Traumatic brain injury (TBI) in Pakistan is associated with a high risk of death and disability long after the initial injury, even in mild to moderate cases, according to two new studies in JAMA Network Open led by Weill Cornell Medicine researchers. While most TBIs occur in low- and middle-income countries due to road traffic accidents, long-term patient outcomes remain poorly understood.
To shed light on this critical issue, the researchers analyzed data from a trauma registry of all injured patients from two care centers in Karachi, Pakistan, from December 2021 to May 2024. The studies followed patients for a year after injury, providing one of the most detailed pictures to date of what happens after TBI in a resource-limited setting.
The first study , published Aug. 11, focused on patients with severe to moderate TBI. A second paper, published Aug. 13, looked at outcomes of mild traumatic brain injuries. Together, the studies found that the consequences of brain injury depend on more than severity at admission and many patients remain vulnerable after leaving the hospital.
"We found that TBIs are responsible for a high number of trauma-related deaths in Pakistan, even with more mild to moderate injuries, which we were not expecting," said senior author Dr. Junaid Razzak , professor of emergency medicine at Weill Cornell and an emergency medicine physician at NewYork-Presbyterian/Weill Cornell Medical Center. "Patients are falling through gaps in the trauma care system before, during and especially after hospitalization."
The study suggests that many deaths and disabilities could potentially be prevented in Pakistan and similar low- and middle-income countries with stronger trauma systems, including faster access to appropriate care, structured post-discharge monitoring and expanded rehabilitation services.
Focusing on the First Month After Discharge
Clinicians use the Glasgow Coma Scale (GCS) , a 15-point measure of eye, verbal and motor responses to gauge how alert patients are after a head injury. Severe TBI, a score of 3 to 8, means people cannot follow commands or respond to pain and may have trouble with their airway. Moderate TBI, a score of 9 to 12, means patients may be confused but can still respond to simple commands.
The first study focused on 819 registry patients diagnosed with moderate (45%) to severe (55%) TBI based on the GCS. As expected, patients with severe injuries faced the greatest risk of death and disability. However, researchers were surprised by the poor outcomes among patients with moderate injuries, who would typically be expected to have a better chance of recovery.
Many deaths occurred during the first month after discharge, suggesting that patients remain vulnerable during the transition from hospital care to life at home. At 12 months, mortality reached nearly 60% in patients with moderate TBI and almost 88% among those with severe injury. In comparison, a previous study in high-income countries found respective mortality rates of 9% and 30%.
For both studies, the researchers found that older age, no surgical intervention and greater injury severity were associated with a higher risk of death.
Telehealth and regular remote follow-up may be a practical way to monitor recovery and identify complications early, proposed the authors.
Reconsidering How "Mild" TBI Is Defined
The second study assessed 602 registry patients with mild TBI, defined as a GCS of 13 to 15. These patients tend to be awake and can follow commands but may experience brief confusion or memory loss.
The researchers found that not all mild TBIs had the same prognosis. Some patients at the lower end of the GCS mild range experienced substantially worse outcomes, including higher mortality and poorer quality of life during recovery, than those who scored 15. Potentially, some injuries classified and treated as mild may have actually been more serious, said the authors. In addition, premature hospital discharge may have contributed to this finding, as patients stayed approximately two days.
Overall, the 12-month mortality rate was 14% for all groups in the second study, which is relatively high, compared to higher-income countries in the published literature.
"My hunch is that even people with mild disabilities, who are already living at the edge of poverty, fall below the poverty line when they can't work or perform basic tasks," Dr. Razzak said. "Then their access to basic healthcare and ability to take care of themselves drops significantly."
Future Research
"A broken 'chain of survival' exists, in which bystanders don't know how to respond to an accident, ambulance drivers don't know which hospitals have open beds and emergency room healthcare providers race against the clock," Dr. Razzak said. "Treatment in the first 48 hours is critical for better outcomes."
Dr. Razzak plans to research how trauma care systems can be designed and better equipped to get patients to the right facilities. "By making this issue more visible to the government, we hope these gaps can be fixed, saving a significant number of lives," he said.
This research was funded by the Fogarty International Centre of the National 3 Institutes of Health under award No. D43TW007292—The Aga Khan University Trauma and 4 Injury Research Training Program; this funding solely supported data collection.
