Predicting Factors Associated with In-hospital Mortality in Traumatic Brain Injury

Abstract

Introduction

The accurate identification of predictors of mortality is of utmost importance in risk stratification, as it empowers health care teams to efficiently allocate resources and interventions to patients who are at a higher risk. Our objective was to investigate the factors linked to in-hospital mortality in patients who have suffered a traumatic brain injury (TBI).

Materials and Methods

This study employed a retrospective design, utilizing data from the National Trauma Registry of Iran spanning September 17, 2016, to July 31, 2022. The study included TBI patients admitted to participating hospitals with a hospital stay exceeding 24 hours, those who died during hospitalization, or those transferred from other facilities. TBI cases were identified using specific International Classification of Diseases, Tenth Revision codes. The study incorporated various variables, including baseline characteristics such as age (categorized into pediatric, adult, and geriatric groups), gender, trauma mechanism, and mode of transportation. Clinical characteristics considered included the Glasgow coma scale (GCS), injury severity score (ISS), types of injuries sustained, interventions performed, and vital signs. The primary outcome was mortality following hospital admission.

Results

The study included 874 patients, and the observed mortality rate was 12.2%. Road traffic crashes were identified as the leading cause of TBI, accounting for 72.5% of the cases. Utilizing multiple logistic regression analysis, the study confirmed that older age, severe GCS score, tracheostomy, and abnormal oxygen saturation were significant predictors of mortality.

Conclusion

The findings of this study demonstrate that older age, lower GCS scores (severe TBI), tracheostomy, and abnormal oxygen saturation are significant predictors of mortality in patients with TBI. These results emphasize the significance of incorporating age, neurological status, and respiratory function into the assessment of prognosis and mortality risk in TBI patients. By considering these factors, health care professionals can better evaluate the potential outcomes and allocate appropriate care for TBI patients.

Keywords

traumatic brain injury - in-hospital mortality - Trauma Registry - Prediction

Introduction

Traumatic brain injury (TBI) is a condition marked by impairments in cognitive or physical abilities due to head trauma, leading to substantial health and socioeconomic challenges. Often termed a silent epidemic, TBI is a major cause of death and disability worldwide particularly in low- and middle-income countries.[1] [2] It is estimated that each year, between 64 and 74 million individuals experience a TBI.[3] TBI stands out among various trauma forms due to its severe impact on mortality and disability, significantly contributing to the worldwide incidence of death and disability.[4] Moreover, TBI is associated with a marked reduction in life expectancy, as it increases mortality rates by 30 to 70% when compared with other types of injury.[5] [6]

In Iran, TBI stands as a prominent cause of both death and disability. The incidence rate of TBI in Iran ranges from 15.3 to 144 cases per 100,000 individuals. The mortality rate of TBI in Iran was 10.4%.[7] Over the years, due to the high mortality rate of TBI patients, extensive research has been conducted to identify the key factors contributing to in-hospital mortality in TBI patients. A longitudinal, retrospective study conducted by Pastor et al (2023) at the neurosurgery clinic identified clinical factors such as injury severity, low Glasgow coma scale (GCS), and polytrauma as predictive of early in-hospital mortality in patients with TBI.[8] Similarly, a cross-sectional study conducted by Ziaeirad et al (2018) revealed age, gender, GCS score, pupillary reflex, hypernatremia, and increased intracranial pressure as significant predictors of in-hospital mortality in severe TBI.[9]

This article aims to prospectively investigate the factors associated with in-hospital mortality for patients who sustained TBI. By gaining a comprehensive understanding of the factors that contribute to in-hospital mortality in TBI patients, health care providers can develop tailored interventions and optimize treatment plans. This knowledge enables early identification of high-risk patients, leading to efficient resource allocation and the implementation of preventive strategies. Consequently, not only patient outcomes can be improved but overall health care costs associated with TBI management can also be reduced.

Materials and Methods

Study Design

This registry-based study was conducted at the National Trauma Registry of Iran (NTRI) from September 17, 2016 to July 31, 2022.

