Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP])

Results of therapy in children diagnosed with severe traumatic brain injury

The aim of this research is to enhance therapeutic outcomes in children diagnosed with severe craniocerebral trauma by evaluating the contributing factors involved in cerebral injury. The investigation focused on evaluating the impact of infusion therapy on the improvement of pediatric patients' conditions with SCCT, particularly by assessing hydrobalance indicators. Adaptive changes associated with the humoral stress response were evaluated through alterations in hormone concentrations (thyrotropin (TSH), cortisol (C), prolactin (P)). Concentrations of plasma protein and glucose were analyzed. A total of 804 children with isolated severe craniocerebral trauma (SCCT) were enrolled and stratified into retrospective (n = 474) and prospective (n = 100) cohorts. Children with negative hydrobalance exhibited a higher mortality rate compared to those with positive hydrobalance (24% vs. 10%, p ≤ 0.05). Positive hydrobalance, in conjunction with appropriate infusion therapy and rehydration, positively influenced the prognosis of severe cranio-cerebral trauma (SCCT). These findings can be applied in clinical practice to optimize the treatment of children with SCCT and improve their prognosis. The level of total protein was higher in conscious children after 48 h (59.9 ± 1.5 g/L, p ≤ 0.05) in comparison to deceased individuals (54.9 ± 1.6 g/L, p ≤ 0.05). Stress-induced hyperglycemia was associated with the severity of severe cranio-cerebral trauma. The study corroborated the significance of infusion therapy in the treatment of children with SCCT. Indicators of total protein, glucose, and P concentrations can serve as valuable tools for assessing the severity and prognostication of SCCT.

Enhancing Nutrient Profile and Reducing Acrylamide in California-Style Table Olives with Cassia grandis Fortification

In this study, Californian-style black table olives were enriched with fresh and lyophilized "Carao" (Cassia grandis L.) to enhance their mineral composition, antioxidant activity, phenolic compound content, and to evaluate their potential for reducing acrylamide levels. Mineral concentrations were quantified using inductively coupled plasma optical emission spectrometry (ICP-OES). The addition of both fresh and lyophilized "Carao" significantly increased the iron concentration in the olives. Additionally, levels of calcium, magnesium, and potassium were elevated in both "Carao" treatments. Among the treatments, the addition of fresh "Carao" resulted in the highest increase in antioxidant activity, followed by the lyophilized "Carao", with increases of 62.3% and 68.3%, respectively. The effect of fresh and lyophilized "Carao" on acrylamide reduction in oxidized olives is also discussed.

BOOTStrap-SCI: Beyond One option of treatment for spinal trauma and spinal cord injury: Consensus-based stratified protocols for pre-hospital care and emergency room (part I)

Introduction

Spinal trauma (STx), with or without spinal cord injury (SCI), represents a significant global health burden, particularly in low- and middle-income countries (LMICs). Existing guidelines often rely on tools and resources that are not always universally available, especially in less resourced settings, contributing to disparities in care and outcomes. A pragmatic, resource-adapted approach may help optimize management in these contexts.

Research question

This study aimed to develop resource-adapted protocols for pre-hospital and emergency room management of STx and SCI, addressing challenges specific to LMICs while supported by clinical evidence and expert based practices.

Material and methods

A multidisciplinary Delphi consensus combined international evidence-based guidelines with expert opinions. Iterative discussions and voting by healthcare providers from LMICs and high-income countries (HICs) ensured the development of context-sensitive protocols. These were tailored to varying levels of training, resource availability, and healthcare infrastructure.

Results

The resulting protocols address key areas of pre-hospital and emergency management, including initial resuscitation, immobilization, clinical interventions, and timely referral. These protocols emphasize adaptability, providing structured plus flexible guidance for optimizing care according to specific contexts from low to high resourced clinical settings.

Discussion and conclusion

The proposed protocols are not intended as gold-standard guidelines but as adaptable frameworks to guide management of STx/SCI in contexts with different availability of resources. By addressing disparities in resource availability and clinical competencies, they can serve as a foundation for local adaptations and improvements in care. Future research should evaluate their implementation and impact on outcomes.

Current status of neurotrauma management in resource-limited settings

Over the last several decades neurotrauma has become recognized as a significant contributor to poor health outcomes, with growing physical, cognitive, social, and economic burdens. Although it serves as a significant contributor globally, it disproportionately affects low- and middle-income countries (LMIC). In this manuscript, we will be comparing how neurotrauma is managed across the globe with special consideration on how variations in environment, resources, infrastructure, and access can influence patient care and outcomes. Moreover, we will be examining the challenges faced by health care systems in LMIC and exploring strategies for quality improvement.

