Epidemiology of Traumatic Brain Injury over the World: A Systematic Review

Review Article

Austin Neurol & Neurosci. 2016; 1(2): 1007.

Epidemiology of Traumatic Brain Injury over the World: A Systematic Review

Min Li, Zilong Zhao, Gongjie Yu and Jianning Zhang*

Department of Neurosurgery, Tianjin Neurological Institute, Tianjin Medical University General Hospital, PR China

*Corresponding author: Jianning Zhang, Department of Neurosurgery, Tianjin Neurological Institute, Tianjin General Hospital, PR China

Received: May 31, 2016; Accepted: June 28, 2016; Published: July 01, 2016

Abstract

We identified 60 reports from 29 countries with data on Traumatic brain injury (TBI) epidemiology in the published literature. Men were at higher risk of TBI than women. The average age at the time of TBI ranged from 27 to 59.67 years while the median age ranged from 29 to 45 years. The incidence of TBI in Sweden, Italy and Norway was decreased while the incidence of TBI in Spain and Taiwan was increased. The countries with the incidence of TBI from high to low were New Zealand, United States, Spain, Sweden, South Africa, Austria, France, Italy, Germany, Canada, Norway, Australia, Portugal, Finland, China, Iran, Switzerland and Belgium. The overall mild: moderate: severe ratio was 55: 27.7: 17.3 based on Glasgow Coma Scale (GCS). In patients with moderate and severe TBI, death was the most common outcome. In TBI patients with all severities, good recovery was the major clinical outcome. Motor vehicle collision (MVC) was the leading cause of TBI in China, Pakistan, Japan, Australia, France, Spain, Austria, England, Croatia, Slovakia, Bosnia, Macedonia, Netherland and Italy, whereas fall was the leading cause in The United States, Canada, New Zealand, Sweden, Scotland, Norway and Finland. The MVC-related TBIs were the most common causes in developing countries, whereas the fall-related TBIs were the most common causes in developed countries. The percentage of MVC-related TBIs were the highest in Asia. Europe had the highest percentage of fall-related TBIs and work-related TBIs. North America, followed by Oceania, had the highest percentage of sport-related TBIs.

Keywords: Head injury; Traumatic brain injury; Epidemiology; Incidence; Injury prevention

Introduction

TBI is one of the most devastating types of injury, and it results in varying degrees of paralysis, loss of consciousness, amnesia and even death. Head trauma accounts for the majority of trauma deaths [1]. The effects of TBI are not limited to an individual’s health; it also creates a financial burden for families and societies. There was a widespread agreement that the fundamental aim of managing TBI is to avoid brain injury. Studying the epidemiology of TBI is challenging for a number of reasons, including various inclusion criteria and different methods for classifying TBI severity. Advances in understanding the mechanisms of TBI have yielded to effective prevention. Numerous articles on TBI epidemiology have come out of Europe and North America due to their TBI registries or databases [1-3]. Although most Asian countries do not have TBI registries, the number of studies from Asian countries has increased in recent years [4-7].

The knowledge of the epidemiology of TBI worldwide was required; however, a systematic review on TBI epidemiology worldwide has not been performed or published. The aim of this review was to compile epidemiological characteristics of TBI in order to improve the effectiveness of TBI prevention.

Methods

Search strategy: Pub Med, EBSCO, MEDLINE, EMBASE, and Google Scholar™ databases were searched for TBI articles published from January 1980 through May 2014 with the following key indexing and MeSH terms: “head injury”, “traumatic brain injury”, “epidemiology”, and “incidence”. These terms were linked using combinations of “epidemiology” or “incidence” plus “head injury” or “traumatic brain injury”. No language restrictions were used. References from the retrieved reports were reviewed to find additional relevant articles that may have been omitted from the database search (Figure 1).

Figure 1: The flow diagram of study selection.

    

    
    

    

    Figure 1:  The flow diagram of study selection.

Two independent reviewers assessed the titles and abstracts of the publications produced by the initial search strategy. To be eligible for inclusion, studies had to meet the following criteria: (1) human subjects; (2) original studies involving TBI; (3) epidemiological data available. General population studies were eligible for inclusion. The exclusion criteria were as below: (1) studies only included children and adolescence; (2) studies only included older adults; (3) studies involving military subjects or prisoners.

Data extraction: Available methodological information and data were extracted from the articles, including country (region), year of publication, and number of patients, source population, case criteria, incidence period, gender features, age features, incidence, and causes of TBI, mortality, severity and clinical outcome. Aggregated data were calculated based on data provided by each study and its study population.

Results

7639 articles were identified by the primary literature search. However, after screening the titles and abstracts, 7571 studies were excluded due to duplicates, laboratory studies, review articles, or the irrelevancies to the current study. 68 potentially relevant manuscripts were retrieved for detailed review. 4 of these studies only included children and adolescence, 2 studies only included older adults, 2 studies included military subjects or prisoners.

Consequently, we identified 60 reports from 29 countries (regions) with data on TBI epidemiology in the published literature. Of those, 9 reports were from the United States of America, 5 from Italy, 4 from China, 3 from Australia, 3 from Finland, 3 from France, 3 from Norway, 4 from Sweden, 3 from Austria, 2 from New Zealand, 2 from Germany, 2 from Spain, 2 from Denmark, 2 from Scotland and 2 from Iran, 1 from Ireland, 1 from Britain, 1 from Canada, 1 from Belgium, 1 from Portugal, 1 from Switzerland, 1 from Pakistan, 1 from South Africa, 1 from Croatia, Slovakia, Bosnia and Macedonia, 1from Netherland, 1 from Japan.

Study characteristics, including country (region), authors, year of publication, source population, case source, case criteria, gender features and age features are listed in (Table 1). The epidemiologic data, including incidence, mortality, and severity and Glasgow Outcome Score (GOS) outcome are summarized in (Table 2). The etiology of TBI is summarized in (Table 3).

Table 1: Characteristics of the included studies of traumatic brain injury worldwide.



     

  

    
    
Study author(s) (year) [ref.] 

    
Country (region) 

    
Incidence period 

    
Study population 

    
Case ascertainment 

    
Case criteria 

    
Gender features 

    
Age features 

  

  

    
North America 

    
Sugerman et al (2012)[14]

    
United States

    
2007-2009

    
321,013

    
Data from the American College of    Surgeons National Trauma Databank National

      
Sample Population

    
Head AIS score of 3 or greater    and TBI using a ICD-9-CM definition. Infants and children younger than 18    years, those with a total ISS of less than 16, those with GCS motor score of    6 were excluded

    
Male: female= 1.97:1 in    transferred patients; male: female= 2.76:1 in direct admitted patients

    
The mean age was 59.67 yrs in    transferred patients; 50.39 yrs in direct admitted patients

  

  

    
    
Colantonio et al (2010)[2]

    
province of Ontario, Canada

    
2002-2007

    
84,042

    
Hospitalization records from    the Canadian Institute for Heath Information Discharge Abstract Database,    records of EDs were from the National Ambulatory Care

      
Resource System database.

    
ICD-10 codes: S02 and T90

    
Male: female ratio=1.85:1

    
The rate of hospitalization was    highest for elderly over 75 yrs; episodes of care were greatest in youth    under the age of 14 yrs and elderly over the age of 85 yrs.

