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Physiological and radiological parameters predicting outcome from penetrating traumatic brain injury treated in the deployed military setting
  1. John Breeze1,2,
  2. A Whitford3,
  3. W G Gensheimer4 and
  4. C Berg5
  1. 1Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
  2. 2Department of Bioengineering, Imperial College London, London, UK
  3. 3Gaza Barracks, Joint Hospital Group, Catterick, UK
  4. 4Warfighter Eye Center, Malcolm Grow Medical Clinics and Surgery Center Joint Base Andrews, Prince George's County, Maryland, USA
  5. 5Department of Neurosurgery, Wright-Patterson Air Force Base, Dayton, Ohio, USA
  1. Correspondence to LtCol John Breeze, Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, B15 2WB, UK; editor.bmjmilitary{at}


Introduction Penetrating traumatic brain injury (TBI) is the most common cause of death in current military conflicts, and results in significant morbidity in survivors. Identifying those physiological and radiological parameters associated with worse clinical outcomes following penetrating TBI in the austere setting may assist military clinicians to provide optimal care.

Method All emergency neurosurgical procedures performed at a Role 3 Medical Treatment Facility in Afghanistan for penetrating TBI between 01 January 2016 and 18 December 2020 were analysed. The odds of certain clinical outcomes (death and functional dependence post-discharge) occurring following surgery were matched to existing agreed preoperative variables described in current US and UK military guidelines. Additional physiological and radiological variables including those comprising the Rotterdam criteria of TBI used in civilian settings were additionally analysed to determine their potential utility in a military austere setting.

Results 55 casualties with penetrating TBI underwent surgery, all either by decompressive craniectomy (n=42) or craniotomy±elevation of skull fragments (n=13). The odds of dying in hospital attributable to TBI were greater with casualties with increased glucose on arrival (OR=70.014, CI=3.0399 to 1612.528, OR=70.014, p=0.008) or a mean arterial pressure <90 mm Hg (OR=4.721, CI=0.969 to 22.979, p=0.049). Preoperative hyperglycaemia was also associated with increased odds of being functionally dependent on others on discharge (OR=11.165, CI=1.905 to 65.427, p=0.007). Bihemispheric injury had greater odds of being functionally dependent on others at discharge (OR=5.275, CI=1.094 to 25.433, p=0.038).

Conclusions We would recommend that consideration of these three additional preoperative clinical parameters (hyperglycaemia, hypotension and bihemispheric injury on CT) when managing penetrating TBI be considered in future updates of guidelines for deployed neurosurgical care.


Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors JB—conceptualisation, data collection, data analysis, project administration and writing. AW—data collection, data analysis and writing. WGG—writing. CB—conceptualisation and writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed are solely those of the authors and do not reflect the official policy or position of the US Air Force, the Department of Defense, the US Government, the British Army, the Ministry of Defence or Her Majesty’s Government.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.