Past, present and future perspectives of traumatic brain injury

Despite extensive research, traumatic brain injury (TBI) imposes significant mortality and morbidity burden globally. This narrative review provides a comprehensive overview of how TBI classification, surgical and critical care management, and physiological treatment goals have evolved based on recent evidence, shaping future directions for TBI care. We highlight the conceptual shift in TBI classification from the Glasgow Coma Scale to a new framework that integrates clinical and imaging features, biomarkers, and modifiers to improve disease characterization and describe disease trajectories. We review landmark trials that refine the role and timing of surgical interventions in TBI, and emphasize the shift from fixed intracranial pressure goals to physiology-driven approaches with dynamic individualized autoregulation metrics and cerebral oxygen monitoring. We also highlight recent changes in critical care management, including the shift from restrictive transfusion strategies to more liberal transfusion goals, and deliberate monitoring and adjustment of ventilatory settings, hemodynamic goals, and volume status. An enhanced understanding of the prolonged recovery journey and recognition of cognitive motor dissociation may further inform our neuroprognostication and cautions against early withdrawal of life sustaining treatment. Artificial intelligence offers the integration of multimodal data from large databases and enables dynamic patient-specific management. Innovative trial design, incorporating multifaceted, individualized strategies targeting multiple pathophysiological mechanisms, may better account for the complexity and heterogeneity of TBI.