Study Participants

All patients presenting to NTRI participating hospitals who stayed at the hospital for more than 24 hours, died in the hospital (including deaths in the emergency department), or were transferred from other hospitals, with a TBI diagnosis were potential participants. Among eligible participants, patients with abbreviated injury scale (AIS) scores of ≥3 for the head only and ≤1 for other body regions were included in the study. Patients with an AIS score more than 1 for anybody region other than the head and those with an AIS score less than 3 for the head were excluded.

International Classification of Diseases, Tenth Revision codes used to define TBI were as follows:

• S01.0-S01.9: the open wound of the head.

• S02.0, S02.1, S02.3, S02.7–S02.9: fracture of skull and facial bones.

• S04.0: injury to optic nerve and pathways.

• S06.0-S06.9: intracranial injury.

• S07.0, S07.1, S07.8, S07.9: crushing injury of head.

• S09.7–S09.9: unspecified injuries of head.

• T01.0, T02.0, T04.0, T06.0: injuries involving head and neck.

• T90.1, T90.2, T90.4, T90.5, T90.8, T90.9: sequelae of injuries of head.[10] [11]

Variables

Baseline Characteristics

Age was categorized into three groups (pediatric <18, adult 18-64, and geriatric ≥65).[12] Gender was registered as male or female. Trauma mechanism was grouped into road traffic crashes (RTC) or falls. The mode of transportation was ambulance or private vehicles.

Clinical Characteristics

The GCS classifies TBI as mild (14–15), moderate (9–13), or severe (3–8).[13] All patients are divided into two categories in terms of injury severity score (ISS): moderate (9–15) and severe (≥16).[14] The types of injuries were classified based on the diagnosis codes as subdural hemorrhage, epidural hemorrhage, subarachnoid hemorrhage, and diffuse brain injury. The most frequent intervention was performed for patients retrieved from data (craniotomy, cranioplasty, and tracheostomy). Vital signs are categorized as below: systolic blood pressure (SBP) as ≥90 or <90 mm Hg,[12] pulse rate as <60, 60 to 100, and >100,[12] and oxygen saturation as <90 and 90 to 100%.[15]

Outcome

The primary outcome was mortality after admission to the hospital.

Statistical Analysis

Number and percentage were used to describe nominal and categorical variables. Crude and adjusted logistic regression models were employed to assess the association between covariates and death outcomes. The p-values < 0.05 were considered to indicate statistical significance. STATA 14.0 software was used for all the data analyses.

Results

Baseline Characteristics of TBI Patients

From September 17, 2016, to July 31, 2022, a total of 874 TBI patients were eligible for inclusion in these analyses. The mortality was 107 patients (12.2%). In total, 715 (81.8%) patients were male and 159 (18.2%) were female. TBI patients were dominated by adults (18–64 age group). The most frequent mechanism of TBI was RTC by 634 patients (72.5%) ([Table 1]).

Table 1 Baseline characteristics of TBI victims

Characteristics	Total (n = 874) N (%)	Alive (n = 767) N (%)	Dead (n = 107) N (%)	Crude OR (95% CI)	p-Value
Gender
Female	159 (18.2)	136 (85.5)	23 (14.5)	1
Male	715 (81.8)	631 (88.3)	84 (11.7)	0.79 (0.48–1.29)	0.34
Age group, y
Pediatric (<18)	172 (19.7)	167 (97.1)	5 (2.9)	1
Adult (18–64)	553 (63.3)	491 (88.8)	62 (11.2)	4.22 (1.67–10.66)[a]	0.002
Geriatric (≥65)	149 (17.0)	109 (73.2)	40 (26.8)	12.26 (4.69–32.02)[a]	<0.001
Trauma mechanism
RTC	634 (72.5)	557 (87.9)	77 (12.1)	1
Fall	240 (27.5)	210 (87.5)	30 (12.5)	1.03 (0.66–1.62)	0.89
Mode of transportation
Ambulance	691 (79.3)	596 (86.3)	95 (13.7)	1
Private vehicle	180 (20.7)	169 (93.9)	11 (6.1)	0.41 (0.21–0.78)[a]	0.007

Abbreviations: CI, confidence interval; OR, odds ratio; RTC, road traffic crashes; TBI, traumatic brain injury.

^a Variables are significantly associated with the mortality according to univariate analysis at the 95% confidence level.

