What are the demographic and clinical differences between those older adults with traumatic brain injury who receive a neurosurgical intervention to those that do not? A systematic literature review with narrative synthesis

Figures & data

Figure 1. PRISMA flow diagram for study selection

Table 1. Summary of included studies. GCS; Glasgow Coma Score, SAH, Subarachnoid Hemorrhage; EDH, Extradural Hematoma; SDH, Subdural Hematoma; aSDH, Acute Subdural hematoma; cSDH, Chronic Subdural Hematoma; NSI, Neurosurgical intervention, I, Intervention; C, Control; AC, Anticoagulant; ICH, Intracranial hemorrhage; AIS, Abbreviated Injury Score.

Patients considered for neurosurgical intervention
Authors	Country	Design	Time period	TBI definition	Patient demographic		TBI Severity		Brain injury		Clinical difference
					I	C	I	C	I	C
Hawley et al. (2017)^25	UK	Retrospective cohort, single center	Six year	GCS (Mild, 13–15; Moderate 9–12; Severe <8); Mayo Score	n = 94 (15%)	n = 483 (77%)	Mild, n = 439 (76%); Moderate, n = 61 (11%); Severe, n = 79 (13%); Mayo: Moderate or severe, n = 502 (80%); Mild possible, n = 34 (6%); mild probably, n = 88 (14%);		SDH 44.7%; Skull fracture 20.8%; SAH 18.8%; Contusion 14.1%; EDH 1.6%		NSI associated with younger age 77.6 ± 7.7 vs 80 ± 8.9 (p < 0.02)
					Mean age 79.2 years ± 8.7; Male, n = 349 (56%)
Herou et al., (2015)^39	Sweden	Retrospective cohort, single center	9 year (intervention) 1 year (control)	GCS (Mild, 10–15; Moderate, 6–9; Severe <5).	n = 97 (82%); Median age, 76 (70–100); sex, not reported	n = 22 (18%); Median age, 81.5 (Not reported); sex, not reported	Mild, n = 54 (56%); Moderate, n = 36 (37%); Severe, n = 7 (7%)	Mild, n = 16 (73%); Moderate, n = 3 (14%); Severe, n = 2 (9%)	aSDH, n = 52 (53%); aSDH+ one other bleed, n = 33 (34%); Other, n = 12 (12%)	aSDH, n = 11 (50%); aSDH+ one other bleed, n = 2 (9%); Other, n = 9 (41%)	NSI observesed in younger older adults;
Moore Pasquale and Badellino., (2012)^47	USA	Retrospective cohort, single center	2 years	GCS, Mild (14,15)	Not on AC n = 29 (2%); On AC n = 36 (5%)	Not on AC n = 1296 (98%); On AC n = 636 (95%)	Not reported		Not reported		Age greater than 65 and on anticoagulation resulted in same day NSI; Confusion was a positive indicator for NSI but not statically significant.
Shimoda et al. (2014)^45	Japan	Retrospective cohort, Multi center	9 years	GCS Mild/Moderate (9–15), Severe (3–8)	n = 478 (54%); Mean age 76 years ±7.2; Male, n = 299 (63%)	n = 410 (46%); Mean age, 77 years ±7.5; Male, n = 247 (60%)	Severe, n = 310 (65%); Mild/Moderate, n = 168 (35%)	Severe, n = 368 (90%), Mild/Moderate, n = 42 (10%)	aSDH, n = 171 (36%); EDH, n = 20 (4%); Contusion & ICH, n = 47 (10%)	aSDH, n = 135 (33%); EDH n = 21 (5%); Contusion & ICH, n = 70 (17%)	Early hypotension and hypoxia were associated with not undergoing NSI; NSI < 4 hours associated with better outcome
Solomon et al. (2019)^44	Isreal	Retrospective cohort, single center	Three year	AIS; GCS (Mild, 13–15; Moderate 9–12;Severe <8)	n = 29 (15%)	n = 171 (85%)	Head AIS, 4 (3–5); Mild, n = 168 (84%); Moderate, n = 13 (6%); Severe, n = 19 (9%)		Not reported		A higher proportion of 80+ had NSI (18% vs 12%) but higher GCS 15 vs ten and comparable AIS 5
					Median age 79.5 years (70–99); Male, n = 93 (46%)
Wan et al. (2016)^41	China	Retrospective cohort, single center	6 year	GCS	n = 70 (63%); 73 yeats ± 4.2; Male, n-51 (6%).	n = 42 (37%); 74.5 years ± 6.2; Male, n = 31 (38%)	GCS 3–5, n = 15 (36%); GCS 6–8, n = 27 (64%)	GCS 3–5, n = 15 (36%); GCS 6–8, n = 27 (64%)	ICH, n = 46 (66%); tSAH, n = 26, (37%) SDH, n = 16 (14%); EDH, n = 8 (7%)	ICH, n = 32 (76%); tSAH, n = 20 (48%); SDH, n = 9 (21%); EDH, n = 1 (21%)	NSI more likely in older patients 65 vs 60 (0.001); NSI in higher ISS 19.7 vs 13.1 0.001; SDH NSI found in older patients 70.2 vs 65.7. however, injury patterns not associated with NSI
Patients considered for intensive care unit admission
Authors	Country	Design	Study length	TBI definition	Patient Demographic		TBI severity		Brain injury		Clinical difference
					I	C	I	C	I	C
Gore et al. (2015)^37	USA	Retrospective cohort, single center	12 years	GCS; Head AIS	n = 88 (36%)	n = 156 (64%)	Mild (GCS 15, 73%; GCS 14, 19%; GCS13, 8%)		SDH, 80%; Multiple ICH, 50%; Mass effect, 34%	SDH, 55%; Multiple ICH, 50%; Mass effect, 8%	ICU admissions had lower GCS; higher HAIS (5); more likely to have an SDH
					Median age, 78 (65–100), Male, n = 118 (48%).		Head AIS 4.1 ± 0.8	Head AIS 3.5 ± 0.7
Rajwani et al., (2020)^38	UK	Retrospective cohort, single center	Four months	GCS (Mild, 13–15; Moderate 9–12; Severe <8); Marshall Score	n = 52 (17%); Median age, 71.5 (not reported); male, n = 167 (58%)	n = 286 (83%); Median age, 65.9 (not reported). Male, n = 45 (85%).	Mild, n = 42 (79%); Moderate, n = 7 (13%); Severe, n = 4 (8%) Marshall Score, 2, n = 10 (19%);3, n = 0 (0%);4, n = 4 (8%);5, n = 37, (70%);6, n = 2, (3%)	Mild, n = 246 (86%); Moderate, n = 21 (7%); Severe, n = 16 (6%) Marshall Score, 2 n = 259 (91%);3, n = 6 (2%);4, n = 3 (1%);5, n = 0, (0%);6, n = 16, (6%%)	aSDH 38.3%; *e-mail author		older age reduced the likelihood of secondary transfer; higher Marshall score; cSDH; Skull fracture; Contusions increased likelihood
Yun et al. (2017)^42	USA	Retrospective cohort, single center	1 year	GCS	n = 39 (19%)	n = 166 (81%)	Mild (GCS 15 92%; GCS 14 = 7%; GCS 13 = 1%)		SDH 58.53%; SAH 40.48%; IPH 8.7%		Warfarin use and an SDH ≥10 mm were associated with admission to the ICU
					Mean age 71 years ± 17 Male, n = 95 (46%)

