Age-stratified outcomes after small-volume isolated blunt traumatic brain injury: A national ACS-TQIP analysis

Small-volume traumatic brain injuries (TBIs) are often considered low risk clinically, but older adults may face disproportionate adverse outcomes. Evidence outlining age-specific risks related to limited subdural hematomas (SDH), epidural hematomas (EDH), and cerebral contusions remains limited.

We performed a retrospective cohort study using data from the American College of Surgeons Trauma Quality Programs Participant Use File (ACS-TQIP-PUF), 2017-2022. Adults aged 40 years and older with isolated blunt TBI were included, excluding skull fractures and multisystem trauma (AIS >1 in non-head regions). Injuries were classified as SDH ≤ 8 mm, EDH ≤ 8 mm, or contusions ≤ 2 cm. Patients were stratified by age (40-64 vs. ≥65 years). Subtype-stratified multivariable logistic regression examined associations between age group and (1) in-hospital mortality and (2) emergency department (ED) disposition to the intensive care unit (ICU), adjusting for demographics, comorbidities, injury severity, trauma center level, neurosurgical procedures, anticoagulation, and venous thromboembolism prophylaxis.

The cohort included 135,343 patients, with SDH accounting for 93.2% of cases. Unadjusted in-hospital mortality was higher in elderly patients (≥65 years) than middle-aged adults (40-64 years) across all subtypes: SDH (2.5% vs. 1.5%), EDH (2.1% vs. 1.3%), and contusion (2.0% vs. 0.9%). Unadjusted ICU admission rates were comparable across age groups (SDH: 45.0% vs. 44.7%; EDH: 46.1% vs. 47.3%; contusion: 44.2% vs. 44.2%). On multivariable analysis, elderly patients had significantly higher adjusted odds of in-hospital mortality across all subtypes: SDH (OR 1.774, 95% CI 1.542-2.043), EDH (OR 1.589, 95% CI 1.053-2.397), and contusion (OR 1.591, 95% CI 1.169-2.165). Elderly patients with EDH were more likely to be admitted to the ICU from the ED (OR 1.144, 95% CI 1.020-1.283). Other factors independently associated with mortality included male sex, pre-injury anticoagulation, neurosurgical intervention, renal failure, and functional dependence.

Among adults with radiographically small-volume isolated TBIs, advanced age is independently linked to increased in-hospital mortality and higher likelihood of ICU admission, especially in EDH. These findings challenge the notion that limited intracranial hemorrhage is clinically harmless in older adults and support age-specific risk assessment in ED triage and critical care decisions.