating the characteristics and extent of pTBIs among children will provide valuable insights for developing effective child injuryprevention strategies in the MENA region.
Our findings revealed an overall pediatric pTBI pooled prevalence estimate of 12%, which indicates a significant burden of TBI in children.However, the high heterogeneity observed (I 2 = 95%) suggests that prevalence varies significantly across studies, and additional factors may contribute to the observed variation.Subgroup analysis by the mechanism of TBI indicated that war injuries had the highest prevalence of TBI at 20%, followed by abuse-related TBIs (13%) and road crashes (10%).This finding highlights the importance of identifying the cause of TBI to better understand the risk factors and provide targeted prevention and treatment strategies.
When examining country income, our analysis revealed a wide variation in pooled estimates, with the lowest prevalence of TBI (6%) in HICs and the highest prevalence in LMICs (26%) and UMICs (27%).This result suggests that socioeconomic factors may play a role in the incidence of TBI, and more research is needed to investigate this association.
The most commonly reported causes of pTBI encountered in the literature include falls (50.2%), struck by or against objects (24.8%),MVA (6.8%), assault (2.9%), and others (15.3%). 3Causes vary by age, given that falls, assault (e.g., shaken baby syndrome), and physical abuse are frequently observed among infants, toddlers, and pre-schoolers. 38Velocity injuries (including motor vehicle or bicycle crashes) and sports injuries are more often reported in elementary school children and adolescents. 38Males, especially those ages 0-9, have been reported to have 1.4 times the risk of sustaining moderate or severe pTBI relative to females of the same age group.Females, however, have a higher reported incidence of mild pTBI. 36he data showed that TBI affected both young adults and older adults, with males being the majority of cases in Lebanon.Nonetheless, TBI mortality, rehabilitation, and systemic injury data are rarely reported, with only three studies indicating rates for mild cases. 13Abusive TBI was found to be the most common cause of pediatric TBI in Saudi Arabia, whereas falls and MVAs were the leading causes in Oman and Qatar.Seatbelt compliance was associated with reduced morbidity and mortality in Qatar.However, it is noted that data on TBI mortality, rehabilitation, and systemic injury are often not reported, highlighting the need for further research in this area.
The results of this systematic review also revealed sex-based differences in the distribution of pTBI cases overall and by injury mechanism.Across studies, pTBI cases were predominantly males (75%).MVAs were the most prevalent mechanism, with males representing 86% cases.In the nine studies that revealed violence and assault as the mechanisms of injury, many abuse victims were males.However, it is interesting to note that homicide victims were more commonly females (53%) than males (46%).Among the seven studies related to the military, there were 65-75% more male pediatric cases than females.The remaining studies did not indicate differences between sexes.Mechanisms of pTBI were also distinct across countries.The primary cause of pTBI will vary from caregiver abuse to fall injuries to motor vehicle crashes, and to military-related brain injuries, mostly prevalent in Iraq and Afghanistan. 10,25The higher number of military TBIs in these countries reflects the political unrest and enduring wars and conflicts they face.It is essential to understand each culture and the associated factors leading to TBI to implement interventions accordingly.Identifying the underlying causes could lead to significant improvements in TBI prevention, treatment, and continuum of care.However, causal mechanisms may exceed those indicated by research and should be further investigated.pTBI remains the most consequential pediatric injury in terms of severity and outcomes.There were significant differences in the proportion of cases reported among pTBI severity levels.Of the 32 studies compiled in this review, the vast majority reported severe pTBI (16.25%) compared to mild (0.39%) and moderate (0.58%) severity.Several studies indicated TBI as the most common cause of mortality and disability. 3,4,8ommonly reported disabilities were meningeal hemorrhage and brain contusion, with the latter occurring proportionately higher among adolescents and teenagers.Teenagers (10-14 years) also had a higher mean ISS; however, GCS findings varied among studies.Median ventilation support days, ICU, and hospital length of stay were significantly prolonged in several studies. 3,5,39he study examined the tools used for TBI diagnosis, which may assist in developing clinical practices.Considering the implemented procedures, a series of tools were adopted by emergency medical services personnel to assess the severity of TBIs and consciousness sustained by patients.These tools included GCS, CT scan, x-ray, and surgical interventions.Improving the health outcomes of children requires determining the best clinical practices and minimizing variances in care.Further, undertaking more implementationbased research can ensure that effective therapies are applied to improve clinical outcomes.
Implications and recommendations for future research and health professionals This review recommends specifying the severity of TBIs upon diagnosis, which would allow future studies to analyze the results and understand health outcomes relative to injury severity.Accurate and comprehensive data collection by emergency physicians, neurosurgeons, and nursing staff is essential to further understanding pTBI in the MENA region.Data should include demographics, injury patterns and mechanisms, site and location of the injury, date of injury, and the length of time between the incident and provision of care.Training medical staff to use CT imaging, assess TBI severity, and provide operative and non-operative management is also crucial to evaluating and treating TBI patients.In addition, comorbidities and long-term outcomes should be further investigated.
Existing literature revealed the non-standardized documentation of available TBI studies in the MENA region.Aligning with international standards for a standardized documentation process is recommended to facilitate comparisons and effectively assess prevalence.There is also a need for coordinated efforts between government and communities.A multidisciplinary approach to researching and implementing modern pTBI care is essential to prevention and management.Moreover, educating communities on pTBI, risk factors, and causes is a suitable method for raising awareness.

