Managing Severe Traumatic Brain Injury Across Resource Settings: Latin American Perspectives

Abstract

Severe traumatic brain injury (sTBI) is a condition of increasing epidemiologic concern worldwide. Outcomes are worse as observed in low- and middle-income countries (LMICs) versus high-income countries. Global targets are in place to address the surgical burden of disease. At the same time, most of the published literature and evidence on the clinical approach to sTBI comes from wealthy areas with an abundance of resources. The available paradigms, including the Brain Trauma Foundation guidelines, the Seattle International Severe Traumatic Brain Injury Consensus Conference, Consensus Revised Imaging and Clinical Examination, and multimodality approaches, may fit differently depending on local resources, expertise, and sociocultural factors. A first step toward addressing heterogeneity in practice is to consider comparative effectiveness approaches that can capture actual practice patterns and record short-term and long-term outcomes of interest. Decompressive craniectomy (DC) decreases intracranial pressure burden and can be lifesaving. Nevertheless, completed randomized controlled trials took place within high-income settings, leaving important questions unanswered and making extrapolations to LMICs questionable. The concept of preemptive DC specifically to address limited neuromonitoring resources may warrant further study to establish a benefit/risk profile for the procedure and its role within local protocols of care.

Cross-Institutional Validation of the UChicago PBI Imaging Score in Civilian Penetrating Brain Injury

“…Consistent characterization of structural injury facilitates comparison across studies, enables more meaningful patient selection for clinical trials, improves adjustment for baseline injury severity, and provides a framework for integrating imaging with biomarkers, physiology, genomics, and advanced computational methods. This may be particularly useful in multicenter registries, comparative-effectiveness studies, and future clinical trials evaluating neurosurgical and neurocritical care interventions in PBI 20,21 . Future research may also seek to refine the UChicago PBI Imaging Score by integrating variables consistent with emerging multidimensional approaches to TBI classification.…”

Cross-Institutional Validation of the UChicago PBI Imaging Score in Civilian Penetrating Brain Injury

“…Consistent characterization of structural injury facilitates comparison across studies, enables more meaningful patient selection for clinical trials, improves adjustment for baseline injury severity, and provides a framework for integrating imaging with biomarkers, physiology, genomics, and advanced computational methods. This may be particularly useful in multicenter registries, comparative-effectiveness studies, and future clinical trials evaluating neurosurgical and neurocritical care interventions in PBI 20,21 . Future research may also seek to refine the UChicago PBI Imaging Score by integrating variables consistent with emerging multidimensional approaches to TBI classification.…”

Pediatric severe TBI in South America: Healthcare resource utilization before and during the COVID-19 pandemic

“…Severe TBI, characterized by serious acute symptoms, extended unconsciousness or severely altered consciousness, comprises only a fraction of TBIs [ 5 ]; however, they are associated with high rates of morbidity and mortality, especially in low- and middle-income countries [ 6 , 7 ]. For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ].…”

“…For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ]. Recent efforts to understand resource limitations in South American countries, including Argentina, provide insight into the challenges in providing optimal, guideline-adherent care to severe TBI patients [ 7 – 9 ].…”

“…Established guidelines, such as those published by the Brain Trauma Foundation (BTF), provide evidence-based recommendations for the ICU care management of pediatric severe TBI [ 10 ]. However, these guidelines (and others) have been developed in the context of developed healthcare systems with established infrastructure and capabilities that are not available in resource-limited settings [ 7 ].…”

Cross-Institutional Validation of the UChicago PBI Imaging Score in Civilian Penetrating Brain Injury

“…Consistent characterization of structural injury facilitates comparison across studies, enables more meaningful patient selection for clinical trials, improves adjustment for baseline injury severity, and provides a framework for integrating imaging with biomarkers, physiology, genomics, and advanced computational methods. This may be particularly useful in multicenter registries, comparative-effectiveness studies, and future clinical trials evaluating neurosurgical and neurocritical care interventions in PBI 20,21 . Future research may also seek to refine the UChicago PBI Imaging Score by integrating variables consistent with emerging multidimensional approaches to TBI classification.…”

Pediatric severe TBI in South America: Healthcare resource utilization before and during the COVID-19 pandemic

“…Severe TBI, characterized by serious acute symptoms, extended unconsciousness or severely altered consciousness, comprises only a fraction of TBIs [ 5 ]; however, they are associated with high rates of morbidity and mortality, especially in low- and middle-income countries [ 6 , 7 ]. For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ].…”

“…For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ]. Recent efforts to understand resource limitations in South American countries, including Argentina, provide insight into the challenges in providing optimal, guideline-adherent care to severe TBI patients [ 7 – 9 ].…”

“…Established guidelines, such as those published by the Brain Trauma Foundation (BTF), provide evidence-based recommendations for the ICU care management of pediatric severe TBI [ 10 ]. However, these guidelines (and others) have been developed in the context of developed healthcare systems with established infrastructure and capabilities that are not available in resource-limited settings [ 7 ].…”

Cross-Institutional Validation of the UChicago PBI Imaging Score in Civilian Penetrating Brain Injury

“…Consistent characterization of structural injury facilitates comparison across studies, enables more meaningful patient selection for clinical trials, improves adjustment for baseline injury severity, and provides a framework for integrating imaging with biomarkers, physiology, genomics, and advanced computational methods. This may be particularly useful in multicenter registries, comparative-effectiveness studies, and future clinical trials evaluating neurosurgical and neurocritical care interventions in PBI 20,21 . Future research may also seek to refine the UChicago PBI Imaging Score by integrating variables consistent with emerging multidimensional approaches to TBI classification.…”

Pediatric severe TBI in South America: Healthcare resource utilization before and during the COVID-19 pandemic

“…Severe TBI, characterized by serious acute symptoms, extended unconsciousness or severely altered consciousness, comprises only a fraction of TBIs [ 5 ]; however, they are associated with high rates of morbidity and mortality, especially in low- and middle-income countries [ 6 , 7 ]. For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ].…”

“…For example, in Argentina, which is classified as upper-middle-income, where the estimated incidence of TBI was 228 per 100,000 (2016 estimate; 95% CI: 192–273) [ 2 ], hospital care for severe TBI patients can be hindered by significant challenges, including inadequate staffing, resources, and availability of services [ 8 ]. Recent efforts to understand resource limitations in South American countries, including Argentina, provide insight into the challenges in providing optimal, guideline-adherent care to severe TBI patients [ 7 – 9 ].…”

“…Established guidelines, such as those published by the Brain Trauma Foundation (BTF), provide evidence-based recommendations for the ICU care management of pediatric severe TBI [ 10 ]. However, these guidelines (and others) have been developed in the context of developed healthcare systems with established infrastructure and capabilities that are not available in resource-limited settings [ 7 ].…”