Baseline Characteristics Associated with Mortality in TBI Patients

Older age was associated with increased mortality. The odds of mortality in geriatric (≥65 years) and adult (18–64 years) patients were 12.26 and 4.22 times the odds of mortality in pediatric (<18 years), respectively. We found no statistically significant difference in mortality between males and females (crude odds ratio [OR]: 0.79 [95% confidence interval, CI: 0.48–1.29], p = 0.345). Patients have nearly 0.4 odds of mortality when transported by private vehicles compared with by ambulance (crude OR: 0.41 [95% CI: 0.21–0.78], p = 0.007).

Clinical Characteristics of TBI Patients

About two-thirds (569, 66.5%) of the patients were diagnosed with mild TBI and only 19.6% were diagnosed with severe TBI. The ISS score in 81% of patients was lower than 16. The proportion of patients with subdural and epidural hemorrhages was 37.8 and 28.9%, respectively. Craniotomy and tracheostomy were performed for 22 and 22.2% of patients, respectively. The systolic blood pressures at admission for 97.5% of patients were 90 mm Hg and higher. Oxygen saturation for 82.3% of patients was between 90 and 100% ([Table 2]).

Table 2 Clinical characteristics of TBI patients

Characteristics	Total (n = 874) N (%)	Alive (n = 767) N (%)	Dead (n = 107) N (%)	Crude OR (95% CI)	p-Value
GCS category
Mild (13–15)	569 (66.5)	547 (96.1)	22 (3.9)	1
Moderate (9–12)	118 (13.8)	96 (81.4)	22 (18.6)	5.70 (3.04–10.69)[a]	<0.001
Severe (38)	168 (19.6)	109 (64.9)	59 (35.1)	13.46 (7.91–22.89)[a]	<0.001
ISS category
Moderate (9–15)	708 (81.0)	637 (90.0)	71 (10.0)	1
Severe (≥16)	166 (19.0)	130 (78.3)	36 (21.7)	2.49 (1.60–3.87)[a]	<0.001
Subdural hemorrhage
No	462 (62.2)	420 (90.9)	42 (9.1)	1
Yes	281 (37.8)	237 (84.3)	44 (15.7)	1.86 (1.18–2.92)[a]	0.007
Epidural hemorrhage
No	528 (71.1)	458 (86.7)	70 (13.3)	1
Yes	215 (28.9)	199 (92.6)	16 (7.4)	0.53 (0.30–0.93)[a]	0.03
Subarachnoid hemorrhage
No	623 (83.8)	555 (89.1)	68 (10.9)	1
Yes	120 (16.2)	102 (85.0)	18 (15.0)	1.44 (0.82–2.52)	0.20
Diffuse brain injury
No	653 (87.9)	586 (89.7)	67 (10.3)	1
Yes	90 (12.1)	71 (78.9)	19 (21.1)	2.34 (1.33–4.12)[a]	0.003
Craniotomy
No	682 (78.0)	618 (90.6)	64 (9.4)	1
Yes	192 (22.0)	149 (77.6)	43 (22.4)	2.79 (1.82–4.27)[a]	<0.001
Cranioplasty
No	821 (93.9)	720 (87.7)	101 (12.3)	1
Yes	53 (6.1)	47 (88.7)	6 (11.3)	0.91 (0.38–2.18)	0.83
Tracheostomy
No	680 (77.8)	634 (93.2)	46 (6.8)	1
Yes	194 (22.2)	133 (68.6)	61 (31.4)	6.32 (4.13–9.68)[a]	<0.001
SBP (mm Hg)
≥90	842 (97.5)	745 (88.5)	97 (11.5)	1
<90	22 (2.5)	16 (72.7)	6 (27.3)	2.88 (1.10–7.54)[a]	0.03
Pulse rate
60–100	723 (83.6)	652 (90.2)	71 (9.8)	1
<60	17 (2.0)	9 (52.9)	8 (47.1)	8.16 (3.05–21.82)[a]	<0.001
>100	125 (14.5)	101 (80.8)	24 (19.2)	2.18 (1.31–3.63)[a]	0.003
Oxygen saturation
90–100%	719 (82.3)	643 (89.4)	76 (10.6)	1
<90%	155 (17.7)	124 (80.0)	31 (20.0)	2.12 (1.34–3.35)[a]	0.001

Abbreviations: CI, confidence interval; GCS, Glasgow coma scale; ISS, injury severity score; OR, odds ratio; RTC, road traffic crashes; SBP, systolic blood pressure.