  

  

    
    
Selassie et al (2008)[30]

    
South Carolina, United States

    
1999-2002

    
288,009

    
Data from the South Carolina    Traumatic Brain Injury and Follow-up Registry

    
ICD-9-CM: 800.0-801.9,    803.0-804.9, 850.0-854.1 and 959.01

    
Male: female ratio=1.63:1

    
NA

  

  

    
    
Rutland-Brown et al (2006)[31]

    
United States

    
1998-2003

    
#######

    
Patients with TBI admitted to    the hospitals and ED

    
ICD-9-CM codes and ICD-10 codes

    
NA

    
NA

  

  

    
    
Day et al

    
Minnesota, United States

    
2002-

    
1,854

    
TBI patients admitted to the ED

    
ICD-9-CM codes

    
NA

    
NA

  

  

    
(2006)[32]

    
2003

    

  

    
    
Gerberding et al (2006)[33]

    
United States

    
2002

    
74,517

    
Patients related to TBI    admitted to hospitals in 12 States

    
ICD-9 and/or ICD-10 codes

    
Male: female ratio=1.79:1

    
NA

  

  

    
    
Tieves et al (2005)[3]

    
Wisconsin, United States

    
2001

    
5,065

    
The medical records on TBI    injuries from National Center for Vital Statistics and the Wisconsin Bureau    for Health Information

    
ICD-9-CM and ICD-10

    
NA

    
NA

  

  

    
    
Wagner et al (2000)[7]

    
Carolinas, United States

    
1994-1998

    
2,637

    
Patients sustaining TBI    admitted to Carolinas Medical Center Trauma Registry

    
ICD-9-CM code ranging from E950    to E976

    
1930 male patients (73.2%),707    female patients(26.8%);

    
NA

  

  

    
male: female ratio=2.73:1

    

  

    
    
Harmon et al (1996)[34]

    
Wisconsin, United States

    
1989-1992

    
2,764 (1989); 2,626 (1990);    2,446 (1991); 2,349

    
TBI patients admitted to    Wisconsin Hospital

    
ICD-9-CM codes:

    
NA

    
NA

  

  

    
-1992

    
800.1- 800.4, 800.6- 800.9,    801.1- 801.4, 801.6-801.9, 801.1-803.4, 803.6-803.9, 851.0, 851.2- 851.9,    852.0- 852.5, 853.0- 853.1, 854.0-854.1,

    

  

    
    
Annegers et al (1980)[35]

    
Olmsted County, Minnesota,    United States

    
1935-1974

    
3,587

    
Data from the medical records    linkage system of the Rochester Project at the Mayo Clinic

    
A head injury with evidence of    presumed

    
NA

    
NA

  

  

    
brain involvement: concussion    with LOC, PTA, neurologic signs of brain injury and skull fractures.

    

  

    
Oceania 

    
Feigin et al (2013)[36]

    
Urban area of Hamilton and    rural area of Waikato District, New Zealand

    
2010-2011

    
1,369

    
Patients with head trauma admitted and not admitted to hospital

    
ICD-10 S00-S09

    
Male: female ratio=1.67:1

    
The mean age was 28.1 yrs

  

  
 

  

    
    
Myburgh et al (2008)[37]

    
Australia and New Zealand

    
2000

    
635

    
Adult patients with TBI admitted to the ICUs of major    trauma centers

    
NA

    
Male: female ratio=2.87:1

    
The mean age was 41.6 ±19.6 yrs

  

  

    
    
Tate et al (1998)[38]

    
Australia

    
1988

    
413

    
Patients admitted to regional    hospitals

    
ICD 9th code: 310,    800, 801, 803, 804, 850, 851, 852, 853, 854, 905.0, 907.0

    
Male: female ratio=2.6:1

    
NA

  

  

    
    
Hillier et al (1997)[39]

    
South Australia

    
1987

    
177

    
Data from all recognized public    and private hospitals

    
ICD-9 codes: 348, 800 to 804,    840, 851, 852 and 854

    
Male: female ratio=2.3:1

    
NA

  

  

    
Europe 

    
Shivaji et al (2014)[40]

    
Scotland

    
1998-2009

    
208,195

    
The records relating to TBI    contained in the Scottish Morbidity Record data-set.

    
ICD-10 codes

    
Male: female ratio=2.33:1

    
The hospitalisation was highest

  

  

    
in people aged less than 35 yrs    with a further peak in people aged over 65 yrs

  









Table 1:  Characteristics of the included studies of traumatic brain injury worldwide.

Table 1 of 2: 



      

  

    
Mauritz et al (2013)[41]

    
Austria

    
2009-2011

    
25,456

    
Patients with head

    
ICD-10 codes S06.0–S06.9, T68, or T07.

    
Male: female ratio= 1.4:1

    
The mean age was 44.5 yrs

  

  

    
trauma at hospital emergency    rooms

    

  

    
Perez et al (2012)[11]

    
Spain

    
2000–2009

    
206,503

    
Patients with head trauma at    the public and private hospitals

    
ICD9-CM codes: 800, 801, 803,    804,850, 851, 852, 853 and 854

    
Male: female ratio= 1.92:1

    
NA

  

  

    
Stocchetti et al (2011)[42]

    
Milan and Monza, Italy

    
1997–2007

    
1,478

    
Patients admitted consecutively    to 3 neurosurgical ICUs

    
(1) admission because of head    trauma, with or without extracranial injuries; (2) brain injury severity    requiring admission to an ICU; (3) time from trauma to arrival at the ICU    < 24 h; and (4) age over 18 years

    
NA

    
The median age was 45 yrs    ranged from 19–94 yrs, 44% were 50 yrs old or older

  

  

    
Numminen (2011)[43]

    
South East Finland

    
2002-2004

    
370

    
Patients with symptoms of brain    injury after a head trauma at health centres and the South Karelia Central    Hospital

    
ICD-10 codes

    
Male: female ratio=1.18:1

    
The mean age was 54.3 yrs

  

  

    
S06

    

  

    
Andriessen et al

    
Netherland

    
2008–2009

    
508

    
5 out of 11 specialized trauma    centers in the Netherlands.

    
All patients with TBI

    
Male: female ratio=2.3:1

    
The mean age was 47.3 yrs

  

  

    
(2011)[15]

    
and an ED admission of GCS    score =13; exclusion criteria were age    < 16 years and hospital admission > 72 h after injury

    

  

    
Andelic et al (2008)[44]

    
Oslo, Norway

    
2005-2006

    
445

    
TBI patients admitted to    Ulleval University Hospital

    
ICD-10 codes: S02.0–S02.9, S06.0–S06.9, S07.0, S07.1, S07.8, S07.9,  S09.7–S09.9, T04 and T06

    
Male: female ratio=1.8:1

    
The median age was 29 yrs

  

  

    
Koskinen & Alaranta    (2008)[45]

    
Finland

    
1991–2005

    
77,959

    
Patients of hospitalized and    fatal TBI collected from the national registers of Finland

    
1991–1995 are based ICD 9 and    from 1996–2005

    
male: female ratio=1.45:1

    
The highest incidence of TBI    among both genders was in the age of 0–9, 50–59 and 60–69 yrs

  

  

    
on ICD 10

    
ranged from 1.42–1.49

    

  

    
Mauritz et al (2008)[17]

    
Austria, Bosnia, Croatia,    Macedonia and Slovakia

    
January 2001- June 2005

    
1,172

    
The data were collected in 13    tertiary care level centres located in Austria, Bosnia, Croatia, Macedonia    and Slovakia

    
Inclusion criteria defined by    the US National Traumatic Coma Database such as a GCS score of 8 or less    following resuscitation or a GCS score deteriorating to 8 or less within 48 h    of injury.