Development and Validation of a Neuro-Intensive Care Protocol for Traumatic Brain Injury Management

Introduction Traumatic brain injury (TBI) is a global public health concern with high mortality and disability rates, particularly among younger populations. Structured treatment protocols might improve outcomes and reduce mortality. This study aims to develop and validate the Neuro-Intensive Care Protocol for TBI (NICP-TBI) using the Medical Research Council framework for designing and evaluating complex interventions. Methods The protocol was developed using a systematic literature review, expert consensus, and validation. A 15-member multidisciplinary expert consensus group used the Delphi consensus method to refine the protocol, achieving a consensus threshold of 80%. Validation involved a seven-member expert group evaluating the protocol's relevance, clarity, comprehensiveness, and appropriateness using a five-point Likert scale. The Content Validity Index (CVI) was calculated. Results The NICP-TBI incorporated interventions from clinical practice guidelines and evidence-based protocols. It established clear treatment goals and interventions for each parameter concerned such as airway, ventilation, systemic and cerebral perfusion, intracranial pressure (ICP), sedation, seizure prophylaxis, fluid management, nutrition, infection prophylaxis, temperature management, venous thromboembolism (VTE), blood glucose management, positioning, tapering treatment and family involvement in care. The protocol used a tiered structure adaptable to resource-limited settings. The Delphi process reached a 99.2% final consensus after five rounds, and the CVI was determined to be 1, confirming high validity. Conclusions The NICP-TBI provides a structured, evidence-based framework for managing moderate and severe TBI. The protocol's consensus-driven development, tiered approach in management, and expert validation ensure its applicability across diverse clinical settings, including resource-limited environments. This study highlights the importance of expert consensus and validation in developing effective critical care protocols.

The epidemiology of motorcycle-related acute traumatic brain injury: The NOMADEN study

Background

Although persisting to be a public health hazard in Indonesia, motorcycle-related traumatic brain injury (TBI) due to road traffic accidents (RTA) lacks comprehensive national data. We aim to study the epidemiological pattern of motorcycle-related TBI and analyze the determinants related to mortality in the only neurosurgical center in the rural province of North Maluku, Indonesia.

Methods

Using the North Maluku Database in Neurosurgery register, information regarding age, sex, health insurance, alcohol use, point of referral, degree of severity, brain computed tomography abnormalities, helmet use, surgery, injury-to-admission time (IAT), and relationship to the motorcycle were obtained from patients admitted to Chasan Boesoirie General Hospital, Ternate, in 2021-2022. Multivariable logistic regression analysis was performed to investigate associations with in-hospital mortality.

Results

Of all RTA-related TBI patients (n = 353), 91.8% (n = 324) were caused by motorcycle collision (mean age ± standard deviation of 30.5 ± 16.7 years old). The majority were motorcyclists (66.7%), male (64.8%), IAT >4 h (55.9%), financed by non-Jaminan Kesehatan Nasional mechanism (66.4%), not under alcohol influence (78.4%), referred from Ternate (55.2%), and suffered mild TBI (75%). Thirty patients (9.3%) succumbed to death. Moreover, 9.3% and 91.2% were ≤17 years old and helmetless. Glasgow coma scale and IAT were significantly associated with in-hospital mortality (odds ratio [95% confidence interval]: 0.58 [0.49-0.68] and 5.44 [1.00-30.34], respectively).

Conclusion

The young and productive males dominated the motorcycle-related TBI patients in North Maluku. Poor compliance with road traffic laws, as demonstrated by a considerable proportion of underage, alcohol-intoxicated, and helmetless patients, necessitated prompt actions from all related elements.

Low-Cost Strategies for the Development of Neurocritical Care in Resource-Limited Settings

This review explores low-cost neurocritical care interventions for resource-limited settings, including economical devices, innovative care models, and disease-specific strategies. Devices like inexpensive ventilators, wearable technology, smartphone-based ultrasound, brain4care, transcranial Doppler, and smartphone pupillometry offer effective diagnostic and monitoring capabilities. Initiatives such as intermediate care units, minimally equipped stroke units, and tele-neurocritical care have demonstrated benefits by reducing hospital stays, preventing complications, and improving clinical and economic outcomes. The review emphasizes locally applicable tailored approaches for diagnosing and managing conditions such as traumatic brain injury, neuroinfections, status epilepticus, autoimmune neurological disorders, and acute stroke as viable and affordable solutions.