^a Variables are significantly associated with mortality according to univariate analysis at the 95% confidence level.

Clinical Characteristics Associated with Mortality in TBI Patients

Decreasing GCS score, increasing ISS score, subdural hemorrhage, diffuse brain injury, craniotomy surgery, SBP lower than 90 mm Hg, abnormal pulse rate (<60 and >100), and oxygen saturation lower than 90% were all associated with increased mortality in TBI patients. Patients with severe TBI had higher odds of mortality than patients with mild TBI (crude OR: 13.46; 95% CI: 7.91–22.89), and patients with moderate TBI had higher odds of mortality compared with patients with mild TBI (crude OR: 5.70; 95% CI: 3.04–10.69). The odds of mortality in patients with severe ISS (≥16) was 2.49 times that in patients with moderate ISS (9–15) (crude OR: 2.49; 95% CI: 1.60–3.87). In patients who have had a tracheostomy, the odds of mortality were 6.32 times that in patients without tracheostomy (crude OR: 6.32; 95% CI: 4.13–9.68). Lower than 60 pulse rate was associated with increased odds of mortality in TBI patients compared with a normal pulse rate (60–100) (crude OR: 8.16; 95% CI: 3.05–21.82).

Predictors of Mortality in Multiple Analysis

[Table 3] shows the results of the multiple logistic regression model. Age, GCS, tracheostomy, and oxygen saturation variables were entered into the model. After adjusting for other covariates included in the model, the odds of mortality in patients with aged 65 years and older were 17.71 times than in patients with aged younger than 18 years (adjusted OR = 17.71; 95% CI: 5.90–47.47, p < 0.001). Also, the odds of mortality in patients with severe TBI was 8.65 times odds in patients with mild TBI (adjusted OR = 8.65; 95% CI: 4.63–16.15, p < 0.001).

Table 3 Predictors of mortality in multiple analysis

Variables	Adjusted OR (95% CI)	p-Value
Age group, y
Pediatric (<18)	1
Adult (18–64)	3.72 (1.41–9.86)	0.007
Geriatric (≥65)	17.71 (5.90–47.47)	<0.001
GCS category
Mild (13-–5)	1
Moderate (9–12)	4.92 (2.49–9.74)	<0.001
Severe (3–8)	8.65 (4.63–16.15)	<0.001
Tracheostomy
No	1
Yes	3.01 (1.76–5.16)	<0.001
Oxygen saturation
90–100%	1
<90%	2.02 (1.16–3.49)	0.012

Abbreviations: CI, confidence interval; GCS, Glasgow coma scale; OR, odds ratio.

Furthermore, after adjusting for other variables, patients with a tracheostomy were found to have significantly higher odds of mortality (adjusted OR = 3.01; 95% CI: 1.76–5.16, p < 0.001). Similarly, when other covariates were controlled for, patients with abnormal oxygen saturation (< 90%) had 2.02 times the odds of mortality compared with patients with normal oxygen saturation (adjusted OR = 2.02; 95% CI: 1.16–3.49, p < 0.001) ([Table 3]).

Discussion

Rapid and accurate identification of TBI patients at risk of mortality is essential for improving survival. Therefore, in this retrospective study using data from the NTRI, factors associated with in-hospital mortality in patients with TBI were investigated. The results of the univariate regression analysis showed that older age, low GCS score, ISS higher than 16, subdural hemorrhage, diffuse brain injury, craniotomy and tracheostomy surgeries, abnormal pulse rate, and abnormal oxygen saturation were identified as predictive variables for mortality in TBI patients. According to the results of the multiple logistic regression model, older age, low GCS score, tracheostomy surgery, and abnormal oxygen saturation were significant predictors of mortality in TBI patients.

The present study found a mortality rate of 12.2%, which was lower than some other developing countries. For instance, Eaton et al[16] conducted a retrospective study from October 2016 to May 2017 in Malawi and reported a mortality rate of 33%. Similarly, a clinical record review or chart review study by Okidi et al[17] from 2013 to 2017 in Uganda reported a mortality rate of 33%. Another retrospective cohort study by Amare et al[15] in Ethiopia from January 2015 to December 2019 had a mortality rate of 30.4%. Additionally, the retrospective study by El-Menyar et al[18] in Qatar from 2010 to 2014 had a 27% mortality rate. These differences could be attributed to variations in patient characteristics (age and gender), sample size and study duration, prehospital and in-hospital care, mechanisms of injury, and trauma severity.

