Management of Neurotrauma in Low-Resource Settings

The first chapter presents an overview of the burden of disease of traumatic brain injury (TBI) - also referred to throughout the text as neurotrauma - a history of clinical practice guidelines, the Brain Trauma Foundation guidelines for the treatment of severe TBI (sTBI), the paucity of clinical trials carried out in low- and middle-income countries (LMICs) that make the development of treatment guidelines possible, the concept of resource-stratified guidelines (RSGs), the evolution of international TBI guidelines, and a proposed protocol for TBI management in low-resource settings. The introduction will be published by *Frontiers in Neurology* after incorporating the recommended changes from the reviewers. The second chapter systematically reviews the contribution of LMICs to neurosurgical randomised trials. In this chapter, we established that there is a substantial disparity between high-income countries (HICs) and LMICs in the number of published neurosurgical trials and call upon the global neurosurgery community to invest in research capacity building in LMICs as an essential step towards ensuring context- and resource-specific high-quality evidence is generated. A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. Excluding China, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs. a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs. 1.8 sites in LMIC-led studies. Over half of LMIC trials were institutionally funded. The results from this study are presented as a journal article, Neurosurgical randomised trials in low-and middle-income countries, published in the March 2020 issue of *NEUROSURGERY*. To access this publication, click [here](https://journals.lww.com/neurosurgery/fulltext/2020/09000/neurosurgical_randomized_trials_in_low__and.6.aspx). The third chapter reviews recent consensus-based algorithms, protocols, and guidelines proposed for the care of patients with sTBI in regions of limited resources (RLRs). Limitations of care for sTBI include suboptimal or non-existent prehospital care, overburdened emergency services, lack of trained human resources, and surgical and intensive care. Low-cost neuromonitoring systems are currently in testing, and formal TBI 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 (OR) and intensive care unit (ICU). Four multi-institutional collaborations between (HICs) and LMICs have developed evidence and consensus-based documents focused on capacity building for sTBI care to address this substantial burden of disease. The results from this study are presented as a journal article, Management of severe traumatic brain injury in regions with limited resources, published in the September 2021 issue of *Brain Injury*. To access this publication, click [here](https://www.tandfonline.com/doi/full/10.1080/02699052.2021.1972149). The fourth chapter provides a protocol and analysis of the first scoping review on the development, implementation, and validation of RSGs in LMICs. Nearly every field of medicine has some form of clinical practice guidelines. However, only within the past 5–10 years has the medical community acknowledged the need for well-developed guidelines tailored to the local healthcare needs and available resources. In most LMICs, healthcare workers depend on guidelines developed in HICs. Yet, many interventions validated in a HIC are ineffective when implemented in an LMIC. The variation in infrastructure, medical personnel, technology, and environmental conditions exhibited in LMICs relative to HICs necessitates a careful appraisal of the evidence base used in clinical guideline recommendations. This review aims to map the use of RSGs across all fields of medicine. The review seeks to answer three questions for the identified guidelines: (1) What was the method of development? (2) Have they been implemented? If so, (3) Have they been validated? The protocol was presented in the journal article, Development, implementation and validation of resource-stratified guidelines in low-and middle-income countries: a scoping review protocol, published in the September 2022 issue of *BMJ Open*. To access the publication, click [here](https://bmjopen.bmj.com/content/12/9/e059603.long). The results of the scoping review will be submitted to *BMJ Global Health*. The fifth chapter presents a protocol for a pilot study that aimed to identify the facilitators of, and barriers to, collecting data about patients with sTBI and to implement a stratified protocol across the treatment phases of prehospital, emergency department (ED), neurosurgery, and intensive care unit (ICU) in low-resource settings. A consensus process including experts from the four treatment phases took place in Colombia to develop a set of stratified protocols called BOOTStraP (Beyond One Option for the Treatment of Severe Traumatic Brain Injury: A Stratified Protocol), targeting resource-poor environments. However, it had not been systematically implemented and tested. The protocol is presented as a journal article, Protocol for a multicentre, prospective, observational pilot study on the implementation of resource-stratified algorithms for the treatment of severe traumatic brain injury across four treatment phases: prehospital, emergency department, neurosurgery, and intensive care unit in the August 2022 issue of *NEUROSURGERY*. To access this publication, click [here](https://journals.lww.com/neurosurgery/fulltext/2022/08000/protocol_for_a_multicenter,_prospective,.17.aspx). The sixth chapter presents the results of a Key Informant Survey, Bridging the gap: Investigating the treatment practices and guidelines for severe traumatic brain injury in Sub-Saharan African (SSA) urban referral centres and rural district hospitals. We sought to understand the current use of guidelines for the treatment of TBI in rural and urban regions of SSA and to discover and document the barriers to and facilitators of the utilisation of guidelines in this region to formulate a consensus statement and recommendations for improving the treatment of TBI patients in SSA centres. The results from this study will be submitted to *NEUROSURGERY*. A list of current publications can be accessed [here](https://scholar.google.com/citations?user=12sUiCEAAAAJ&hl=en).

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2024

Author dc:creator

• Griswold, Dylan

Advisors dc:contributor.advisor

• Hutchinson, Peter
• Kolias, Angelos

• capacity building
• global health
• low-and middle-income countries
• neurosurgery
• neurotrauma
• resource-stratified guidelines
• severe traumatic brain injury
• traumatic brain injury

Licence

• https://apollo8-f-pro.lib.cam.ac.uk/bitstreams/bb8a1f34-69ad-4621-a50c-72b5133552fd/download
• https://www.rioxx.net/licenses/all-rights-reserved/

Language dc:language

eng

Author Identifier

0000-0003-0291-8360

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/375382