Equitable and effective clinical guidance development and dissemination: trauma aims to lead the way

Thirty-four per cent of deaths among Americans aged 1-46 are due to injury, and many of these deaths could be prevented if all hospitals performed as well as the highest-performing hospitals. The Institute of Medicine and the National Academies of Science, Engineering and Medicine have called for learning health systems, with emphasis on clinical practice guidelines (CPGs) as a means of limiting preventable deaths. Reduction in mortality has been demonstrated when evidence-based trauma CPGs are adhered to; however, guidelines are variably updated, redundant, absent, inaccessible, or perceived as irrelevant. Ultimately, these barriers result in poor guideline implementation and preventable patient deaths. This multidisciplinary group of injury providers, clinical guidance developers and end users, public health and health policy experts and implementation scientists propose key areas for consideration in the definition of an ideal future state for clinical guidance development and dissemination. Suggestions include (1): professional societies collaborate rather than compete for guideline development.(2) Design primary clinical research for implementation, and where relevant, with guideline development in mind.(3) Select clinical topics for guideline development through systematic prioritization, with an emphasis on patient-centered outcomes.(4) Develop guideline authorship groups with a focus on transparency, equity of opportunity and diversity of representation.(5) Establish a plan for regular review and updating and provide the date the guideline was last updated for transparency.(6) Integrate options for adapting the guideline to local resources and needs at the time of development.(7) Make guidelines available on a platform that allows for open feedback and utilization tracking.(8) Improve discoverability of guidelines.(9) Optimize user-experience with a focus on inclusion of bedside-ready, mobile-friendly infographics, tables or algorithms when feasible.(10) Use open access and open licenses.(11) Disseminate clinical guidance via comprehensive and equitable communication channels. Guidelines are key to improve patient outcomes. The proposed focus to ensure trauma guidelines are equitably and effectively developed and disseminated globally.

Nanoparticle targeting strategies for traumatic brain injury

Nanoparticle (NP)-based drug delivery systems hold immense potential for targeted therapy and diagnosis of neurological disorders, overcoming the limitations of conventional treatment modalities. This review explores the design considerations and functionalization strategies of NPs for precise targeting of the brain and central nervous system. This review discusses the challenges associated with drug delivery to the brain, including the blood-brain barrier and the complex heterogeneity of traumatic brain injury. We also examine the physicochemical properties of NPs, emphasizing the role of size, shape, and surface characteristics in their interactions with biological barriers and cellular uptake mechanisms. The review concludes by exploring the options of targeting ligands designed to augment NP affinity and retention to specific brain regions or cell types. Various targeting ligands are discussed for their ability to mimic receptor-ligand interaction, and brain-specific extracellular matrix components. Strategies to mimic viral mechanisms to increase uptake are discussed. Finally, the emergence of antibody, antibody fragments, and antibody mimicking peptides are discussed as promising targeting strategies. By integrating insights from these scientific fields, this review provides an understanding of NP-based targeting strategies for personalized medicine approaches to neurological disorders. The design considerations discussed here pave the way for the development of NP platforms with enhanced therapeutic efficacy and minimized off-target effects, ultimately advancing the field of neural engineering.

Neurosurgical Advocacy in the Prevention of Neural Tube Defects: Impacting Global Fortification Policies Through Leadership, Collaboration, and Stakeholder Engagement

The G4 Alliance and its member organizations formed a delegation that participated in the 76th World Health Assembly (WHA) in 2023, which unanimously adopted the resolution to address micronutrient deficiencies through safe, effective food fortification to prevent congenital disorders such as spina bifida and anencephaly, the first neurosurgery-led resolution since the founding of the World Health Organization. The WHA included other resolutions and side events by the G4 Alliance and other organizations relevant to neurosurgery. An opportunity exists for neurosurgeons to harness the momentum from this resolution to promote initiatives to prevent neurosurgical disease or expand access to neurosurgical care.

Global Neurosurgery: An Overview

In the following article, we define the practice of global neurosurgery and review the major historical events defining this movement within the larger context of global surgery. The current state of the neurosurgical workforce, disease burden, and ongoing collaborative efforts are highlighted. Ethical practice leading the sustainability is discussed, as well as future targets for the global community as we look beyond the next decade of opportunities to affect the neurosurgical burden of disease.