The analysis revealed that patients transported by private vehicles had a lower mortality rate than those transported by ambulance. Similar results were found in a study that examined the impact of transportation mode on mortality following isolated penetrating torso trauma. This study compared the use of ground ambulances and private vehicles for transporting patients with these injuries. The key finding was that patients transported by ambulance had nearly twice the odds of mortality compared with those transported by private vehicles.[19] This finding may be due to several factors, such as patients with severe injuries being more likely to be transported by ambulance or the delays that can occur during ambulance transport.

The research findings were analyzed in two forms: univariate and multivariate analyses. The results of the univariate analysis showed that with increasing age, the mortality rate in TBI patients also increases. The mortality rate increases from about 3% in patients younger than 18 years to nearly 27% in patients aged 65 and older. The mortality prediction in TBI patients is consistent with the finding of a Norwegian study that assessed the influence of age on treatment intensity and mortality among 1,571 TBI patients. It was found that increasing age leads to a 30-day mortality risk increase.[20] A study conducted in one of the provinces of Iran titled “Predictors of Outcomes in TBI Patients” also obtained similar results, showing that the mortality rate increases with age. In the lowest age group (0–14 years old), the mortality rate was approximately 1.9% (one death among 54 patients), while in the highest age group (65 years and older), it was approximately 5.41% (17 deaths among 41 patients).[21]

The findings of the present study also indicated that low GCS scores are associated with an increased likelihood of mortality. This finding is consistent with the results of other studies. The study conducted by Rafiee et al on TBI patients demonstrated that the mortality rate of patients with low GCS scores is higher compared with other TBI patients.[21] In the study by Amare et al, GCS score was also identified as a significant predictor of mortality in TBI patients.[15]

The multiple logistic regression analysis revealed that older age, severe TBI, tracheostomy surgery, and abnormal oxygen saturation status remained significant predictors of mortality associated with TBI, even after controlling for other variables. In this study, patients with severe TBI had a higher likelihood of mortality (adjusted OR = 8.65; 95% CI: 4.63–16.15, p < 0.001) based on GCS scores compared with patients with mild TBI. Similar results were found in studies conducted in Ethiopia (Adjusted Hazard Ratio [AHR]: 4.85; 95% CI: 1.73–13.62),[15] Brazil (crude OR: 5.27; 95% CI: 2.72–10.19),[22] and Serbia (crude OR: 2.83; 95% CI: 1.462–5.48).[23] These findings underscore the significance of age, neurological status, respiratory function, and specific clinical interventions in assessing the prognosis and risk of mortality in patients with TBI.

Limitations of the Study

Potential limitations in research studies can significantly compromise the reliability of the findings, and this study is no exception. Although the retrospective design using a national trauma registry is suitable for the study's objectives, it has some limitations. The used data were mainly collected for nonresearch purposes and were constrained by limited access to specific factors impacting TBI, particularly prehospital care. Since a significant portion of influential factors in TBI occurs before hospital admission, these data limitations precluded a comprehensive analysis. To address this, we utilized proxy measures, such as the GCS upon hospital admission, as indirect indicators of these prehospital factors. While the study focuses on in-hospital mortality, incorporating data on long-term outcomes would provide a more holistic view of TBI impacts. Future studies could track patient progress postdischarge.

Conclusion

The analysis of the data revealed that several factors were significantly associated with mortality in TBI patients. Older age, a severe TBI, the presence of a tracheostomy, and abnormal oxygen saturation levels were all found to be predictors of increased mortality risk. These findings emphasize the importance of considering age, neurological status, and respiratory function when evaluating the prognosis and mortality risk in individuals with TBI. By accurately assessing and monitoring these factors, health care professionals can identify patients at higher risk and implement appropriate interventions to improve outcomes and potentially reduce mortality rates.

Conflict of Interest

None declared.

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Artikel online veröffentlicht:
25. März 2025