Santiago Cardona-Collazos

Introduction: Blast‐ and penetrating‐mechanism traumatic brain injury (TBI) is increasingly prevalent in settings affected by conflict and explosive violence, including among local casualties in environments where neurosurgical infrastructure, advanced imaging, and critical care resources may be limited or absent. No protocols or guidelines comprehensively address the full spectrum of TBI from blast and penetrating mechanisms across variable resource levels. Methods: The Explosive Weapons Trauma Care Collective (EXTRACCT) conducted a targeted narrative literature review across key clinical domains, including initial assessment, hemodynamic and airway management, medical treatment of intracranial hypertension, noninvasive neuromonitoring, surgical decision‐making, and interfacility transport. Searches were performed in PubMed and supplemented by military, penetrating and trauma system clinical practice guidelines (Joint Trauma System, Brain Trauma Foundation, TCCC). Evidence was synthesized by a multidisciplinary authorship team and consensus was achieved through iterative expert review, following the AGREE II framework. Results: This document provides stratified recommendations across variable resource contexts. Key recommendations include: early physiological stabilization with avoidance of hypotension and hypoxia; structured neurological assessment using postresuscitation GCS and pupillometry; noncontrast head CT as the primary imaging modality, with CT angiography for penetrating TBI and high‐risk blunt mechanisms; hyperosmolar therapy as first‐line treatment for intracranial hypertension; evidence‐based sedation, analgesia, and neuromuscular blockade protocols; noninvasive multimodal neuromonitoring when invasive ICP monitoring is unavailable; surgical thresholds for decompressive craniectomy and craniotomy; and standardized transport protocols to minimize secondary brain injury during interfacility transfer. Conclusions: This document addresses a critical gap in context‐appropriate blast‐TBI management for settings with variable resource availability. Strict control of basic physiological parameters, structured clinical decision‐making, and early transfer to neurosurgical care remain the primary determinants of outcome in resource‐limited environments.

Traditional surgical decision-making in traumatic brain injury (TBI) has relied on static intracranial pressure (ICP) thresholds and fixed volumetric criteria, an approach that inadequately reflects the dynamic physiological nature of secondary brain injury. These conventional metrics fail to capture the critical determinant of clinical deterioration: the progressive loss of intracranial compliance, the brain’s capacity to buffer additional volume without harmful pressure escalation. This manuscript proposes a practical, compliance-based framework for selecting precise, personalized surgical strategies using real-time physiological, imaging, and neuromonitoring indicators. Based on the Intracranial Compartment Syndrome (ICCS) model, this approach translates the loss of compensatory reserve into actionable operative decisions. Compliance is assessed through multimodal tools, including ICP waveform morphology, cerebral oxygenation, and complementary noninvasive neuromonitoring. ICCS staging delineates three operative contexts: Stage 1, preserved compliance; Stage 2, compliance failure with maintained oxygenation requiring physiology-guided interventions to restore buffering capacity; and Stage 3, global decompensation with lost of compliance plus oxygenation failure requiring immediate, aggressive intervention for partial or total brain tissue survival. By shifting surgical reasoning from fixed anatomical thresholds to a physiology-centered assessment of intracranial compliance, this framework aims to enhance the timing, selection, and overall effectiveness of neurosurgical interventions in TBI.

