Blast-induced traumatic brain injury: the experience from a level I trauma center in southern Thailand

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OBJECTIVE

In the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.

METHODS

A retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.

RESULTS

During the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1–3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3) were the only factors predicting a poor outcome of bTBI.

CONCLUSIONS

bTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.

ABBREVIATIONS bTBI = blast-induced traumatic brain injury; DCNS = damage control neurosurgery; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; IED = improvised explosive device.

Abstract

OBJECTIVE

In the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.

METHODS

A retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.

RESULTS

During the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1–3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3) were the only factors predicting a poor outcome of bTBI.

CONCLUSIONS

bTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.

Trauma from war has been part of the human condition since the beginning of civilization. In historical conflicts, gunshot injuries were responsible for most of the damage. Currently, the improvised explosive device (IED) is the handmade weapon used to demoralize victims, even in the conflict in southern Thailand. As of 2018, this conflict has been ongoing in the southern border provinces for more than 10 years (https://en.wikipedia.org/wiki/South_Thailand_insurgency; Fig. 1).8,17 Blast injury has occurred most commonly during events such as strikes on military convoys, attacks with mines, and IEDs concealed in motorcycles. These handmade weapons cause unique patterns of injuries, especially brain injuries.4

FIG. 1.
FIG. 1.

Map showing the southern conflict region, composed of three southern border provinces (gray) and four districts of the Songkhla province.

The general mechanisms of blast-induced traumatic brain injury (bTBI) are an explosion that generates immediate blast energy and a wave that impacts the head, resulting in a primary blast injury. Secondary blast injuries are found in victims who are further away from the center of detonation, often sustaining injuries from penetrating flak. Victims can be thrown against a fixed object, causing acceleration-deceleration injuries.3,9 Because explosive injuries are found in particular situations, there are a few reports about common clinical characteristics of bTBI victims.

About 80% of IED-induced injuries are fatal, and the most commonly injured regions are the lower extremities (24.6%–28%), upper extremities (16%–24%), and head (2%–34%). About 88% of the fatal cases involve bTBI.1,26 The clinical details and management of bTBI in war situations have been reported.1,12,26 However, our experience with civilian cases has revealed certain differences. Therefore, in this study, we aimed to explore the clinical information associated with such cases, including the clinical characteristics, intracranial injuries, treatment, and outcomes of bTBI, and to analyze the factors associated with clinical outcomes.

Methods

This study was a retrospective review of patient records from our institution’s trauma registry. We reviewed the medical records of blast injury patients who had been admitted to Songklanagarind Hospital in the years 2009–2017. Data collected for analysis included demographics, intracranial injuries, other associated injuries, treatment, and outcomes. Additionally, patients were divided into three groups according to their initial Glasgow Coma Scale (GCS) score: mild TBI (GCS score 13–15), moderate TBI (GCS score 9–12), and severe TBI (GCS score 3–8).

Neuroimaging studies were reviewed to evaluate intracranial injuries. Following the definitions outlined by Rosenfeld and colleagues, we categorized the intracranial injuries as primary, secondary, and tertiary blast effects.20,21 Moreover, we also documented illustrative cases demonstrating the mechanisms of bTBI (Figs. 24).

FIG. 2.
FIG. 2.

A 29-year-old military person with a primary blast injury. A: Axial CT scan showed diffuse brain swelling with an obliterated basal cistern. B: Sagittal CT scan showed focal hemorrhages at the parasagittal white matter. C: Coronal CT scan showed microhemorrhage at the gray and white matter located in both parasagittal areas. Acute subdural hematoma along the left convexity was observed.

FIG. 3.
FIG. 3.

A 32-year-old military person with a secondary blast injury. Axial (A) and coronal (B) CT scans showed a bone fragment that penetrated into the deep parietal lobe.

FIG. 4.
FIG. 4.

A 27-year-old military person with a tertiary blast injury. A: Axial CT scan showed a coup scalp hematoma at the impact site and contracoup left temporal contusion. B: Coronal CT scan showed a compound depressed left parietal bone fracture at the impact site and contracoup temporal contusion.

Anemia was defined as a hemoglobin level below 9 g/dl at admission, and hypoxia was defined as oxygen saturation < 92% or partial pressure of oxygen < 80 mm Hg.15,22,23 According to Wu et al. and clinical practice at our institute, coagulopathy was defined as thrombocytopenia (platelet count < 100,000/μl) or elevated international normalized ratio > 1.2 or prolonged activated partial thromboplastin time > 40 seconds at admission.30

Surgical treatments and outcomes were reviewed from computer-based medical records. Patients were divided into five groups according to their Glasgow Outcome Scale (GOS) at the time of hospital discharge: 1 (death), 2 (persistent vegetative state), 3 (severe disability), 4 (moderate disability), and 5 (good recovery).10 Finally, the GOS scores were dichotomized into favorable (GOS scores 4 and 5) and unfavorable (GOS scores 1–3) categories.2,28 The study was performed with the approval of the Ethics Committee of the Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University.