Global Neurosurgery at the 76th World Health Assembly (2023): First Neurosurgery-Driven Resolution Calls for Micronutrient Fortification to Prevent Spina Bifida

Since 2018, a neurosurgery delegation has been actively engaged and consistently present at the World Health Assembly. Recognizing the growing impact of neurosurgical diseases, the neurosurgery delegation participated in the 76th World Health Assembly in May 2023, advocating for timely, safe, and affordable global neurosurgical care. The delegation focused on forging new collaborations, strengthening the World Health Organization-World Federation of Neurosurgical Societies official relations, and actively supporting resolutions that impact the neurosurgical patients. However, there is a long advocacy journey ahead to address unmet neurosurgical needs. Patient-centered advocacy is an inherent task of our profession and the essence of the Global Neurosurgery Bogota Declaration of 2016. The highlight of the 76th World Health Assembly was the adoption of the first neurosurgery-driven resolution calling for micronutrient fortification to prevent spina bifida and other micronutrient deficiencies. For the last 4 years, the Global Alliance for Prevention of Spina Bifida, a group spearheaded by neurosurgeons, advocated for spina bifida prevention. This Alliance collaborated with many stakeholders, notably, the Colombian government to promote the resolution: "Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification." This is a proud milestone for the neurosurgical profession. There are many strategies available for neurosurgeons, when working together with elected leaders, other stakeholders, and allied professionals, to implement initiatives that can prevent future cases of spina bifida and other neurological disorders and reduce the burden of neurosurgical disease.

Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings

Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.

Reducing the incidence and mortality of traumatic brain injury in Latin America

Traumatic brain injury (TBI) represents a considerable portion of the global injury burden. The incidence of TBI will continue to increase in view of an increase in population density, an aging population, and the increased use of motor vehicles, motorcycles, and bicycles. The most common causes of TBI are falls and road traffic injuries. Deaths related to road traffic injury are three times higher in low-and middle-income countries (LMIC) than in high-income countries (HIC). The Latin American Caribbean region has the highest incidence of TBI worldwide, primarily caused by road traffic injuries. Data from HIC indicates that road traffic injuries can be successfully prevented through concerted efforts at the national level, with coordinated and multisector responses to the problem. Such actions require implementation of proven measures to address the safety of road users and the vehicles themselves, road infrastructure, and post-crash care. In this review, we focus on the epidemiology of TBI in Latin America and the implementation of solutions and preventive measures to decrease mortality and long-term disability.

An update on pediatric traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice.

METHODS

Targeted review of the literature on various aspects of paediatric TBI over the last 5 years.

RESULTS

Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies.

CONCLUSION

Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.

Early management of isolated severe traumatic brain injury patients in a hospital without neurosurgical capabilities: a consensus and clinical recommendations of the World Society of Emergency Surgery (WSES)

BACKGROUND

Severe traumatic brain-injured (TBI) patients should be primarily admitted to a hub trauma center (hospital with neurosurgical capabilities) to allow immediate delivery of appropriate care in a specialized environment. Sometimes, severe TBI patients are admitted to a spoke hospital (hospital without neurosurgical capabilities), and scarce data are available regarding the optimal management of severe isolated TBI patients who do not have immediate access to neurosurgical care.

METHODS

A multidisciplinary consensus panel composed of 41 physicians selected for their established clinical and scientific expertise in the acute management of TBI patients with different specializations (anesthesia/intensive care, neurocritical care, acute care surgery, neurosurgery and neuroradiology) was established. The consensus was endorsed by the World Society of Emergency Surgery, and a modified Delphi approach was adopted.

RESULTS

A total of 28 statements were proposed and discussed. Consensus was reached on 22 strong recommendations and 3 weak recommendations. In three cases, where consensus was not reached, no recommendation was provided.

CONCLUSIONS

This consensus provides practical recommendations to support clinician's decision making in the management of isolated severe TBI patients in centers without neurosurgical capabilities and during transfer to a hub center.

Traumatic brain injury: progress and challenges in prevention, clinical care, and research

Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research.

In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents.

Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery.

The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition.

Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers.

In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI.

Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation.

Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority.

This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.

The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey

Objective

Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries.

Methods

A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders.

Results

A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24).

Conclusions

While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Intracranial pressure management: moving beyond guidelines

PURPOSE OF REVIEW

The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts.

