Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank

Abstract

There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.

Keywords: National Trauma Data Bank; epidemiology; intracranial hemorrhage; mild; neurosurgical intervention; time; traumatic brain injury.

FIG. 1.

Changes to yearly admissions and neurosurgical interventions in patients with complicated mTBI, stratified by ICH. (A) Long-term trends in average number of complicated mTBI patients admitted to each hospital by ICH type. Solid lines indicate observed data, and dashed lines indicate trends adjusted for average patient age. Isolated subdural hemorrhages had the largest absolute increase in average number of patients admitted per hospital, whereas isolated lacerations/contusions had the steepest decrease in average patients per hospital. Adjusting for average patient age minimally explained the trends observed in the observed data. (B) Long-term trends in average number of patients receiving a neurosurgical intervention per hospital, stratified by ICH type. Isolated SDHs were the only hemorrhage type to show increasing trends over time; the remaining hemorrhage types show stable trends over time. EDH, epidural hemorrhage; ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage.

FIG. 2.

Observed and fully adjusted long-term outcome trends by year and ICH type. (A) Long-term trends in percentage of complicated mTBI patients who received a neurosurgical intervention. Solid lines indicate observed data, and dashed lines indicate trends adjusted for all 14 demographic, injury, and hospital characteristics. There were significant long-term declines in the adjusted percentage of patients with isolated subdural, subarachnoid, unspecified, and multiple hemorrhage types who received a neurosurgical procedure. (B) Long-term trends in the percentage of patients with an in-hospital mortality or discharge to hospice. Most ICH types did not have a significant long-term change in the adjusted percentage of patients suffering from an in-hospital mortality or discharge to hospice; the only exception was the significant positive trend observed in patients with isolated lacerations/contusions. Asterisks indicate statistically significant adjusted slopes (p < 0.05). Adjusted slope lines from the random-effect model were plotted with an intercept centered at 2013 that aligned to the average 5-year observed outcome percentage during 2011–2015. EDH, epidural hemorrhage; ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage; SDH, subdural hemorrhage.