Long Awaited Update on Guidelines for Penetrating TBI: Coming Soon


Dominic A. Siler, MD, PhD
James Wright, MD, FAANS
Oregon Health & Science University, Portland, OR

It has been more than 20 years since clinical practice guidelines for penetrating TBI (pTBI) were published in 2001 by an independent group. 1  Since that time, there have been an estimated 480,000 civilian deaths due to pTBI, 2  a number that far exceeds the 5,740 recorded pTBI’s sustained by U.S. military service members during the same timeframe. 3 Mortality reported in civilian pTBI studies ranges from 35-90% in contrast to an overall 18% mortality reported in military pTBI cohorts. 4 While there are key differences in the mechanism of civilian pTBI compared to military pTBI that partially explain the differences in outcomes, there have also been advances in the military practice model that are likely a primary driver of the disparities. 5

In communities marked by an alarming surge in civilian gun violence over the last several decades, neurosurgeons find themselves in critical need of updated clinical practice guidelines. 6 We commend these neurosurgeons for the work in simultaneously advocating for concrete measures to reduce the incidence and severity of gun violence in their respective areas of practice and nationally, while struggling with knowledge gaps and recommendations to guide care. 7

In recognition of this, the Brain Trauma Foundation (BTF), in collaboration with military and civilian TBI experts in the field, and with funding from the American Department of Defense, formed a multi-disciplinary workgroup in 2021 to conduct an exhaustive evidence review from both civilian and military pTBI populations. 8 This body of work aims to answer key questions related to pTBI care and will serve as the basis for updated guidelines.

The guidelines will focus on a wide range of key clinical questions regarding pre-hospital care, prognosis, surgical and non-operative management, as well as best practices regarding prophylaxis against infections, cerebrospinal fluid leaks, thrombotic complications and seizures. Importantly, questions regarding screening and management of vascular injuries as well as expert consensus on decision-making regarding surgical debridement of missile fragments have the potential to change the role of the neurosurgeon in management of these complex patients. With the unsettling prospect of a continued rise in gun violence, there is a shared aspiration that evolving treatment paradigms may lead to a positive shift, altering the historical trajectory of clinical outcomes for both civilian and military populations.

  1. Part 1: Guidelines for the management of penetrating brain injury. Introduction and methodology. J Trauma. 2001;51(2 Suppl):S3-6.
  2. Adult Firearm-Related Traumatic Brain Injury in United States Trauma Centers. Journal of Neurotrauma. 2019;36(2):322-337.
  3. DOD. DOD TBI worldwide numbers. 2023; https://health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers.
  4. Karras CL, Texakalidis P, Nie JZ, et al. Outcomes Following Penetrating Brain Injuries in Military Settings: A Systematic Review and Meta-Analysis. World Neurosurgery. 2022;166:39-48.
  5. DuBose JJ, Barmparas G, Inaba K, et al. Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma. 2011;70(1):11-16; discussion 16-18.
  6. Gramlich J. What the data says about gun deaths in the U.S. 2023; https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/.
  7. Anderson MG, Anuar A, Tomei KL, et al. Survey of United States neurosurgeons on firearm injury prevention. J Neurosurg. 2023:1-11.
  8. Hawryluk GWJ, Selph S, Lumba-Brown A, et al. Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma Rep. 2022;3(1):240-247.