RECENT FINDINGS

Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull.

SUMMARY

ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.

How to manage traumatic brain injury without invasive monitoring?

PURPOSE OF REVIEW

Severe traumatic brain injury (TBI) is an extremely serious health problem, especially in low-middle income countries (LMICs). The prevalence of severe TBI continues to increase in LMICs. Major limitations in the chain of care for TBI patients are common in LMICs including suboptimal or nonexistent prehospital care, overburdened emergency services, lack of trained human resources and limited availability of ICUs. Basic neuromonitoring, such as intracranial pressure, are unavailable or underutilized and advanced techniques are not available.

RECENT FINDINGS

Attention to fundamental principles of TBI care in LMICs, including early categorization, prevention and treatment of secondary insults, use of low-cost technology for evaluation of intracranial bleeding and neuromonitoring, and emphasis on education of human resources and multidisciplinary work, are particularly important in LMICs. Institutional collaborations between high-income and LMICs have developed evidence focused on available resources. Accordingly, an expert group have proposed consensus recommendations for centers without availability of invasive brain monitoring.

SUMMARY

Severe TBI is very prevalent in LMIC and neuromonitoring is often not available in these environments. When intracranial pressure monitors are not available, careful attention to changes on clinical examination, serial imaging and noninvasive monitoring techniques can help recognize intracranial hypertension and effectively guide treatment decisions.

Prehospital Trauma Airway Management: An NAEMSP Position Statement and Resource Document

Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific. NAEMSP recommends:The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.Management of immediately life-threatening injuries should take priority over advanced airway insertion.Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.

Exploring perspectives and adherence to guidelines for adult spinal trauma in low and middle-income healthcare economies: A survey on barriers and possible solutions (part I)

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Most spinal trauma occurs in low- and middle-income countries (LMICs), but some elements may limit the application of current guidelines.

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In LMICs, a respectable proportion of physicians treating spinal trauma is not aware of any guidelines on this topic.

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Most physicians managing spinal trauma in LMICs believe that following the guidelines may positively affect patient outcomes.

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Most believed they have the capability to apply, the guidelines, but variation according to income and geographical region exists.

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The perceived limitations and their relevance to guideline adherence vary across different income and geographic areas worldwide.

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Resource-targeted guidelines for spinal trauma are considered a valuable option to overcome the limitations of real-life application of the current guidelines.

A survey on the early management of spinal trauma in low and middle-income countries: From the scene of injury to the diagnostic phase (part II)

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Most spinal trauma worldwide occurs in low-and middle-income countries (LMICs). Several factors may limit the applicability of current guidelines as regards the early management of spinal injury.

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The pre-hospital management per se of spinal trauma in LMICs is subject to partial adherence to recommendations, with possible impact on patient outcomes.

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The use of clinical (eg ASIA) and morphological (eg SLIC, TLICS, AO Spine) grading scales is not homogeneous.

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The availability and cost of diagnostic equipment, and the timing of emergency imaging can vary significantly from one region to another, probably affecting the timely management of spinal injury patients.

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The introduction of resource-targeted guidelines for spinal trauma may be a valuable option to overcome the limitations of real-life application of current guidelines.

Perioperative management of severe brain injured patients

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.

Management of severe traumatic brain injury in regions with limited resources

IMPORTANCE

Severe traumatic brain injury (sTBI) is a critical health problem in regions of limited resources (RLRs). Younger populations are among the most impacted. The objective of this review is to analyze recent consensus-based algorithms, protocols and guidelines proposed for the care of patients with TBI in RLRs.

OBSERVATIONS

The principal mechanisms for sTBI in RLRs are road traffic injuries (RTIs) and violence. Limitations of care include suboptimal or non-existent pre-hospital care, overburdened emergency services, lack of trained human resources, and surgical and intensive care. Low-cost neuromonitoring systems are currently in testing, and formal neurotrauma registries are forming to evaluate both long-term outcomes and best practices at every level of care from hospital transport to the emergency department (ED), to the operating room and intensive care unit (ICU).

CONCLUSIONS AND RELEVANCE

The burden of sTBI is highest in RLRs. As working-age adults are the predominantly affected age-group, an increase in disability-adjusted life years (DALYs) generates a loss of economic growth in regions where economic growth is needed most. Four multi-institutional collaborations between high-income countries (HICs) and LMICs have developed evidence and consensus-based documents focused on capacity building for sTBI care as a means of addressing this substantial burden of disease.