    
Male: female ratio=2.57:1 in    Austria; male: female ratio=4.56:1 in Crotia and Slovakia; male: female    ratio=3.55:1 in Bosnia and Macedonia.

    
The mean age was 49 yrs (55 yrs    for males and 47 yrs for females) in Austria, 45 yrs (49 yrs for males and 44    yrs for females), 29 yrs in Crotia and Slovakia, (26 yrs for males and 30 yrs    for females) in Bosnia and Macedonia.

  

  

    
Styrke et al (2007)[46]

    
Sweden

    
2001

    
449

    
The data from the Umea University    Hospital’s injury register

    
Injured person that arrived    alive at the hospital within 24h after a brain trauma causing any degree of    disturbed consciousness, amnesia, neurological deficit, severe headache,    nausea, or vomiting

    
Male: female ratio= 1.22:1

    
Median age was 23 years ranged    from 0–91 yrs

  

  

    
Maegele et al (2007)[47]

    
Western Europe

    
1990–1999

    
650

    
Patients admitted to general    hospitals with relevant TBI

    
NA

    
Male: female ratio=2.67:1

    
The mean age was 40.3 yrs

  

  

    
Rosso et al (2007)[21]

    
Austria

    
NA

    
492

    
The data for this study were    collected in five centers.

    
Severe TBI defined by the US    National Traumatic Coma Database: GCS score of 8 or less following    resuscitation or GCS score deteriorating to 8 or less within 48 hours of    injury.

    
Male: female ratio=2.57:1

    
The mean age was 48 yrs

  

  

    
Steudel et al (2005)[48]

    
Germany

    
1972-2002

    
NA

    
Data collected from Federal    Bureau of Statistics, hospital admissions register and mortality register

    
ICD 9 and ICD 10

    
NA

    
NA

  

  
 

  

    
Lannoo et al

    
Flanders, Belgium

    
NA

    
72

    
Cases with the history of    acquired brain injury

    
NA

    
Male: female ratio=3.8:1

    
The mean age was 38 yrs

  

  

    
(2004)[49]

    

  

    
Andersson et al (2003)[50]

    
western Sweden

    
1992-1993

    
489

    
Patients with TBI admitted to    the Central Hospital Bora°s and the registers at the Regional Department of    Neurosurgery and at the Department of Forensic Medicine

    
ICD no. 850–854 and 800–804

    
Male: female ratio=1.42:1

    
The mean age was 27 yrs

  









Table 1 of 2:

Table 1 of 3: 





  

    
Baldo et al (2003)[13]

    
Italy

    
1996-2000

    
55,368

    
Hospital discharge records in    Veneto Region

    
ICD-9-CM 800.0–801.9,    803.0–804.9, 850.0–854.1

    
Male: female ratio=1.55:1

    
The mean age of males was 37.7    yrs; the mean age of female was 45.6 yrs

  

  

    
Kleiven et al (2003)[51]

    
Sweden

    
1987-2000

    
NA

    
Swedish Hospital Discharge    Register at National Board for Health and Welfare

    
Public hospital in-patients    discharged with ICD-9 800–804, 850–854 (1987–1996); ICD-10 S2.0–S2.9,    S6.0–S6.9 (1997–2000)

    
Male: female ratio=2.1:1

    
Among males, the highest rates    were for ages 15–19 and over 85 yrs; among females, the highest rates were    for ages 0–4 and over age 85 yrs

  

  

    
Masson et al (2003)[19]

    
France

    
1996

    
248

    
Patients of 19 public hospitals    with prolonged coma

    
Persons with significant    intra-cranial injury with coma >24 hrs or GCS of 8 or less before sedation

    
Male: female ratio= 3:1

    
The median age was 41 yrs,    27.0% of patients over 60 yrs

  

  

    
Santos et al (2003)[52]

    
Portugal

    
1994, 1996 and 1997

    
NA

    
NA

    
ICD-9: 800, 801, 803, 804, 850,    851, 852, 853, 854 and 907.0

    
Male: female ratio=1.8:1 in    hospital admissions and 3.4:1 in mortality

    
The highest risk was in age    20-29 yrs and after 80 yrs

  

  

    
Servadei et al (2002)[53]

    
Romagna, Italy

    
1998

    
2,430

    
Patients admitted to region    hospitals following a head injury

    
ICD-9-CM codes of 800.0 to    800.3, 801.0 to 801.3, 803.0 to 804.3, 850, 851, 851.1, 852.0, 852.1, 853.0,    853.1, 854.0, 854.1

    
Male: female ratio=2.74:1

    
NA

  

  

    
Servadei et al (2002)[54]

    
Romagna and Trentino, Italy

    
1998

    
4,442

    
Medical records of 4442    hospital admissions for head injury

    
ICD-9 codes 800.0–800.3, 801.0–801.3, 803.0–803.3, 850, 851.0–851.1, 852.0–852.1, 853.0–853.1, 854.0–854.1

    
Male: female ratio=1.65:1

    
NA

  

  

    
Engberg & Teasdale    (2001)[55]

    
Denmark

    
1979-1996

    
166,443

    
Patients with TBI diagnoses in    Danish National Hospital Register

    
For TBI patients from 1979 to    1993: ICD 800,801,803,851-854;

    
NA

    
NA

  

  

    
For fatal cases from 1994 to    1996: ICD 10 of S01.0-S09.9

  

  

    
Masson et al (2001)[18]

    
France

    
1996

    
497

    
Persons admitted to hospital    via an emergency service with diagnosis of severe brain injury

    
AIS score of 4 or 5 to head    region

    
Male: female ratio= 2.5:1

    
The median age was 44 yrs, with    a quarter of patients more than 70 yrs

  

  

    
Firsching & Woischneck    (2001)[56]

    
Germany

    
1996

    
279,029

    
Data from death certificates    and Federal Board of Statistics

    
ICD-9 codes for hospital    admitted persons

    
Male: female ratio= 2.45:1

    
NA

  

  

    
Alaranta et al (2000)[57]

    
Finland

    
1991-1995

    
NA

    
Hospital Discharge Register of    the Finnish National Research Development Center for Welfare and Health

    
First time admissions with    ICD-9 codes of 800–801, 803, 850–854

    
Male: female ratio=1.5:1,

    
The highest age specific rates    for males at ages 0–9 yrs, 10–19yrs, and 40–49yrs; for females at ages    0–9yrs, and over age 70 yrs

  

  

    
Thornhill et al (2000)[58]

    
Glasgow, Scotland

    
February 1995-February 1996

    
769

    
Patients with acute head    injuries admitted to five general hospitals

    
ICD9 codes 800804 and 850854

    
Male: female ratio=3.93:1

    
The median age was 38 yrs    ranged from 14-98 yrs

  

  

    
Murray et al

    
Britain

    
1986-1988

    
988

    
Patients admitted to one of    four British neurosurgical units within 3 days of a severe head injury

    
severe head injury defined as    no eye opening, no comprehensible verbal response, and not obeying commands

    
NA

    
NA

  

  

    
(1999)[20]

  

  

    
Murray et al

    
12 European countries

    
February 1995-April 1995

    
1,005

    
Patients admitted to 67 centers    in twelve countries

    
Patients were to be included if    their GCS was 12 or less

    
Male: female ratio=2.85:1

    
The median age was 38 yrs

  

  

    
(1999)[16]

  

  

    
Ingebrigtsen et al

    
Norway

    
1993

    
247

    
Patients referred first to    University Hospital, or admitted to any hospital department plus ED treated    and discharged

    
Head injury defined as physical    damage to the brain or skull by external force and GCS and head ISS

    
Male: female ratio=1.7:1

    
The highest age specific rates

  

  

    
(1998)[59]

    
for males was 10–24 yrs and    above 80 yrs; for females was 0–10 yrs and 20–24 yrs

  

  

    
O’Brien & Phillips    (1996)[60]

    
Ireland

    
July1992– June 1993

    
NA

    
All head injury admissions to    neurosurgical unit

    
NA

    
Male: female ratio =3:1.

