Traumatic brain injury is the most important cause of death following multiple traumas. In many instances, severe damage to the brain was found to be the leading cause of early departure or fatality in the first week after a traumatic experience.9 The increasing incidence of traumatic brain injury is associated with several factors such as motor vehicle-related injuries, falls, and assaults, which are mostly comprised of gunshot wounds to the head and neck region. It has been well established that the leading cause of brain injury is motor vehicle-related injuries. The most severe manifestations of brain injury are often seen in road traffic accidents.10 The conventional classification of TBI is based on the mechanism of injury, severity, and structural damage. Similar to our study, clinical severity in TBI is assessed universally by the Glasgow coma score. Lastly, neuroimaging is a convenient tool for evaluating structural damage.11
TBI is broadly classified into primary and secondary types. Primary Injury occurs at the time of external impact brain and results in a concussion, contusion, laceration, or diffuse axonal injury. Secondary Injury takes place hours to days after the initial insult. It is comprised of complications due to primary injury such as systemic hypotension, hypoxia, or an increase in intracranial pressure leading to cerebral edema. A series of cellular and biochemical reactions resulting in mitochondrial damage, and cell death and necrosis form the basis of secondary injury.12,13 Importantly, hypotension and hypoxia fall under the most acute and easily treatable mechanisms of secondary injury.14 Hence, early preventive measures and treatment strategies are important in stabilizing the patient, so that secondary injury can be prevented. The current study found a mild TBI in 93.6% of patients with a GCS of 13-15. Moreover, 67.2% of these patients were discharged just after first-aid management.
The statistics concerning TBI from low and middle-income countries are scarce. The epidemiology of TBI across various regions and socioeconomic divides was shown in a study by Dewan et al. in which the authors established a comprehensive relationship between RTA and TBI. Approximately 69 million cases of TBI emerge each year globally with the highest incidence in America and Canada, with a proportion of 29% of RTA that resulted in TBI compared to 34 % in Southeast Asia and the pacific, reflecting a more significant overall burden in this region.15 This is on par with our data showing 38.8% of TBI were due to RTA. These findings are maybe attributable to the association between traffic regulations and the incidence of RTA across the globe.16 Moreover, the scarcity of sidewalks, traffic lights, and safety measures by pedestrians and cyclists contribute to TBI following RTA. An increasing level of motor vehicles in our country is proportional to RTA-associated deaths. Additionally, the use of helmets and seatbelts is not common in Pakistan.17 In contrast, falls are a more frequent cause of TBI in the elderly and children.18
Although the region-specific data from Asia is limited, the global burden of disease (GBD) study provides some insight into TBI-related outcomes in India, China, and other Asian regions. Our research also shows that falls are the second most common cause of TBI. Compared to the other areas in GBD where RTA contributes to a majority of the TBI cases, falls are a leading cause of TBI in Asia whereas individual country data shows that RTA is the leading cause of TBI in India and China accounting for approximately 45-60 % and 61 % cases respectively.19 These results are consistent with our study. Despite the lack of literature on the epidemiology of TBI in Pakistan, Raja et al. conducted a survey in Pakistan to determine the demographics of head and spinal injuries from public sector hospitals. The annual incidence of TBI in Pakistan was estimated to be 50/100,000 of the total population. The study also addressed RTA as the most prevalent cause of TBI.20
Our study result shows that the majority of the patients were males (73%) and were found to be in the first decade of life. Falls are the leading cause of TBI in this age group, particularly in children aged less than five years just like Saher M et al. reported. This could be a result of parental negligence.17,21,22 A meta-analysis by Nguyen et al. also showed a higher incidence rate of TBI in males and for combined adolescents and adults.6 This trend could be a result of young adults and males, in particular, engaging in more risky and impulsive behavior such as reckless driving.23 Likewise, a compilation of Retrospective and prospective studies on the epidemiology of TBI in Europe reported a mean age of 26.7.24 Similarly, the mean age calculated in our study was 25.9. A vast literature provides evidence that there was always a male predominance irrespective of age, severity, and mechanism of injury.10,12,18
Regarding hospital admissions surveys by the National Institutes of Health Consensus Development Panel on Rehabilitation of Persons with TBI show that TBI represents 15.1% of all hospital admissions in the USA.25 In contrast, this study reveals that only 9.9% of patients were admitted, whereas a vast majority of them were discharged. People with low income tend to underreport; this could be a possible explanation for the low hospitalization frequency among people who encounter head injury given the socioeconomic status of the majority of the population in our country.26 Likewise, a retrospective study of patients with TBI presenting to hospitals in California demonstrated that the majority of these patients (78.9%) were discharged. This is in accordance with our results and highlights that most of the cases of TBI are mild and hence, do not require hospitalization.27
The literature search showed that mild TBI (MTBI) is more prevalent than moderate or severe. A systematic review by the world health organization showed that 70-90% of all treated brain injuries are mild. Moreover, adolescents in the age group of 16–20 years have a higher frequency of MTBI compared to other age groups. This again could be due to a more active and carefree attitude amongst them. Patients presenting with MTBI are usually not admitted to hospitals; therefore, such cases are likely to be overlooked. These results were similar to our study. Such patients can present with chronic symptoms later in life. Moreover, there is a high probability of MTBI being under-diagnosed. As such, the need to call for better interventions by physicians plays an integral part in preventing long-lasting symptoms in these patients.6,28–30
There are several limitations in our study that need to be considered. Firstly, this was a single-center study with a small number of patients; hence, it does not cover TBI-related incidents in other centers. Similarly, factors such as the mechanism of injury, rural vs. urban incidence, and occupation of patients were not taken into account. Moreover, we did not follow the patients until the end and assess their outcome. Secondly, we believe there may be that MTIB may have been underestimated or overlooked. Lastly, minor discrepancies in the definitions of TBI used by various researchers and conflicting severity scores may have influenced our results.