Decision-Making in Neurotrauma: a multidimensional model of cognitive and contextual factors influencing surgical...

Surgical decision-making in acute neurotrauma settings is a cognitively complex process shaped by multiple factors beyond neuroimaging and clinical examination. Despite established evidence-based guidelines for traumatic brain injury (TBI) management, significant variability in surgical practice persists globally. Understanding the cognitive and contextual determinants of surgical judgment is essential for improving outcomes and neurosurgical education.

What cognitive and contextual factors shape surgical decision-making in neurotrauma, and how can a hippocampal-prefrontal cortex model informs strategies to improve judgment and reduce practice variability?

This narrative review integrates knowledge from cognitive neuroscience, surgical decision-making research, and clinical neurotrauma management. We apply a validated algorithmic model based on hippocampal-prefrontal cortex (PFC) interaction to neurosurgical TBI decision-making, analyzing both information sources available to the surgeon and surgeon-specific contextual modulators shaping the final clinical judgment.

Surgical decisions in neurotrauma are influenced by two factor categories: (1) hippocampal inputs (clinical experience, published evidence, guidelines, expert consensus, bioethical considerations, neuromonitoring data, and neuroimaging), each carrying variable cognitive bias; and (2) PFC modulators (risk-benefit analysis, emotional state, work environment, fatigue, and level of training), which determine how information is weighted and transformed into action. Evidence-based protocols provide structured decision anchors, but their implementation remains subject to the surgeon's interpretive and contextual filters.

A multidimensional, neuroscience-informed model of surgical decision-making in neurotrauma has practical implications for training, quality improvement, and decision-support tool development. Recognizing cognitive biases, incorporating objective neuromonitoring data, and standardizing decision frameworks are key strategies for optimizing surgical outcomes in TBI.