Statistical Analysis

Patient characteristics, intracranial injuries, and treatments were analyzed using descriptive analysis and were presented as proportions or the means ± standard deviation. Binary logistic regression was used to analyze correlation and magnitude of associations between several factors and intracranial injuries. In the multivariable analysis, logistic regression was used to determine which variables were included in the model and stratification. We proposed the odds ratio and 95% confidence interval of binary logistic regression analysis by forest plot. A p value < 0.05 was considered statistically significant. Statistical analyses were performed with the R program, version 3.4.1 (The R Foundation).

Results

In the study period between 2009 and 2017, 70 patients met the inclusion criteria. Table 1 shows the clinical characteristics of the study population. The mean age was 35 ± 10.8 years (range 19–61 years). More than 90% of the patients were male, and more than two-thirds were military personnel. Secondary brain injuries, especially hypotension and hypoxia, accounted for 21.4% and 4.3% of all injuries, respectively. Among the victims, 67.1% had a mild TBI and 22.9% had a severe TBI.

TABLE 1.

Clinical characteristics of 70 patients with bTBI

FactorNo. (%)
Age group in yrs
 <202 (2.9)
 20–4042 (60)
 41–6024 (34.3)
 >601 (1.4)
Sex
 Male64 (91.4)
 Female6 (8.6)
Military personnel
 Military50 (71.4)
 Nonmilitary20 (28.6)
Signs & symptoms
 Scalp injury49 (70.0)
 Alteration of consciousness20 (28.6)
 Loss of consciousness14 (20.0)
 Hypotension15 (21.4)
 Bleeding per nose/ear3 (4.3)
 Headache2 (2.9)
 Weakness8 (11.4)
 Visual problem8 (11.4)
Initial GCS score
 15–1347 (67.1)
 12–97 (10.0)
 8–316 (22.9)
Pupil reactivity
 Both eyes reactive58 (82.9)
 Unequal7 (10.0)
 Both eyes nonreactive3 (4.3)
Laboratory
 Anemia13 (18.6)
 Coagulopathy11 (15.7)
 Hypoxia3 (4.3)
 Acidosis4 (5.7)

Almost two-thirds (65.7%) of imaging studies revealed significant intracranial injuries. The overall injury characteristics are shown in Table 2. The most common findings were coup contusion (63.0%), subarachnoid hemorrhage (54.3%), and subdural hematoma (47.8%). According to the definitions of Rosenfeld and colleagues,20,21 the most common mechanism was primary blast injury (48.6%), while secondary blast injury was found in 37.1% of patients.

TABLE 2.

Injury characteristics of patients with bTBI

FactorNo.
Mean Injury Severity Score (SD)24.6 (11.4)
Abbreviated Injury Scale score, head (%)
 220 (28.6)
 316 (22.9)
 424 (34.3)
 510 (14.3)
Intracranial injury characteristic, n = 46 (%)
 Linear skull fracture7 (15.2)
 Depressed skull fracture20 (43.5)
 Basilar skull fracture8 (17.4)
 Epidural hematoma10 (21.7)
 Subdural hematoma22 (47.8)
 Coup contusion29 (63.0)
 Contracoup contusion2 (4.3)
 Brainstem injury1 (2.2)
 Subarachnoid hemorrhage25 (54.3)
 Intraventricular hemorrhage1 (2.2)
 Diffuse brain edema7 (15.2)
Lateralization, n = 46 (%)
 Bilat8 (17.4)
 Unilat38 (82.6)
  Lt15 (32.6)
  Rt23 (50.0)
Location of major injury, n = 46 (%)
 Frontal lobe24 (52.2)
 Temporal lobe12 (26.1)
 Parietal lobe8 (17.4)
 Occipital lobe5 (10.9
 Brainstem1 (2.2)
 Thalamus/hypothalamus1 (2.2)
 Other1 (2.2)
Mechanism of injury, n = 70 (%)
 Primary blast34 (48.6)
 Secondary blast26 (37.1)
 Tertiary blast10 (14.3)
Pressure effect on CT, n = 70 (%)
 Basal cistern effacement61 (87.1)
 Midline shift
  <5 mm64 (91.4)
  >5 mm6 (8.6)
Associated injury (%)
 Orbit20 (28.6)
 Lower extremities17 (24.3)
 Upper extremities16 (22.9)
 Pneumothorax/hemothorax15 (21.4)
 Maxillofacial11 (15.7)
 Tympanic membrane perforation11 (15.7)
 Lumbar spine10 (14.3)
 Cervical spine7 (10.0)
 Retroperitoneal6 (8.6)
 Burn5 (7.1)
 Mediastinum4 (5.7)
 Thoracic spine3 (4.3)
 Rib fracture3 (4.3)
 Bowel perforation3 (4.3)
 Pelvis2 (2.9)
 Larynx/tracheal2 (2.9)
 Liver1 (1.4)
 Splenic1 (1.4)

SD = standard deviation.