Limitations
There were several limitations to this review.The heterogeneity of the included studies was a barrier to applying a concise meta-analysis.Further, the number of articles per country should be normalized to the population size to reduce bias.It was also difficult to verify whether the existing selected samples were representative of the country's population.Having representative samples is essential to assimilate the true prevalence of TBI within a population.Sampling variations further made it challenging to estimate the incidence rate and outcomes; this stems from nonstandardized reporting and the absence of a universal system for reporting and classifying TBI cases.In addition, many of the included articles failed to mention multiple important variables, including the pTBI severity and SES of families and children.As a result, the reporting of results and analysis of pTBI consequences in the MENA region were affected.Other articles failed to mention the presented symptoms and complications associated with the pTBI.These two factors are highly essential given that they would alert the parents to escort their child to the emergency room for better management.

Conclusion
This study has shed light on the various mechanisms of pTBI in the MENA region.Moreover, it has revealed how pTBI manifests in several forms, ranging from mild alterations of consciousness to severe morbidity and death.TBI among children is a significant health problem that affects the anatomy and physiology of the brain.However, developing primary healthcare services can prevent severe complications and mortality.The future recommendations are to gain a further understanding of pBI risk factors.Such insight can guide the development of strategies to reduce pTBI occurrence and improve health outcomes for communities within the MENA region.

FIG. 1 .
FIG. 1. PRISMA flow diagram for pediatric TBI in the MENA region showing the selection process, number of documents screened, evaluated for eligibility, and included and reasons for exclusion after screening.CINAHL, Current Index to Nursing & Allied Health Literature; MENA, Middle East and North Africa; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; TBI, traumatic brain injury; WOS, Web of Science.

FIG. 2 .
FIG. 2. Age distribution of traumatic brain injuries (years) across different studies conducted in different countries within the MENA region.MENA, Middle East and North Africa.

FIG. 4 .
FIG. 4. Total sex distribution of pediatric traumatic brain injury cases across included studies within the MENA region (%).MENA, Middle East and North Africa.

FIG. 3 .
FIG. 3. Length of hospital stay distribution of pediatric traumatic brain injuries (day).

Table 1 .
Summary of Aims and Key Findings of Included Studies followed by falls (39%).The most frequent anatomical location of traffic-related injuries was the head, accounting for nearly 40% of injuries.The proportion of males with severe TBIs of AIS ‡3 was >4 times greater than the proportion of females (27% vs. 6%).116(continued)

Table 1 .
(Continued) UAE Mortality of pedestrian injured patients in the UAE is high.The lower limb was the most injured region, followed by the head.Severe TBI was the main cause of death.Al-Hajj et al.; Neurotrauma Reports 2023, 4.1 http://online.liebertpub.com/doi/10.1089/neur.2023.0007 most common injuries were to the head and extremities.TBI is the most common cause of morbidity and mortality.The risk factors associated with a high volume of motor vehicle injuries in children include males, 1-8 years, and pedestrians.This study suggests that nation-wide programs should target the use of seatbelts and helmets and dangerous driving practices.followed by the extremities.Male drivers and UAE nationals were at high risk of RTC as drivers and as motorcyclists.The ejection rate was high because safety restraint use was extremely low in our community.132 0-19 years KSA, Kingdom of Saudi Arabia; UAE, United Arab Emirates; TBI, traumatic brain injury; EDH, epidural hematoma; pTBI, pediatric traumatic brain injury; RTCs, road traffic collisions; FIM, Functional Independence Measurement; DRS, Disability Rating Scale; CT, computed tomography; MVCs, motor vehicle crashes; PTS, Pediatric Trauma Score; ISS, Injury Severity Score; PRISM, Paediatric Risk of Mortality; RR, risk ratio; CI, confidence interval.

Table 2 .
STROBE Analysis of the Studies

Table 3 .
Distribution of Studies per Country KSA, Kingdom of Saudi Arabia; UAE, United Arab Emirates; HIC, highincome country; LMIC, low-to middle-income country.

Table 4 .
Distribution of Studies by Diagnosed Injury Characteristics

Table 5 .
Distribution of Total TBI Cases by Mild, Moderate, Severe, or Unclassified Severity Across All Studies