Traumatic brain injury: an underappreciated public health issue
Authors: Mark H Wilson
Journal: The Lancet Public Health (2016)

The public health consequences of traumatic brain injury (TBI) are currently woefully underappreciated. The burden created is often presented as number of deaths and injuries, with the cost calculated by the expense of ongoing care. However, many patients and their families live with the psychological consequences of minor TBI that have hidden costs such as the inability to hold down work, disinhibited (often aggressive or easily agitated) behaviour, and altered mood states.1Kim E Agitation, aggression, and disinhibition syndromes after traumatic brain injury.NeuroRehabilitation. 2002; 17: 297-310PubMed Google Scholar The increased incidence of brain injury within vulnerable populations—especially homeless people,2Oddy M Moir JF Fortescue D Chadwick S The prevalence of traumatic brain injury in the homeless community in a UK city.Brain Inj. 2012; 26: 1058-1064Crossref PubMed Scopus (46) Google Scholar and the prison3Williams WH Mewse AJ Tonks J Mills S Burgess CNW Cordan G Traumatic brain injury in a prison population: prevalence and risk for re-offending.Brain Inj. 2010; 24: 1184-1188Crossref PubMed Scopus (125) Google Scholar and refugee4Doherty SM Craig R Gardani M McMillan TM Head injury in asylum seekers and refugees referred with psychological trauma.Global Mental Health. 2016; 3: e28Crossref Google Scholar populations—is considerable, and many of these people enter a downward spiral of head injury associated with altered behaviour, alcohol, and further head injuries.5McMillan TM Teasdale GM Stewart E Disability in young people and adults after head injury: 12–14 year follow-up of a prospective cohort.J Neurol Neurosurg Psychiatr. 2012; 83: 1086-1091Crossref PubMed Scopus (70) Google Scholar Such escalation probably contributes to the substantially shortened life expectancy observed after mild TBI compared with other forms of injury.6McMillan TM Teasdale GM Death rate is increased for at least 7 years after head injury: a prospective study.Brain. 2007; 130: 2520-2527Crossref PubMed Scopus (61) Google Scholar In The Lancet Public Health, Marek Majdan and colleagues7Majdan M Plancikova D Brazinova A et al.Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis.Lancet Public Health. 2016; 1: e76-e83Summary Full Text Full Text PDF PubMed Scopus (224) Google Scholar used the best data available to attempt to quantify the burden of TBI across Europe. The currently unavoidable differences in coding however mean that comparisons between countries are limited. For example, it is hard to explain a range of admission rates that varies between 0·3% and 44%, or a mean length of stay from 3 days (Norway) to 21 days (Malta) as differences in quality of care. For TBI comparisons to be meaningful, a variable that reflects severity of disease is crucial. The traditional measure of initial Glasgow Coma Score is poor at reflecting differences in TBI. A tool quantifying the nature of the condition (extradural, subdural, contusion, diffuse axonal injury) and the severity of the injury (mild, moderate, severe) would give considerably more granular data and allow meaningful comparisons. The uptake of EuroTARN—the Trauma Audit and Research Network, and the use of the Abbreviated Injury Scoring system might enable such comparisons. Similarly, the comparative analysis work of the Center-TBI project,8Maas AIR Menon DK Steyerberg EW et al.Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study.Neurosurgery. 2015; 76: 67-80Crossref PubMed Scopus (298) Google Scholar which is studying TBI across Europe might give more insights into the demographics of TBI and the comparative outcomes from differences in management. However, such collaborations and analyses will reflect TBI management at those centres that have the capacity and resources to undertake Center-TBI. As such, hospitals recruiting to the study might not be representative of hospitals in poorer areas of the same country. Despite these limitations, the authors have used the best data available to provide an interesting and much needed glimpse into the epidemiology of TBI across Europe. This Article demonstrates the need for a unified approach to the classification and recording of brain injury. Recording of these data in a consistent manner is key to be able to estimate the burden of TBI accurately, and to evaluate the impact of public health measures (eg, alcohol control, public safety initiatives) that are initiated to tackle TBI, accordingly. Trauma is a disease that affects the poorer and more vulnerable members of society;9Hauser WA Beghi E First seizure definitions and worldwide incidence and mortality.Epilepsia. 2008; 49: 8-12Crossref PubMed Scopus (173) Google Scholar brain injury specifically leads to a cycle of yet further vulnerability. I declare no competing interests. Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysisTBI is an important cause of death and hospital admissions in Europe. The substantial between-country differences observed warrant further study and suggest that the true burden of TBI in Europe has not yet been captured. Rigorous epidemiological studies are needed to fully quantify the effect of TBI on society. Despite a great degree of consistency in data reporting across countries already being achieved, further efforts in this respect could improve the validity of between-country comparisons. Full-Text PDF Open Access