Table 2. Risk of bias assessment of included studies.

Study	Risk of Bias Selection
	Selection				Comparability		Outcome			Total
	1	2	3	4	1a	1b	1	2	3
Hawley et al^25			⋆		⋆	⋆	⋆	⋆		6
Herou et al^39	⋆	⋆	⋆				⋆	⋆		4
Moore, Pasquale and Badellino^40	⋆	⋆	⋆		⋆	⋆	⋆	⋆		7
Shimoda et al^45	⋆	⋆	⋆		⋆	⋆	⋆	⋆	⋆	8
Solomon et al^44		⋆	⋆		⋆	⋆	⋆	⋆	⋆	7
Wan et al^41		⋆	⋆		⋆	⋆	⋆	⋆	⋆	7
Gore et al^37	⋆	⋆	⋆		⋆	⋆	⋆	⋆		7
Rajwani et al^38		⋆	⋆		⋆	⋆	⋆	⋆	⋆	7
Yun et al^42	⋆	⋆	⋆		⋆	⋆	⋆	⋆	⋆	8

Vassar MJ, Holcroft JJ, Knudson MM, Kizer KW. Fractures in access to and assessment of trauma systems. J Am Coll Surg. 2003;197(5):717–25.doi:10.1016/S1072-7515(03)00749-X.

 PubMed Web of Science ®Google Scholar

Hsia RY, Wang E, Torres H, Saynina O, Wise PH. Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006. J Trauma - Inj Infect Crit Care. 2010;68(1):217–24.doi:10.1097/TA.0b013e3181a0e66d.

 PubMedGoogle Scholar

Roozenbeek B, Maas AIR, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol. 2013;9(4):231–36.doi:10.1038/nrneurol.2013.22.

 PubMed Web of Science ®Google Scholar