War-related traumatic brain injury in Gaza: a multi-center prospective analysis of patterns and outcomes

Since October 2023, the Gaza War has caused thousands to suffer from war-related traumatic brain injuries (TBIs) amid the collapse of Gaza's healthcare system. Little is known about the epidemiology and outcomes of TBI in such severely resource-limited settings.

We conducted a prospective cohort study at the two largest neurosurgical centers in the southern Gaza Strip from July 15, 2024, to January 19, 2025. Patients with war-related TBI were enrolled consecutively and followed for 30 days after admission. Data were collected on demographics, clinical presentation, imaging findings, interventions, complications, and outcomes. The primary outcome was 30-day mortality, while secondary outcomes included the neurological status at discharge and complications.

A total of 244 patients were included, with a median age of 21 years, and 74.5% were males. The 30-day mortality rate was 26.2%. Severe TBI (GCS ≤ 8) at admission was associated with a higher mortality compared to mild and moderate TBI (p < 0.001). Non-survivors had significantly higher rates of multilobar and bilateral injuries, subdural and intraventricular hemorrhages, midline shifts, and effaced basal cisterns. Among survivors (n = 180), 27.2% experienced neurological deficits at discharge, most commonly motor impairment and aphasia. Neurological deficits were linked to penetrating injuries, multilobar involvement, midline shifts, and ≥ 3 shrapnel fragments on imaging. Complication rates were generally low but higher among individuals with neurological impairments. Multivariate regression analysis showed that TBI severity (moderate: aRR = 7.05, 95% CI: 2.32-14.23; severe: aRR = 9.91, 95% CI: 4.56-18.64), older age (aRR = 1.02 per year, 95% CI: 1.01-1.03), brain matter extrusion (aRR = 2.24, 95% CI: 1.06-4.70), intraventricular hemorrhage (aRR = 2.38, 95% CI: 1.39-4.03), and subdural hemorrhage (aRR = 1.90, 95% CI: 1.30-4.03) were significant predictors of 30-day mortality.

In this cohort of war-related TBI patients in Gaza, mortality was significantly linked to admission GCS, age, brain matter extrusion, IVH, and SDH. The study highlights how resource-limited, conflict-driven healthcare disruptions impact TBI outcomes and emphasizes the need to strengthen neurosurgical capacity, emergency response systems, and rehabilitation efforts in such environments.