Current Management of Traumatic Brain Injury: Time is Brain

Abstract

Traumatic brain injury (TBI) remains one of the leading causes of mortality and long term disability among individuals under 45 years of age worldwide. Despite major advances in neurocritical and surgical care, the prevention of secondary brain injury continues to be the cornerstone of management. Early resuscitation with avoidance of hypotension and hypoxia remains vital for improved outcomes. Invasive intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring are widely recommended in severe TBI, though RCTs have not demonstrated clear superiority over clinical examination-based management. Landmark trials such as DECRA, RESCUEicp and RESCUE-ASDH have reshaped understanding of surgical intervention, showing that while it effectively reduces ICP, outcomes depend on timing and patient selection. Integration of quantitative pupillometry, biomarkers (GFAP, UCH-L1), and multimodal monitoring into tiered management frameworks represents a shift toward individualized, physiology-guided treatment. The aim of this review is to provide an updated synthesis of evidence-based management strategies for TBI, incorporating new insights from the 2024 American College of Surgeons (ACS) Best Practices Guidelines for the Management of Traumatic Brain Injury and recent clinical trials, with a focus on early recognition and the "time is brain" paradigm. The article reviews the current understanding of TBI pathophysiology, critical care monitoring strategies, and surgical management based on recent evidence and clinical trials.