    
The mean age was 28.3 yrs

  









Table 1 of 3:

Table 1 of 4: 





  

    
Engberg (1995)[8]

    
Fredericksburg County, Denmark

    
1988

    
NA

    
ED and ICU in 4 hospitals,    hospital records, search of National Board of Health causes of death

    
Severe head trauma defined as    PTA posttraumatic amnesia 24 hrs to 7 days. Very severe=7 days PTA. Diagnoses included ICD-9th 851–854,    800, 801, 803

    
Male: female average rate    ratio: 2.1:1

    
The highest rates for both    genders were 65 yrs older

  

  

    
Vazquez-Barquero et al(1992)[61]

    
Spain

    
1988

    
477

    
Persons of head injury admitted    to the University Hospital

    
Hospital contact <24 hours    from injury with LOC, skull fracture, objective neurologic findings    attributed to head injury including in-hospital deaths

    
Male: female ratio=2.7:1

    
The highest rates were in    ages<15 and 15–24 yrs for both genders

  

  

    
Annoni et al(1992)[62]

    
St Gallen, Switzerland

    
1987

    
80

    
Data from patients who had been    treated neurosurgically for brain injuries in neurosurgical units

    
Patients who showed    intracranial lesions on the admission CT scan were included in the study.

    
Ma1e:female ratio=3: 1

    
The mean age of the patients    was 44.6 yr ranged from 4-91

  

  

    
in Cantons, Zurich and Chur and    patients who were living at the

  

  

    
time of the accident in Canton

  

  

    
Johansson et al

    
Northern Sweden

    
April 1984–October 1985

    
NA

    
All hospital admissions with    ICD diagnoses of 850–854 plus deaths in files of department of forensic    medicine

    
Those with ICD codes 850–854    8th were surveyed 1.5–3 yrs post-injury by mail

    
Male: female ratio=1.5:1

    
NA

  

  

    
(1991)[63]

  

  

    
Tiret et al (1990)[64]

    
France

    
1986

    
8,940

    
Sample from admissions of all    public and private hospitals and death certificates

    
Head trauma defined as    contusions, lacerations, skull fractures, or brain injuries and/or LOC after    a relevant injury

    
Male: female ratio=2.1:1

    
Peak rates at<5 yrs, 15–24    yrs, and over 75 yrs

  

  

    
Nestvold et al (1988)[12]

    
Norway

    
1974-1975

    
488

    
All head injured patients    referred to the county hospital

    
Trauma to face, head or neck    with any of unconsciousness, retrograde amnesia, PTA, skull or neck fracture    or trauma with headache, nausea or vomiting during 1st day of event

    
NA

    
The mean age of male was 29.8    yrs and the mean age of female was 29.7 yrs

  

  

    
Servadei et al (1988)[65]

    
Italy

    
April 1984–March 1985

    
644

    
Cases presenting at Ravenna    City Hospital emergency room and admitted to hospital

    
LOC, DOA, or death in ED if    confirmed brain injury on autopsy

    
Male: female ratio= 1.63:1

    
The mean age was 38 yrs

  

  

    
Aghakhani et al

    
West Azarbaijan province, Iran

    
2005-2006

    
1,796

    
The medical records based on    the ICD items, TBI-related death based on the death certificate and    demographic data

    
NA

    
Male: female ratio= 3.45:1

    
The most common age group was    20-29 yrs; mean age of dead persons was 31.9 yrs

  

  

    
(2013)[66]

  

  

    
Rahimi-Movaghar et al (2013)[67]

    
Tehran, Iran

    
2007-2008

    
21

    
History of TBI from the    samples, medical records and radiographs

    
NA

    
Male: female ratio=4.25:1

    
The mean age was 28.7 yrs

  

  

    
Wu et al (2008)[4]

    
Eastern China

    
2004

    
14,948

    
TBI patients admitted to 77    hospitals in eastern China

    
NA

    
Male: female ratio=3.27:1

    
The mean age was 39.49 yrs

  

  

    
Chiu et al (2007)[5]

    
Taipei City and Hualien County,    Taiwan, China

    
2001

    
7,228

    
Patients admitted to the large    medical centers and the medium-sized to small medical facilities

    
ICD-9-CM

    
NA

    
NA

  

  

    
Nakamura et al (2002)[68]

    
Japan

    
NA

    
202

    
Records from Data Bank Program    for Traumatic Brain Injury in Nine Advanced Life-saving Emergency Centers

    
NA

    
Male: female ratio=1.65:1

    
The mean age was 47.7 yrs    ranged from 6-94 yrs

  

  

    
Zhao et al (2001)[10]

    
China

    
1983-1985

    
63,195 (1983) 246,812 (1985)

    
The data from two large-scale    epidemiological investigations in 1983 and 1985

    
The following diagnostic    criteria were used: (1) clear history of head trauma, with primary coma and    retrograde amnesia; (2) residual neurological deficit, and/or abnormality in    CT or x-ray exam; (3) formal diagnostic certification issued by neurologists    or neurosurgeons; (4) confirmation by at least two neurological specialists    if the diagnosis was uncertain.

    
Male: female ratio=1.7:1    (six-city);

    
The peak incidence was in ages    from 20 to 30 yrs.

  









Table 1 of 4:

Table 1 of 5: 





  

    
Servadei et al (1988)[65]

    
Italy

    
April 1984–March 1985

    
644

    
Cases presenting at Ravenna    City Hospital emergency room and admitted to hospital

    
LOC, DOA, or death in ED if    confirmed brain injury on autopsy

    
Male: female ratio= 1.63:1

    
The mean age was 38 yrs

  

  

    
Aghakhani et al

    
West Azarbaijan province, Iran

    
2005-2006

    
1,796

    
The medical records based on    the ICD items, TBI-related death based on the death certificate and    demographic data

    
NA

    
Male: female ratio= 3.45:1

    
The most common age group was    20-29 yrs; mean age of dead persons was 31.9 yrs

  

  

    
(2013)[66]

  

  

    
Rahimi-Movaghar et al (2013)[67]

    
Tehran, Iran

    
2007-2008

    
21

    
History of TBI from the    samples, medical records and radiographs

    
NA

    
Male: female ratio=4.25:1

    
The mean age was 28.7 yrs

  

  

    
Wu et al (2008)[4]

    
Eastern China

    
2004

    
14,948

    
TBI patients admitted to 77    hospitals in eastern China

    
NA

    
Male: female ratio=3.27:1

    
The mean age was 39.49 yrs

  

  

    
Chiu et al (2007)[5]

    
Taipei City and Hualien County,    Taiwan, China

    
2001

    
7,228

    
Patients admitted to the large    medical centers and the medium-sized to small medical facilities

    
ICD-9-CM

    
NA

    
NA

  

  

    
Nakamura et al (2002)[68]

    
Japan

    
NA

    
202

    
Records from Data Bank Program    for Traumatic Brain Injury in Nine Advanced Life-saving Emergency Centers

    
NA

    
Male: female ratio=1.65:1

    
The mean age was 47.7 yrs    ranged from 6-94 yrs

  

  

    
Zhao et al (2001)[10]

    
China

    
1983-1985

    
63,195 (1983) 246,812 (1985)

    
The data from two large-scale    epidemiological investigations in 1983 and 1985

    
The following diagnostic    criteria were used: (1) clear history of head trauma, with primary coma and    retrograde amnesia; (2) residual neurological deficit, and/or abnormality in    CT or x-ray exam; (3) formal diagnostic certification issued by neurologists    or neurosurgeons; (4) confirmation by at least two neurological specialists    if the diagnosis was uncertain.

