Traumatic Brain Injury in Austere Environments: a Review of Recent Advances

Traumatic brain injury (TBI) is still a leading cause of death and disability worldwide, with a disproportionate burden in low- and middle-income countries (LMICs) where access to imaging, invasive intracranial pressure (ICP) monitoring, and neurosurgical care is limited. This review examines recent advances in TBI management in austere environments, where standard high-resource paradigms are frequently impractical, and analyzes the quality of evidence supporting context-adapted approaches.

Recent literature highlights the growing role of protocolized care pathways, noninvasive neuromonitoring adjuncts such as optic nerve sheath diameter ultrasonography, quantitative pupillometry, transcranial Doppler, and selected serum biomarkers, as well as alternative surgical strategies including hinge craniectomy. Emerging physiological frameworks, including stage-based models of intracranial decompensation, offer structured decision-making support when numeric ICP thresholds are unavailable. However, most supporting evidence remains observational, heterogeneous, and frequently extrapolated from high-income settings, with major limitations in external validation and implementation science. Enhancing outcomes in austere TBI care will depend less on technological development than on rigorous implementation science, context-specific validation, and sustainable health system strengthening to bridge the gap between evidence and clinical delivery.