Even mild brain injury in Pakistan may be linked to long-term disability and a higher risk of death, according to new research.
Most traumatic brain injuries (TBIs) occur in low- and middle-income countries, often because of road traffic accidents, but long-term outcomes remain poorly understood.
TBI is damage to the brain caused by an external physical force, such as a strong bump, blow or jolt to the head, or an object piercing the skull.
Researchers analysed trauma registry data from patients treated at two care centres in Karachi between December 2021 and May 2024 and followed them for a year after injury.
The two studies, led by researchers at Weill Cornell Medicine, provide a detailed picture of what happens after TBI in a resource-limited setting.
The first study, published on 11 August, focused on people with moderate or severe TBI, while a second study, published on 13 August, examined outcomes after mild TBI.
Together, the findings showed that the consequences of brain injury depend on more than severity at admission and that many patients remain vulnerable after leaving hospital.
Senior author Junaid Razzak, professor of emergency medicine at Weill Cornell and an emergency medicine physician at NewYork-Presbyterian/Weill Cornell Medical Center, said: “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.
“Patients are falling through gaps in the trauma care system before, during and especially after hospitalisation.”
The studies suggest many deaths and disabilities could potentially be prevented in Pakistan and similar low- and middle-income countries through stronger trauma systems, including faster access to appropriate care, structured post-discharge monitoring and expanded rehabilitation services.
Doctors assess the severity of a head injury using the Glasgow Coma Scale, a 15-point measure of eye, verbal and movement responses used to gauge how alert someone is after a head injury.
Scores of three to eight indicate severe TBI, when people may be unable to follow commands or respond to pain and can have problems with their airway.
Scores of nine to 12 indicate moderate TBI, when patients may be confused but can still respond to simple commands.
The first study examined 819 patients, with 45 per cent diagnosed with moderate TBI and 55 per cent with severe injuries.
People with severe injuries faced the greatest risk of death and disability, but researchers were also surprised by poor outcomes among those with moderate TBI, who would normally be expected to have a better chance of recovery.
Many deaths occurred during the first month after discharge, suggesting patients remain vulnerable during the transition from hospital care to life at home.
At 12 months, mortality was nearly 60 per cent among people with moderate TBI and almost 88 per cent among those with severe injuries.
By comparison, a previous study in high-income countries found mortality rates of 9 per cent and 30 per cent respectively.
Across both studies, older age, no surgical intervention and greater injury severity were linked to a higher risk of death.
The researchers suggested telehealth and regular remote follow-up could offer practical ways to monitor recovery and identify complications early.
The second study assessed 602 patients with mild TBI, defined as a Glasgow Coma Scale score of 13 to 15.
These patients tend to be awake and able to follow commands but may experience brief confusion or memory loss.
Researchers found that not all mild TBIs had the same prognosis.
Patients at the lower end of the mild range had substantially worse outcomes, including higher mortality and poorer quality of life during recovery, than those who scored 15.
The researchers suggested some injuries classified and treated as mild may have been more serious than initially recognised.
Premature hospital discharge may also have contributed, with patients staying for approximately two days.
The overall 12-month mortality rate across the groups in the second study was 14 per cent, which was relatively high compared with higher-income countries in published research.
Razzak said: “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.
“Then their access to basic healthcare and ability to take care of themselves drops significantly.”
Razzak said: “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.
“Treatment in the first 48 hours is critical for better outcomes.”
Razzak plans further research into how trauma care systems could be designed and better equipped to get patients to the right facilities.
He said: “By making this issue more visible to the government, we hope these gaps can be fixed, saving a significant number of lives.”
The research was funded by the Fogarty International Center of the US National Institutes of Health through the Aga Khan University Trauma and Injury Research Training Program, with the funding supporting data collection.