    
Male: female ratio=1.7:1    (six-city);

    
The peak incidence was in ages    from 20 to 30 yrs.

  

  

    
male: female ratio=2.5:1 (rural    areas)

  

  

    
  

  

    
Raja et al (2001)[6]

    
Pakistan

    
July 1, 1995 to June 30, 1999

    
260,000

    
The patients of head injury    admitted to various neurosurgical centers in Pakistan

    
NA

    
Male: female ratio= 3:1.

    
The most common age group was    21-30 yrs

  

  

    
Wang et al (1986)[9]

    
China

    
1983

    
63,195

    
TBI patients in six cities of    the People's Republic of China

    
Patients with history of head    trauma together with any of the following: (1) LOC; (2) posttraumatic    amnesia; or (3) clinical evidence of subsequent focal brain dysfunction.

    
Male: female ratio=1.6:1

    
NA

  

  

    
Nell & Brown (1991)[69]

    
Johannesburg, South Africa

    
1986

    
5,106

    
Trauma cases at all hospitals    in Johannesburg.

    
Persons with cerebral contusion    or laceration, with or without the LOC, or trauma related unconsciousness or    amnesia of whatever duration

    
Male: female ratio=4.81:1

    
NA

  

  

    
 

    
 

    
NA= not available, TBI= Traumatic Brain Injury, yrs=    Years, AIS=Abbreviated Injury Score, ISS=Injury Severity Score, GCS=Glasgow    Coma Scale, ICU=Intensive Care Unit, ED=Emergency Department,    PTA=Posttraumatic Amnesia, LOC= Loss of Consciousness, DOA= Dead on Arrival.

      
 

    
 

  









Table 1 of 5:

Table 2: Incidence, mortality, severity and GOS outcome in selected studies.





  

    
    
Study author(s)    (year) [ref.]

    
Incidence

    
Mortality

    
Mild1 (%)

    
Moderate2 (%)

    
Severe3 (%)

    
GOS outcome

  

  

    
North America

    
Sugarman et al (2012)[14]

    
NA

    
NA

    
0%4

    
0.6%5

    
99.4%6

    
NA

  

  

    
    
Colantonio et    al (2010)[2]

    
Male:270/100,000/year

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
Females: 

  

  

    
116/100,000/year

  

  

    
    
Rutland-Brown et    al (2006)[31]

    
1998:538.4/100,000/year 

    
1998:18.1/100,000/year

    
NA

    
NA

    
NA

    
NA

  

  

    
1999:549.9/100,000/year 

    
1999:17.7/100,000/year

  

  

    
2000:555.8/100,000/year 

    
2000:17.2/100,000/year

  

  

    
2001:517.3/100,000/year 

    
2001: 17.7/100,000/year

  

  

    
2002:538.9/100,000/year 

    
2002:17.4/100,000/year

  

  

    
2003:538.2/100,000/year 

    
2003:17.5/100,000/year

  

  

    
    
Gerberding et    al (2006)[33]

    
79/100,000/year

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Tieves et al (2005)[3]

    
94.4/100,000/year

    
19.7/100,000/year

    
NA

    
NA

    
NA

    
NA

  

  

    
Oceania

    
Feigin et al (2013)[36]

    
811/100,000/year

    
NA

    
94.80%

    
NA

    
NA

    
NA

  

  

    
    
Myburgh et al (2008)[37]

    
NA

    
NA

    
24.70%

    
18.10%

    
57.20%

    
NA

  

  

    
    
Hillier et al (1997)[39]

    
322/100,000/year 

    
NA

    
75%

    
9%

    
16%

    
NA

  

  

    
    
Tate et al (1998)[38]

    
100/100,000/year 

    
NA

    
62.20%

    
20.30%

    
13.60%

    
NA

  

  

    
Europe

    
Mauritz et al (2013)[41]

    
303/100,000/year

    
11/100,000/year

    
NA

    
NA

    
NA

    
NA

  

  
 

  

    
    
Perez et al (2012)[11]

    
472.6/100,000/year 

    
NA

    
41.1%7

    
26.8%8

    
32.2%9

    
NA

  

  

    
    
Stocchetti et    al (2012)[42]

    
NA

    
NA

    
NA

    
NA

    
NA

    
GOS was assessed    six months later with 33% good recovery, 17% moderate disability, 14% severe    disability, 3% PVS and 33% death

  

  

    
    
Numminen    (2011)[43]

    
221/100,000/year 

    
7.6%10

    
71.40%

    
11.90%

    
16.80%

    
GOS was assessed    three months later with 70.5% good recovery, 9.8% moderate disability, 3.1%    severe disability and 16.5% death

  

  

    
    
Andriessen et al (2011)[15]

    
NA

    
Moderate2:    22%11

    
0%

    
25.40%

    
74.60%

    
GOS was assessed    six months later with 20% good recovery, 18% moderate disability, 13% severe    disability, 0.7% PVS and 46% death.

  

  

    
Severe3:    46%11

  

  

    
    
Andelic et al (2008)[44]

    
83.3/100,000/year 

    
NA

    
86%

    
7.90%

    
6.10%

    
NA

  

  

    
    
Koskinen &    Alaranta (2008)[45]

    
101/100 000/year 

    
18.3/100 000/year

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Mauritz et al (2008)[17]

    
NA

    
42%12 in Austria 48%12 in Crotia and Slovakia 55%12 in Bosnia    and Macedonia

    
0%

    
0%

    
100%

    
34% favorable    outcome13 in Austria, 28% favorable outcome in Crotia and    Slovakia, 34% favorable outcome Bosnia and Macedonia

  

  

    
    
Styrke et al (2007)[46]

    
354 /100,000/year 

    
NA

    
97%

    
1%

    
2%

    
  

  

    
    
Maegele et al (2007)[47]

    
7.3/100,000/year

    
24.8%14

    
NA

    
NA

    
NA

    
GOS was assessed    at the time of discharge with 32.52% good recovery, 16.8% moderate    disability, 3.7% severe disability, 1% PVS and 45.8% death

  

  

    
    
Rosso et al (2007)[21]

    
NA

    
31.7%15

    
82.80%

    
11.40%

    
5.70%

    
NA

  

  

    
    
Lannoo et al (2004)[49]

    
11/100,000/year

    
72/100,000/year

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Andersson et    al (2003)[50]

    
546/100,000/year 

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Baldo et al (2003)[13]

    
#######

    
1996:    7.4/100,000/year

    
64%4 

    
23%5

    
13%6

    
NA

  

  

    
301/100,000/year 

    
1997:    7.7/100,000/year

  

  

    
1997:    270/100,000/year 

    
#######

  

