Patients With Blunt Head Injury at High Risk for Serious Intracranial Injury

Older patients with traumatic blunt head injuries are at high risk for sustaining serious intracranial injury, even with low-risk mechanisms of injury, such as ground-level falls, according to study results published in Annals of Emergency Medicine.

Traumatic brain injuries (TBIs) are prevalent among older patients with trauma with this population accounting for 45%-58% of hospitalizations for TBI. TBI has a clear clinical impact in older patients, but there is limited data on its clinical effects.

Researchers conducted a secondary analysis between April 2006 and December 2015 to explore the clinical presentations and outcomes of older patients with blunt head injuries who visit the emergency department. Patients aged 65 and older who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study and underwent head computed tomography (CT) imaging were included in the study. Clinicians were asked to provide demographic data on each patient and radiologists were asked to review and record their interpretation of the CT imaging studies while blinded to the demographic data.

Patients were classified as either uninjured or having any intracranial injury, with those classified as the latter further categorized as either having a significant injury or no significant injury. The significant injury group was then further broken down into those who needed neurosurgical intervention or did not need neurosurgical intervention.

Primary outcomes of interest included mechanisms of falls, injuries, neurosurgical interventions, and outcomes among older patients. Data were analyzed using point measures and associated unadjusted confidence intervals.

Of the total 11,770 patients enrolled in the NEXUS validation study, 3659 (median age, 81; women, 51.9%; White, 77.5%) were aged 65 and older. Of these 3659 patients, 500 (13.7%) had evidence of injury on their CT imaging. Of those who had evidence of injury on their CT imaging, 325 (65%) had significant intracranial injuries, 177 (35.4%) needed interventions, and 81 died.

Compared with women, men in the older cohort were more likely to sustain any intracranial injury (39.8% vs 60.0%), significant injury (37.8% vs 62.2%), injury requiring intervention (35.2% vs 64.8%), or death (33.3% vs 66.7%), despite women outnumbering men.

All older patients would have been classified as high-risk due to age criteria; however, 77 (15.4%) of the injured patients exhibited no other NEXUS criteria, including 48 (14.8%) of the 325 patients with significant injuries and 20 (11.3%) patients who required intervention.

Subdural hematomas and subarachnoid hemorrhages were the most frequent types of injuries observed in the older cohort (337 lesions in 299 patients and 333 lesions in 256 patients, respectively). These injuries were present in 68.8% of those patients who died.

A ground-level fall was the most frequent mechanism by which patients presented with injury, occurring in 2211 of 3175 (69.6%) patients, including:

• 59.2% of those with any intracranial injury,
• 55.7% of those with significant injuries,
• 53.4% of those requiring intervention, and
• 45.7% of those who died due to their injuries.

Although a ground-level fall was the mechanism associated with the greatest number of deaths (45.7%; 37 of 81 patients), the associated mortality rate (2.1%; 95% CI, 1.2%-2.3%) was low vs those associated with falls from a ladder (11.8%; 95% CI, 3.3%-27.5%) and automobile-related events (10.7%; 95% CI, 6.2%-16.9%).

Among the 165 patients who required interventions for head injuries, only 27 (16.4%; 95% CI, 11.1%-22.9%) were able to return home, 53 required facility care (32.1%; 95% CI, 25.1%-39.8%), and 69 (41.8%; 95% CI, 34.2%-49.7%) died of the injury.

Study limitations included the limited generalizability of results to more focused settings and limited environments; potential practitioner variation as it pertains to clinical evaluations and assessments, as well as radiographic interpretations and patient management; the inclusion of neurosurgical intervention as a primary outcome; and the possible underestimation of injury prevalence.

“Cautious clinicians who feel compelled to identify all spine injuries, including injuries that require no intervention, should obtain CT spine imaging in conjunction with CT head imaging,” the researchers concluded.