Head injury complicating falls and syncope: State of the art

Giles CritchleyConsultant NeurosurgeonHurstwood Park Neurological CentreBrighton and Sussex University Hospitals NHS

Trust

The problem

.....the other silent epidemic – falls and injuries in the home.These accidents increasingly involve our aging population and result in significant disability and death.

The problem

Traumatic brain injury

1. Epidemiology – Socio demographic factors

2. Mechanism of injury – falls and syncope

3. Efficiency of healthcare system – ‘State of the art’

Incidence of traumatic brain injury in different populations (selected studies)

Elderly ratesage range yrs inc per 100,000

USA Kraus, Nourjah 1989 65-75 200 Cooper et al 1983 60-80 150-200

FinlandKannus et al 2007 male 80-84 465

85-89 61790 > 976 female 80-84 39785-89 60890> 735

Age-specific rates of head injury hospitalization in Ontario, overall 1994/95 through 1998/1999 (from the Minimal Data

Set of the Ontario Trauma Registry)

Socio – demographic factors

• Age – trimodalchildren 0-4 yrs

young adults 15 -19 yrselderly 75 >

yrs

• Gender – male 3: 1

Causes of head injury – all ages

European Brain Injury Consortium – those admitted to neurosurgical unitsRTA 51% Falls 12% Assault 7%

CRASH study

RTA 64% Falls 13%

USA, 1995–2001

Causes of head injury – elderly

age yrs distributionIndia (Sinha et al 2008) 60> falls 56.3% RTA 44.1%Singapore(Gan et al 2004) 64> falls 73.8% RTA

21.5%

Ireland (Phillips report 2008) 25%>65 falls 59% RTA 22%

Socio – demographic factors

Falls – 60% at home

Alcohol – 25% falls associated with alcohol

In NSU fall patients :-Aspirin – 14%Warfarin – 8%

Mechanism of injury – falls and syncope

Definition of falls: FICSIT, ICD , < 1metreClassification: explained, unexplained

intrinsic, extrinsicrecurrent, non recurrent

Syncope: a transient loss of consciousness due to cerebral iscaemia

Mechanism of injury – falls and syncope

40-60% of falls lead to injuries.Low impact injuriesFewer multiple injuriesBUTMore severe CT findings – mass lesions,

SAH, mid line shift

Pattern of injury

diagnosis – CT scanning (MRI)

• Chronic subdural haematoma• Contusions• Acute subdural haematoma

Chronic subdural haematoma

Chronic subdural haematoma

• mean age around 71 yrs (74 yrs 20-91)

• head trauma identified in < 50%

• ‘soft’ neurological signs

Chronic subdural haematoma - treatment

• Burr hole drainage – local/ GA• Twist drill craniostomy• Mini craniotomy – GA

• Randomised control trial

Use of drains versus no drains after burr-hole evacuation of chronic subdural

haematoma: a randomised controlled trial.T. Santarius et al Lancet. 2009 Sep 26;374(9695):1067-

73.

108 patients drain into subdural space107 no drainRecurrences: no drain 24% (26 /107)

with drain 9.3% (10 /108)

Mortality at 6 months: no drain 18.1% (19/105)with drain 8.6% (9/105)

Acute subdural haematoma

Acute subdural haematoma

Trauma craniotomy

Acute subdural haematoma

more common 30% of severe HImanifestation of parenchymal damagepoor prognosis – 45% mortality

in elderly 79% mortality

Management

Conservative – allow to become chronic

Cerebral contusions

Coup/contrecoup

Frontal / temporal

Mass effect

Cerebral contusions

• Supportive management• In one series of elderly 19.3% of

geriatric head injuries• Mortality 40%

Outcome

• Elderly have a worse outcome, lower admission GCS – more likely unfavourable outcome

• Moderate TBI in elderly similar to severe TBI in younger

• Outcome of mild TBI worse

Outcome

Reasons: decreased functional reserveloss of elasticity of blood vesselscerebral atrophybridging veins hypertension

Outcome

• Apoprotein E4 (APOE 4)• Patients with APOE episilon 4 allelle

more than twice as likely to have a poor outcome.

• TBI and APO E increased risk of Alzheimer’s 10 fold.

Factors leading to falls

• Weakness• Balance deficit• Mobility limitation• Visual deficit• Cognitive impairment• Postural hypotension

Prevention

• Ward design• Tai chi• Stair design• Lighting

• Helmet use in multiple fallers

The Haddon Matrix

Phase People Vehicle and equipment

Environment

Pre accident (prevention)

EducationAttitudes/behaviourImpairment (alcohol, drugs, fatigue)Police enforcement (traffic laws)Reflective clothing for pedestrians and cyclists

RoadworthinessLighting (daytime lights on motorcycles)Braking and handling

Speed limitation systems

Road design and layout (separation of car, cyclists, and pedestrians; better road marking and lighting)Speed limitsProvision of transport alternatives

Accident Use of seat belts Impairment (drink driving)

Crash-protective design and engineeringOccupant restraints and safety devices (seat belts, air bags, child restraints)

Use of helmets

Crash-protective roadside barriers/objects (centre isle barrier, pedestrian crossing)

Post accident First aid and resuscitationAccess to medical and rehabilitation services

Ease of accessFire risk

CCTV at danger points

Access for rescue services

(congestion) Adapted from, WHO, Geneva, 2004, Queensland Australia 2004 fall

prevention.

The Haddon Matrix - falls

Phase People Vehicle and equipment

Physical environment

SocialEnvironment

Pre - fall EducationAttitudes/behaviourImpairment (alcohol, drugs, fatigue)Bone density,Flexibility, balance and strength

Appropriateness of type of shoe (eg slippers)

Non slip flooringrails on all stairsRationalisation of medicationsLighting

The inevitability of older people falling over and having accidents.Safe physical activity in older people

Accident - fall

Human tolerances to crash forces.Use of helmets

Proper use of helmets Height of fall and surface fallen onto.Contact with other objects

Anti-slip flooring requirements in public places, hospitals and residential elderly care facilities

Post fall Fall victims general health, fractures and other injuries

Personal alarm systems Availability of a timely and effective medical response

Public support for trauma care and rehabilitation

Adapted from World report on road traffic injury prevention, WHO, Geneva, 2004. a

Conclusions

• Falls are an increasing cause of head injury ‘silent epidemic’

• Age is an independent predictor in outcome

• This increasing public health problem requires a multidisciplinary approach for prevention, treatment and rehabilitation of elderly patients