  

    
#######

    
6.8/100,000/year

  

  

    
249/100,000/year 

    
1999: 6.8/100,000/year

  

  

    
1999:    207/100,000/year 

    
#######

  

  

    
#######

    
6.1/100,000/year

  

  

    
212/100,000/year 

    
  

  

    
    
Kleiven et al (2003)[51]

    
259/100,000/year

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Masson et al (2003)[19]

    
8.5/100,000/year 

    
52%14 

    
15.10%

    
16.30%

    
68.60%

    
GOS was assessed    at the time of discharge with 18% good recovery, 9% moderate disability, 16%    severe disability, 3% PVS and 52% death

  

  

    
    
Santos et al (2003)[52]

    
1994:    151/100,000/year; 1996 and 1997: 137/100,000/year

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Servadei et al (2002)[53] 

    
250/100,000/year 

    
18.3/100,000/year

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Servadei et al (2002)[54]

    
297/100,000/year16 332/100,000/year17 

    
7.7/100,000/year16 2.1/100,000/year17

    
NA

    
NA

    
NA

    
NA

  

  

    
NA

    
NA

    
NA

  

  

    
    
Masson et al (2001)[18]

    
17.3/100,000/year 

    
5.2/100,000/year

    
0%

    
0%

    
100%6

    
NA

  

  

    
    
Firsching &    Woischneck (2001)[56]

    
247 /100,000/year

    
11.5    /100,000/year

    
73%

    
NA

    
NA

    
NA

  

  

    
    
Thornhill et    al (2000)[58]

    
NA

    
NA

    
56%

    
17%

    
13%

    
GOS was assessed    one year later with 45% good recovery, 30% moderate disability, 25% severe    disability, 10% PVS and death

  

  

    
    
Murray et al (1999)[20]

    
NA

    
NA

    
NA

    
NA

    
54.70%

    
GOS was assessed    six months later with 41.9% favorable outcome13, 16.6% severe    disability, 40.6% unfavorable outcome18

  

  

    
    
Murray et al (1999)[16]

    
NA

    
NA

    
16.10%

    
18.20%

    
60.40%

    
GOS was assessed    six months later with 31% good recovery, 20% moderate disability, 16% severe    disability, 3% PVS and 31% death

  

  

    
    
Ingebrigtsen et    al (1998)[59]

    
229/100,000/year 

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
    
O’Brien &    Phillips (1996)[60]

    
NA

    
NA

    
NA

    
NA

    
NA

    
GOS was assessed    at the time of discharge with 54% good recovery, 17% moderate disability, 8%    severe disability, 5% PVS and 16% death

  

  

    
    
Vazquez-Barquero et al(1992)[61]

    
91/100,000/year 

    
19.7/100,000/year

    
88%

    
7%

    
5%

    
GOS was assessed    one year later with 97% good recovery, 2% moderate disability, 0.5% severe    disability and 0.5% PVS.

  

  

    
    
Annoni et al(1992)[62]

    
20/100,000/year

    
NA

    
30%

    
46%

    
24%

    
GOS was assessed    with 66.7% good recovery, 22.2% moderate disability, 8.9% severe disability    and 2.2% PVS

  

  

    
    
Tiret et al (1990)[64]

    
281/100,000/year 

    
22/100,000/year

    
80%

    
11%

    
9%

    
NA

  

  

    
    
Nestvold et al (1988)[12]

    
236/100,000/year 

    
4.5%19

    
80.7%20

    
NA

    
11.1%21

    
NA

  

  

    
Asian

    
Aghakhani et    al (2013)[66]

    
NA

    
0.5%14

    
81.70%

    
NA

    
NA

    
NA

  

  

    
    
Rahimi-Movaghar    (2011)[67]

    
56.3/100,000/year

    
19%22

    
42.90%

    
23.80%

    
28.60%

    
GOS was assessed    with 52.4% good recovery, 14.3% mild disability, 4.8% moderate disability,    9.5% severe disability and 19% death

  

  

    
    
Wu et al (2008)[4]

    
NA

    
NA

    
62%

    
18.10%

    
20%

    
GOS was assessed    at the time of discharge with 77.3% good recovery, 7.2% moderate disability,    2.2% severe disability, 2.6% PVS and 10.8% death

  

  

    
    
Chiu et al (2007)[5]

    
218/100,000/year22

    
NA

    
87%23

    
6%23

    
7%23

    
GOS was assessed    with 85.9% good recovery, 5.3% moderate disability, 5.2% severe disability,    0.4% PVS and 3% death

  

  

    
417/100,000/year23

    
83%24

    
9%24

    
8%24

  

  

    
    
Raja et al (2001)[6]

    
NA

    
18%25

    
52%

    
30%

    
18%

    
GOS was assessed    with 67% good recovery, 8% moderate disability, 6% severe disability, 1% PVS    and 18% death

  

  

    
    
Zhao et al (2001)[10]

    
55.4    /100,000/year26

    
6.3 /100,000/year26

    
NA

    
NA

    
NA

    
NA

  

  

    
64.1    /100,000/year27

    
9.7 /100,000/year27

  

  

    
    
Wang et al (1986)[9]

    
56/100,000/year

    
NA

    
NA

    
NA

    
NA

    
NA

  

  

    
Africa

    
Nell & Brown    (1991)[69]

    
316.42/100,000/year

    
80.73/100,000/year

    
87.50%

    
7.90%

    
4.60%

    
NA

  

  

    
1based on Glasgow Come Score 13-15, 2based on Glasgow Come Score 9-12, 3based on Glasgow Come Score=8, 4based on Abbreviated Injury Score 1-2, 5based on Abbreviated Injury Score 3, 6based on Abbreviated Injury Score 4-6, 7based on Injury Severity Score<9, 8based on Injury Severity Score 9-15, 9based on Injury Severity Score 16-75, 10mortality assessed at one month follow-up, 11mortality assessed at six month follow-up, 1290 day mortality, 13favorable outcome was defined as GOS score    4-5, 14in-hospital mortality, 15ICU mortality, 16Romagna    region in Italy, 17Trentino region    in Italy, 18unfavorable outcome was    defined as GOS score 1-2, 19mortality    based on death before admission and death in hospital and death after    discharge, 20based on PTA score 0-3, 21based on PTA score 4-5 and death, 22mortality based on local    residents with traumatic brain injury, 23Taipei    city in Taiwan, 24Hualien country    in Taiwan, 25mortality based on    death before admission and death in hospital, 266    big cities in China, 2721 rural    areas in China, NA= not available, GOS= Glasgow Outcome Scale, PVS= Progressive    Vegetative State, PTA=Posttraumatic Amnesia.

      
 

  









Table 2:  Incidence, mortality, severity and GOS outcome in selected studies.

Table 3: External cause in selected studies.





  

    
 

    
 

      
Study    author(s) (year) [ref.]

