Intensive Care Unit Treated Traumatic Brain Injury from Leisure-Time Sport Injuries: A Retrospective Single Center Descriptive Report

Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Few previous studies have looked at TBIs acquired from leisure-time sport activities. We report a case-series of patients with TBI in a neurosurgical ICU of Helsinki University Hospital due to leisure-time sport injury mechanisms. The patients were screened from the University of Helsinki Neurotrauma database from 2010 to 2015 consisting of 1,284 TBI patients. Outcome variables were 6-month mortality and 6-month neurological outcome dichotomized according to the Glasgow Outcome Scale (GOS). Twenty one leisure-time sport injuries with TBI were identified from the database. At the admission to the hospital, all of the patients were diagnosed with TBI of intermediate or severe difficulty. The most common etiology (12 patients) was fall from horseback. Thirteen of the patients underwent neurosurgical procedure, namely ICP sensor placement, craniotomy and evacuation of hematoma or decompressive craniectomy. Eighteen of the patients had favorable outcome in 6-month followup time. Two patients died during this time. Juho Vehviläinen*, Jari Siironen and Rahul Raj Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Finland Juho Vehviläinen, et al., Sports Medicine and Rehabilitation Journal Remedy Publications LLC. 2017 | Volume 2 | Issue 3 | Article 1024 2 horseback (N=12) with majority of patients being female in this subset (N=9/12). The second-numerous etiologies were motocross accidents (outside traffic areas) and falls during downhill skiing (2 patients in each group). Rest of the patients had suffered the TBI in different team sports (soccer, ice hockey and basketball). Median GCS was 9 (IQR 6-14). Nine of 12 of the patients were intubated when admitted to hospital. Five patients had at least major extracranial injury. Eighteen patients’ both pupils were reacting to light on admission, two patients had one pupil reacting to light on admission and one patient’s both pupils were unresponsive to light on admission. Median Helsinki CT score was 4 (IQR 2-5). More than half of the patients (N=13) underwent a neurosurgical procedure during their treatment at the ICU. The most common was placing an intracranial pressure sensor (ICP), which was performed on six patients (5 had favorable outcome). Four patients needed craniotomy and evacuation (CRT) of a hematoma (all had favorable outcome). Two patients needed decompressive hemicraniectomy (DHC), both had unfavorable outcome. The length of ICU treatment varied from 1 day to 17 days with median being 4 days (IQR 2-10). Patients undergone neurosurgical procedures were treated longer in the ICU (median 6 days, IQR 2-12) compared to conservatively treated patients (median 2 days, IQR 1-5). Three patients had unfavorable outcome (GOS 1-3) at 6-month follow-up and two of these patients died during this time. The rest of the patients, 18 out of 21 had favorable outcome (GOS 4-5) at 6-month follow-up. The patients with unfavorable outcome had admission GCS scores of 6, 3 and 7 and Helsinki CT scores of 5, 7, and 5, respectively. Two of patients with unfavorable outcome required DHC. The high number of injuries originated from fall from horseback compared to any other etiology of leisure-time sport injury in our dataset arises likely from the popularity of horseback riding in Finland. According to The Equestrian Federation of Finland estimate there are 170,000 riders just in Finland alone [10]. Further, the fall itself from horseback can be easily from a height over two meters. This, combined with light safety equipment worn by riders compared to for example motocross riders, increases the risk of TBI or a traumatic neck injury in a fall. According to our data, there is no clear connection between age and sex when compared to mortality or favorability of outcome in 6-month follow-up. Also, one might expect that leisure-time sport activity TBIs requiring ICU treatment occur only to young individuals in so-called extreme sports, however, our data suggest that the patients are almost from all age groups. The strength of this dataset is the large catchment area of the neurosurgical ICU (2 million people). However, the limitation is that in our database we only have those TBI patients admitted to the ICU. This means that the patients are diagnosed initially TBI of at least moderate severity. Taken that in Finland approximately 20,000 people [11] are estimated to suffer some level of TBI annually, our data only represents the most difficult cases. Furthermore, due to the geographical position of our institution it is not surprising the lack of e.g. winter sports injuries that probably are more common in the Northern parts of Finland. Patient Age Sex Injury mechanism Admission GCS score (t if intubated) Pupils MEI Helsinki CT score Neurosurgical procedure Length of ICU stay 6-month mortality 6-month GOS 1 56 Male Fall from horseback 6t Both 0 5 DHC 17 1 Unfav 2 61 Male Fall from horseback 14 Both 1 2 ICP 2 0 Fav 3 63 Female Fall from horseback 13 Both 1 2 None 2 0 Fav 4 42 Female Fall from horseback 14 Both 0 5 None 1 0 Fav 5 37 Male Motocross accident 7t Both 1 2 None 14 0 Fav 6 28 Male Soccer 12 One 0 4 CRT 4 0 Fav 7 15 Female Fall from horseback 7t Both 0 2 ICP 3 0 Fav 8 8 Female Fall from horseback 6t Both 0 2 None 1 0 Fav 9 41 Female Fall from horseback 3t Both 0 9 CRT 11 0 Fav 10 21 Male Motocross accident 7t Both 1 4 None 6 0 Fav 11 16 Male Motocross accident 3t None 0 7 DHC 2 1 Unfav 12 1 Male Fall from horseback 15 Both 0 5 None 4 0 Fav 13 11 Male Downhill skiing 6t Both 1 2 ICP 6 0 Fav 14 19 Male Downhill skiing 14 Both 0 2 ICP 8 0 Fav 15 15 Female Fall from horseback 13 Both 0 2 None 2 0 Fav 16 25 Female Downhill skiing 6 Both 0 5 CRT 15 0 Fav 17 26 Male Ice hockey 15 Both 0 2 CRT 1 0 Fav 18 47 Male Basketball 13 Both 0 4 None 1 0 Fav 19 17 Female Fall from horseback 7t One 0 5 ICP 12 0 Unfav 20 60 Female Fall from horseback 15 Both 0 4 None 2 0 Fav 21 32 Female Fall from horseback 12 Both 0 2 ICP 5 0 Fav Table 1: Patient description. Abbreviations: Pupils: Pupils Dilated; MEI: Major Extracranial Injury (0 = no, 1 = yes); GCS: Glasgow Coma Scale; ICU: Intensive Care Unit; GOS: Glasgow Outcome Scale; DHC: Decompressive Hemi Craniectomy; ICP: Intracranial Pressure sensor; CRT: Craniotomy Juho Vehviläinen, et al., Sports Medicine and Rehabilitation Journal Remedy Publications LLC. 2017 | Volume 2 | Issue 3 | Article 1024 3 Conclusions Our data from the Helsinki Neurotrauma database indicates that moderate-to-severe TBIs originating from leisure-time sport activity are rather rare, 21 out of 1,284 admissions during years 2010-2015. Notably, the most common etiology for leisure-time sport activity TBI was fall from horseback. The majority of patients 18 out of 21 had favorable outcome in 6-month follow-up. Two patients died in the follow-up period.