Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis

Abstract

Study objective: Ground-level falls have become the leading cause of head injury in older adults. However, the risk factors for traumatic intracranial hemorrhage (ICH) in this population remain unclear. We aimed to identify risk factors for traumatic ICH in older patients who sustained a ground-level fall-related head injury presenting in the emergency department.

Methods: A systematic search of Medline (Ovid), Embase (Embase.com), Cochrane Library (Wiley), CINAHL (EBSCO), and Web of Science Core Collection was performed on December 9, 2024. The studies' eligibility criteria included patients aged 65 years and over who consulted in an emergency department following a ground-level fall-related head trauma and who presented with a Glasgow Coma Scale score of at least 13. Head injury was defined as any trauma to the head, including the face. Odds ratios (ORs) for each risk factor were pooled from the selected studies. For each potential risk factor, a random-effects model was used to compare the risk of traumatic ICH between patients with and without the risk factor. We restricted sensitivity analyses to studies providing adjusted odds ratios (AORs) and high-quality studies according to the Newcastle-Ottawa quality assessment Scale (defined as Newcastle-Ottawa quality assessment Scale score ≥7).

Results: A total of 17 observational studies involving 22,520 patients were included in this systematic review with meta-analysis. Seven were prospective (11,501 individuals), and 8 were multicenter studies (14,376 individuals). The prevalence of traumatic ICH was 6.8% (95% confidence interval [CI]: 6.5 to 7.2), occurring in 1,538 patients. Among patients with traumatic ICH, urgent neurosurgery intervention prevalence was 8.0% (95% CI: 5.0 to 12.0). The unadjusted ORs indicate that the risk factors of traumatic ICH were suspected open or depressed skull fracture (OR: 10.9 [95% CI 6.4 to 18.7]), signs of basal skull fracture (OR: 4.7 [95% CI 3.4 to 6.5]), reduced baseline Glasgow Coma Scale score (OR: 4.0 [95% CI 3.4 to 4.7]), focal neurologic signs (OR: 3.8 [95% CI 3.2 to 4.5]), seizure (OR: 3.2, [95% CI 1.5 to 7.0]), vomiting (OR: 2.7 [95% CI 2.1 to 3.5]), amnesia (OR: 2.4 [95% CI 2.0 to 3.0]), loss of consciousness (OR: 2.3 [95% CI 1.9 to 2.8]), headache (OR: 2.1 [95% CI 1.6 to 2.9]), external sign of head trauma (OR: 2.0 [95% CI 1.7 to 2.3]), male sex (OR: 1.5 [95% CI 1.3 to 1.6]), chronic kidney disease (OR: 1.4 [95% CI 1.0 to 1.9]), preinjury single antiplatelet (OR: 1.2 [95% CI 1.0 to 1.3]), and dual antiplatelet medication (OR: 2.3 [95% CI 1.5 to 3.5]). Preinjury anticoagulant was not a significant risk factor (OR: 0.8 [95% CI 0.7 to 1.0]). Based on AOR, only focal neurologic signs (AOR: 4.4 [95% CI 3.0 to 6.5]), external sign of head trauma (AOR: 2.7 [95% CI 2.1 to 3.5]), loss of consciousness (AOR: 1.6 [95% CI 1.2 to 2.1]), and male sex (AOR: 1.4 [95% CI 1.2 to 1.6]) remained associated with traumatic ICH.

Conclusions: This study identified risk factors for traumatic ICH that can be recognized in older patients presenting in the emergency department for a ground-level fall-related head injury. Based on these findings, there is a need for future prospective studies to evaluate potentially avoidable head computed tomography scans in this population.

Keywords: Ground-level fall; Head injury; Neuroimaging; Older patients; Traumatic brain injury.