    
External    cause

  

  

    
MVC

    
Fall

    
Assault/violence

    
Sport-related

    
Work-related

  

  

    
North America

    
Sugarman et al (2012)[14]

    
66%1

    
11.3%1

    
NA

    
NA

    
NA

  

  

    
45.4%2

    
22.3%2

  

  

    
    
Colantonio et al (2010)[2]

    
11.90%

    
41.60%

    
31.10%

    
20.20%

    
NA

  

  

    
    
Selassie et al (2008)[30]

    
37%

    
34.80%

    
7.40%

    
NA

    
NA

  

  

    
    
Rutland-Brown et al (2006)[31]

    
19%

    
32%

    
10%

    
NA

    
NA

  

  

    
    
Tieves et al (2005)[3]

    
34.20%

    
38.30%

    
8.10%

    
NA

    
NA

  

  

    
    
Wagner et al (2000)[7]

    
NA

    
NA

    
35%

    
NA

    
NA

  

  

    
    
Annegers et al (1980)[35]

    
46.80%

    
28.80%

    
3.80%

    
9.40%

    
4.40%

  

  

    
Oceania

    
Feigin et al (2013)[36]

    
20%

    
38%

    
17%

    
NA

    
NA

  

  

    
    
Myburgh et al (2008)[37]

    
61.40%

    
24.90%

    
7.20%

    
3.50%

    
1.10%

  

  

    
    
Tate et al (1998)[38]

    
40%

    
20.60%

    
8.20%

    
25.20%

    
NA

  

  

    
    
Hillier et al (1997)[39]

    
57%

    
29%

    
4%

    
NA

    
NA

  

  

    
Europe

    
Shivaji et al (2014)[40]

    
NA

    
47%

    
18%

    
NA

    
NA

  

  

    
    
Mauritz et al (2013)[41]

    
6.80%

    
NA

    
1.80%

    
5.40%

    
2.70%

  

  

    
    
Perez et al (2012)[11]

    
26.10%

    
NA

    
NA

    
NA

    
NA

  

  

    
    
Numminen (2011)[43]

    
17.80%

    
58.40%

    
7.60%

    
NA

    
NA

  

  

    
    
Andriessen et al

      
(2011)[15]

    
50.60%

    
37.90%

    
3.90%

    
2.50%

    
NA

  

  

    
    
Koskinen & Alaranta

    
16.60%

    
51.80%

    
2.90%

    
NA

    
NA

  

  

    
(2008)[45]

  

  

    
    
Andelic et al (2008)[44]

    
29.70%

    
51%

    
12.80%

    
NA

    
NA

  

  

    
    
Mauritz et al (2008)[17]

    
41%3

      
44%4

      
48%5

    
38%3

      
40%4

      
30%5

    
2%3

      
3%4

    
NA

    
NA

  

  

    
5%5

  

  

    
    
Maegele et al (2007)[47]

    
55.30%

    
35%

    
NA

    
NA

    
NA

  

  

    
    
Rosso et al (2007)[21]

    
44%

    
41%

    
2%

    
5%

    
NA

  

  

    
    
Styrke et al (2007)[46]

    
30%

    
55%

    
NA

    
NA

    
NA

  

  

    
    
Andersson et al (2003)[50]

    
15.75%

    
58.08%

    
14.72%

    
NA

    
NA

  

  

    
    
Baldo et al (2003)[13]

    
48.50%

    
NA

    
NA

    
NA

    
8.80%

  

  

    
    
Masson et al (2003)[19]

    
59%

    
30%

    
NA

    
NA

    
NA

  

  

    
    
Servadei et al  (2002)[53]

    
47.90%

    
32.60%

    
1.30%

    
1.10%

    
7.80%

  

  

    
    
Servadei et al  (2002)[54]

    
48.2%6

    
NA

    
1.4%6

    
1.2%6

    
7.6%6

  

  

    
23%7

    
NA

    
NA

    
NA

    
2.4%7

  

  

    
    
Masson et al (2001)[18]

    
48.30%

    
41.80%

    
6.40%

    
NA

    
NA

  

  

    
    
Thornhill et al (2000)[58]

    
11%

    
46%

    
28%

    
NA

    
NA

  

  

    
    
Murray et al (1999)[20]

    
56%

    
16%

    
NA

    
NA

    
NA

  

  

    
    
Murray et al (1999)[16]

    
42%

    
12%

    
5%

    
3%

    
6%

  

  

    
    
Ingebrigtsen et al (1998)[59]

    
21%

    
62%

    
7%

    
NA

    
NA

  

  

    
    
Vazquez-Barquero et al(1992)[61]

    
60%

    
24%

    
NA

    
NA

    
8%

  

  

    
    
Tiret et al (1990)[64]

    
59.60%

    
32.50%

    
6.10%

    
NA

    
NA

  

  

    
    
Nestvold et al (1988)[12]

    
57.60%

    
NA

    
NA

    
4.10%

    
4.50%

  

  

    
Asian

    
Rahimi-Movaghar et al (2013)[67]

    
47.60%

    
38%

    
NA

    
9.50%

    
NA

  

  

    
    
Wu et al (2008)[4]

    
60.90%

    
13.10%

    
13.40%

    
NA

    
NA

  

  

    
    
Chiu et al (2007)[5]

    
45%8

    
34%8

    
11%8

    
NA

    
NA

  

  

    
55%9

    
28%9

    
13%9

    
NA

    
NA

  

  

    
    
Nakamura et al (2002)[68]

    
63.90%

    
31.70%

    
NA

    
NA

    
NA

  

  

    
    
Zhao et al (2001)[10]

    
31.7%10

    
21.8%10

    
23.8%10

    
NA

    
NA

  

  

    
33.0%11

    
33.5%11

    
12.0%11

    
NA

    
NA

  

  

    
    
Raja et al (2001)[6]

    
52.80%

    
28%

    
14%

    
1%

    
NA

  

  

    
    
Wang et al (1986)[9]

    
31.70%

    
21.80%

    
23.80%

    
15.40%

    
NA

  

  

    
1Patients transferred to Level-I or -II Trauma center, 2Patients admitted direct to Level-I or -II trauma center, 3Patients in Austria, 4Patients in Crotia and Slovakia, 5Patients in Bosnia and Macedonia, 6Romagna region in Italy, 7Trentino region in Italy, 8Taipei city in Taiwan, 9Hualien country in Taiwan, 106 big cities in China, 1121 rural areas in China, NA= not available,    MVC=Motor Vehicle Collision.

      
 

  









Table 3:  External cause in selected studies.

Gender and age: As demonstrated in Table 1, we found that men were at a higher risk of TBI than women. The gender ratio ranged considerably, from 1.18:1 in South East Finland to 4.81:1 in South Africa. The average age at the time of TBI ranged from 27 to 59.67 years while the median age ranged from 29 to 45 years.

Incidence and prevalence: TBI incidence was only mentioned in 34 reports. The studies included in this review employed different case sources and case criteria. Therefore, we found that incidence rates ranged from the highest value of 811/100,000/year in New Zealand to the lowest value of 7.3/100,000/year in Western Europe. The incidence changed over time in many countries. The incidence of TBI in Sweden, Italy, France and Norway decreased over time markedly while the incidence of TBI in Spain and Taiwan increased over time. However, the incidence of TBI in the United States remained unchanged.

The incidence of TBI differs in countries. Based on aggregated data, the countries with an incidence of TBI from high to low were New Zealand, United States, Spain, Sweden, South Africa, Austria, France, Italy, Germany, Canada, Norway, Australia, Portugal, Finland, China, Iran, Switzerland and Belgium.

Prevalence is defined epidemiologically as the measure of the total amount of TBI at a time point or period interval in a certain population. Few studies utilized prevalence level of TBI in a community or nation. Only three included studies [8-10] mentioned the prevalence of TBI.