Background/Objectives: Traumatic brain injury (TBI) is a global public health concern, affecting over 60 million people annually. It is associated with high rates of mortality and disability, particularly among young and economically active individuals, and remains the leading cause of death in people under 40 years of age. Although computed tomography (CT) is the standard method for excluding intracranial bleeding (ICB), it is frequently unavailable in resource-limited settings where the burden of TBI is greatest. The InfraScanner 2000 is a near-infrared spectroscopy (NIRS) device designed to detect ICB and may serve as a triage tool in environments without access to CT imaging. This study aimed to evaluate the diagnostic performance of the InfraScanner 2000 for detecting ICB in the emergency department (ED) of a trauma center in a cohort of Colombian patients with TBI. Methods: This prospective study was conducted in Cali, Colombia, between December 2019 and February 2021. Adult patients presenting to the ED with blunt TBI were enrolled. InfraScanner assessments were performed according to a standardized protocol, and all participants underwent head CT within 6 h of injury. Results: A total of 140 patients were included. Of these, 66% were male and 34% were female. Most patients (63.57%) were between 18 and 39 years old, with a median age of 39 years (IQR: 18–86). The InfraScanner demonstrated a sensitivity of 60.0% (95% CI: 32.5–84.8), specificity of 78.4% (95% CI: 71.2–85.6), positive predictive value (PPV) of 25.0%, and negative predictive value (NPV) of 94.2% for detecting ICB. Conclusions: The InfraScanner 2000 showed good specificity and high NPV in identifying ICB among Colombian patients with TBI. These findings suggest it could serve as a useful triage tool to support decision-making in emergency settings with limited access to CT imaging.

Cerebral edema is the abnormal accumulation of fluid in any of the tissue compartments of the cerebral parenchyma. It remains a significant challenge in neurotrauma care because it contributes to secondary brain injury, affecting prognosis. This review analyzes the recent literature, including foundational studies, to describe the mechanisms of distinct types of cerebral edema following traumatic brain injury (TBI). Emerging concepts, such as the role of the glymphatic system and heme-derived inflammasomes, offer new insights into new types of edemas, differentiated by pathogenesis and potential treatments. Recent advancements in understanding these molecular mechanisms can improve therapeutic strategies, facilitating a better approach in the era of precision and personalized medicine. Although there has been notable progress, a proposal to customize treatments for diverse types of edemas is necessary to improve outcomes following traumatic brain injury. In this review, we describe the current subtypes of post-traumatic brain edemas and link them to a specific management approach.

Traumatic brain injury (TBI) patients often exhibit an increase in their intracranial volume due to blood collection or brain tissue edema, affecting the intracranial compliance. When the volume of any intracranial compartment exceeds a critical threshold, the compensatory mechanisms become overwhelmed, compromising intracranial compliance and blood supply, which leads to Intracranial Compartment Syndrome (ICCS). This condition exacerbates brain damage through secondary injury. When less aggressive measures to treat ICCS are insufficient, cranial decompression is recommended, with decompressive craniectomy (DC) currently being the preferred technique. Although its effectiveness has been demonstrated, DC is also associated with a high incidence of complications, including cerebral spinal fluid (CSF) disturbances and surgical site infections. Expansive craniotomy (EC) has been proposed as an alternative that leverages the benefits of cranial decompression provided by DC while reducing the associated adverse effects. The E-SPACE clinical study is a prospective, multicenter, observational, comparative-effectiveness study enrolling adult TBI patients diagnosed with ICCS who require cranial decompression. This multicenter comparative-effectiveness observational study will compare the functional outcomes and complications associated with DC and EC over a 12-month period.

Intracranial compartment syndrome is a common and potentially lethal complication in patients with traumatic brain injury (TBI). It results from an increase in intracranial volume due to hemorrhage or cerebral edema, exceeding compensatory mechanisms and leading to reduced compliance and reduced cerebral perfusion, even in absence of full intracranial hypertension syndrome. This pathophysiological cascade can cause secondary brain damage if it is not identified early since the emergency room evaluation. One of the primary interventions for managing decreased compliance is external ventricular drainage, which allows for cerebrospinal fluid diversion to improve the intracranial compliance and if it is the case to reduce high intracranial pressure. Spontaneous ventricular catheter displacement is a frequent and risky complication that can reduce treatment efficacy and increase the central nervous system infection rates. The Security And Effectiveness Assessment Of Locking Systems In Ventriculostomy-TBI (SEALS-TBI) clinical study is a prospective, multicenter, observational comparative-effectiveness trial designed to evaluate the impact of ventricular catheter locking systems versus standard ventriculostomy in patients with intracranial compartment syndrome secondary to TBI. The primary objective of the study is to compare functional outcomes and clinical complications associated with both treatment approaches. Data collection will take place from July 2025 to July 2026. The aim of this article is to present the SEALS-TBI study protocol.