Mortality: The mortality rates were given in Table 2. Of the 60 studies included in this current report, 24 studies provided data on mortality. Mortality was expressed as annual death per 100,000 population or percentage of deaths among TBI patients. The annual mortality rate ranged from 80.73/100,000/year in South Africa to a rate as low as 5.2/100,000/year in France. The Percentage of deaths were assessed at discharge or the end of follow-up. The mortality rate in several studies included death before admission. Therefore, it was difficult to compare mortality from different regions.

Severity: The TBI severity is usually measured by GCS. One study [11] used Injury Severity Score (ISS), one study [12] used posttraumatic amnesia (PTA) score and two studies [13,14] used The Abbreviated Injury Score (AIS). The distribution over all three severity levels of TBI injuries indicated the pattern of patients received by hospitals for treatments. Two studies [15,16] only enrolled patients with moderate and severe TBI, 7 studies [8,14,17-21] only enrolled patients with severe TBI. Apart from the above, 20 studies reported all three severity levels of TBI, 3 studies only reported the percentage of mild TBI and 1 study only reported the percentage of severe TBI (Table 2). The proportion of mild TBI varied between 15.1% and 97%, and that of moderate and severe TBI ranged from 6% to 46% and 2% to 68.6% respectively. In studies which enrolled patients with GCS motor score=8 or=12, there were more moderate or severe TBI, according to initial GCS. In studies that enrolled patients with all severity levels, the overall mild: moderate: severe ratio was 55: 27.7: 17.3 based on the GCS.

General outcome: Outcome, as measured by the GOS score, was reported in 16 studies (Table 2) of 16 studies provided by GOS score, 4 reports gave GOS data at the time of discharge, 4 reports gave GOS data at six months, 3 reports gave GOS data at one year, 1 report gave GOS data at three months. The proportion of good recovery (a GOS of 5) varied between 18% and 97% and that of moderate disability (a GOS of 4) varied between 2% and 30%. The severe disability (a GOS of 3) ranged from 0.5% to 25% and vegetative state (a GOS of 2) ranged from 0.7% to 10%. Death accounts for 3%-52% of the total outcome. In studies which enrolled patients with a GCS motor score =8 or =12, death was the most common outcome. In studies which enrolled patients with all severity levels, good recovery was the major clinical outcome.

External causes: 42 studies gave data on external cause or mechanism of injury. The causes of TSCI are summarized in Table 3. In Asian countries such as China, Pakistan, Iran and Japan, the main cause of TBI was MVCs. In North America, falls were the leading causes in both United States and Canada. The leading cause of TBI in Australia, France, Spain, Austria, England, Croatia, Slovakia, Bosnia, Macedonia, Netherland and Italy were MVCs whereas falls were the most common reason in New Zealand, Sweden, Scotland, Norway and Finland.

The MVC-related TBIs were the most common cause (42.4%) in developing countries whereas the fall-related TBIs (34.4%) were the most common cause in developed countries (Figure 2). Developed countries have significantly higher percentage of sport-related TBIs as compared to developing countries (18.2% versus 1%). No data were available for work-related TBIs in Developing countries. A comparison of etiology in different continent based on aggregated data is shown in Figure 3. The percentage of MVC-related TBIs from low to high were in 22.3% in North America, 29% in Europe, 35.8% in Oceania and 42.4% in Asia. Europe had the highest percentage of fall-related TBIs (47.4%) and work-related TBIs (8.5%) as compared to other continents. No data were available on work-related TBIs to Asian. North America (19.8%) followed by Oceania (12.1%) had the highest percentage of sport-related TBIs as compared to other continents.

Figure 2: A comparison of etiology between developing countries and developed countries.

    

    
    

    

    Figure 2:  A comparison of etiology between developing countries and
developed countries.

Figure 3: A comparison of etiology between North America, Europe, Oceania and Asian.

    

    
    

    

    Figure 3:  A comparison of etiology between North America, Europe, Oceania
and Asian.

Discussion

Cases of different age groups represent different epidemiological features. This systemic review excluded studies with an age restriction in order to draw universal conclusions. However, the epidemiological features were quite different in elderly and children. There was a trend of aging of the population with TBI [22]. Older adults acquired TBI due to an increased life expectancy and greater mobility in elderly. Falls are the most common cause of TBI in older adults [23]. Mortality rates for older people with mild TBI were higher than for their younger counterparts [24]. In studies that have examined disability after TBI, older adult TBI survivors had better outcomes than younger survivors using GOS [25]. As a result of the longer hospital stays in older adults, the cost of their care is significantly greater.

Causes of injury vary with child developmental age, with more inflicted injuries in infants, fall-related injuries among toddlers, sports-related injuries among middle-school-aged children and motor vehicle crashes in older children [26]. One half of severely injured children suffered poor outcomes [27]. Their outcomes were correlated with the severity of injury, child age at injury, pre-morbid child characteristics, family factors and the families’ socioeconomic status [26].

Another factor which affects the mechanism of injury and its outcome was local income. In high-income countries, individuals with TBI are generally motor-vehicle occupants, whereas in middleincome and low-income countries patients with TBI are often vulnerable pedestrians, cyclists and motorcyclists [22]. The most common cause of TBI in developing countries was MVCs. Increased use of motor vehicles, a lack of awareness of safety, and delayed implementation of traffic safety regulations account for these MVCrelated TBIs. The traffic safety regulations were demonstrated to be effective in Taiwan, where implementation of the motorcycle helmet law decreased the incidence of motorcycle-related TBI by 33% [5].

Military subjects were considered to have a higher incidence rate and more severe as compared to civilians. It is reported that the overall TBI mortality rates in the US civilian population declined in the 1980 and 1990s. An analysis by severity shows that severe TBI incidence rates rose, moderate TBI rates were level, and mild TBI hospitalizations dropped dramatically. However, a decrease in TBI hospitalization was reported for all severity levels in military subjects during the 1990s [28]. A study by Orman et al. described penetrating brain injury from the wars in Iraq and Afghanistan. 69.8% of penetrating TBIs were caused by explosions. Explosions were the leading cause of combat-related injuries (74%-78%) followed by gunshot wounds [29].

The leading cause in different countries was studied in this article. Fall prevention programs should be implemented to reduce the incidence of TBI in United States, Canada, New Zealand, Sweden, Scotland, Norway and Finland. More specific traffic regulations, strict management and profound education on road safety were required in China, Pakistan, Iran, Japan, Australia, France, Spain, Austria, England, Croatia, Slovakia, Bosnia, Macedonia, Netherland and Italy.

Conclusion

Men were at higher risk of TBI than women. The average age at the time of TBI ranged from 27 to 59.67 years while the median age ranged from 29 to 45 years. The overall mild: moderate: Severe ratio was 55: 27.7: 17.3 based on Glasgow Coma Scale (GCS). Motor vehicle collision (MVC) was the leading cause of TBI in China, Pakistan, Japan, Australia, France, Spain, Austria, England, Croatia, Slovakia, Bosnia, Macedonia, Netherland and Italy, whereas fall was the leading cause in The United States, Canada, New Zealand, Sweden, Scotland, Norway and Finland. The MVC-related TBIs were the most common causes in developing countries, whereas the fallrelated TBIs were the most common causes in developed countries. The percentage of MVC-related TBIs were the highest in Asia. Europe had the highest percentage of fall-related TBIs and work-related TBIs. North America, followed by Oceania, had the highest percentage of sport-related TBIs.

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Citation: Li M, Zhao Z, Yu G and Zhang J. Epidemiology of Traumatic Brain Injury over the World: A Systematic Review. Austin Neurol & Neurosci. 2016; 1(2): 1007.