The mean Injury Severity Score was 24.6 ± 11.4, and more than two-thirds of the Abbreviated Injury Scale scores for the head were severe injury. The most common associated injuries were orbit (28.6%), lower extremities (24.3%), and upper extremities (22.9%). Anemia and coagulopathy were observed on admission in about 18.6% and 15.7% of patients, respectively. Blood loss injuries significantly associated with anemia were basilar skull fracture, coup contusion, and upper and lower extremity trauma, whereas injuries associated with coagulopathy were basilar skull fracture, coup contusion, subarachnoid hemorrhage, and retroperitoneal hematoma (p < 0.05, chi-square test).

Table 3 shows the treatments and outcomes in this study. Surgical treatment was used in all severity levels of TBI, with the depressed skull fracture and coup contusion significantly related to surgical treatment (p < 0.05, chi-square test). The overall mortality rate was 11.4%, and almost a quarter (24.3%) of the patients had an unfavorable outcome. Surgical site infection occurred in 5.7% of the patients and was significantly associated with an externally exposed scalp wound and retained foreign body in penetrating injuries.

TABLE 3.

Treatments and outcomes in 70 patients with bTBI

FactorNo. (%)
Treatment
 Conservative treatment42 (60.0)
 Decompressive craniectomy7 (10.0)
 Craniotomy18 (25.7)
 Other3 (4.3)
GOS score at hospital discharge
 Death8 (11.4)
 Vegetative status4 (5.7)
 Severe disability5 (7.1)
 Moderate disability5 (7.1)
 Good recovery48 (68.6)
GOS score at last follow-up
 Vegetative status2 (2.9)
 Moderate disability4 (5.7)
 Good recovery44 (62.9)

Binary logistic regression was used to analyze factors predicting outcome. Glasgow Outcome Scale scores were dichotomized into favorable and unfavorable categories for binary analysis. In the univariate analysis, the significant factors were preoperative coagulopathy, midline shift ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, the only factors associated with an unfavorable outcome were midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3). Figure 5 shows the odds ratios of factors as a forest plot.

FIG. 5.
FIG. 5.

Forest plot of univariate and multivariable analysis of factors associated with an unfavorable outcome. BE = both eyes; Di = diameter; EDH = epidural hematoma; fx = fracture; MLS = midline shift; SDH = subdural hematoma; SSI = surgical site infection; TSAH = traumatic subarachnoid hemorrhage.

Discussion

Explosive injuries occur in specific conditions such as war, terrorist events, or conflicts. Injuries from IEDs in the conflict in southern Thailand have been common in recent years because of the insurgency.3 In the present study, we found that bTBIs are serious and unique events. Mortality and morbidity in our study were lower than those reported in previous papers1,9,20,31 because the fatal events were the result of a civilian conflict in which victims injured by an explosion were transferred to nearby hospitals where medical devices and medications were suitable for initial evaluation and resuscitation. Moreover, we found that the factors associated with a poor outcome after treatment included subfalcine herniation > 5 mm and coagulopathy on admission. Various other studies have found that midline shift of the brain and basal cistern effacement are related to increased intracranial pressure and a worse prognosis.2,9,19 We also found that patients with bTBI had a poor outcome when their injuries included midline shift of the brain and/or basal cistern effacement.5,13,16

In our experience, patients injured by blast waves frequently develop diffuse brain swelling and clinical brain herniation. Moreover, extracranial injuries cause hemorrhagic shock and hypoxia that precipitate more brain swelling and herniation. Damage control neurosurgery (DCNS) is urgent neurosurgery performed to treat malignant brain edema or large intracranial hematomas in a remote, rural, or military situation.14,18,27,29 It includes rapid surgery to stop major bleeding, evacuate hematomas, decompress brains with extensive craniectomy, and obtain watertight dural closures.7,19,20 In the combat field, DCNS can be immediately performed by a general physician to improve survival in patients with GCS score 3–8 and positive signs of herniation after resuscitation; however, surgical outcome data remain limited. Few published papers have focused on the clinical outcomes of bTBI.12

In the differential situation, victims injured from an explosion in civilian cases were transferred from the event field to the nearest hospitals. Patients were resuscitated, and visualized sources of bleeding were immediately secured. Patients who suffered serious injuries were transferred to provincial hospitals, which have a surgeon and neurosurgeon. The bTBI patients underwent neuroimaging at provincial hospitals, and if clinical signs of brain herniation were observed, DCNS was performed in order to save the patient’s life. Then, when their vital signs were stable, patients were transferred to our hospital via helicopter or ambulance. For example, the patient whose neuroimages appear in Fig. 3 sustained a secondary blast injury, had a scalp laceration, and had a compound skull fracture on brain CT performed at the provincial hospital. Initially, he underwent debridement and craniectomy by the neurosurgeon at the provincial hospital. Then, he was transferred to our hospital via ambulance to have the bone fragment removed. In the mass casualty situation, bTBI patients did not need a life-saving operation, and they were transferred directly to our hospital via helicopter (Fig. 4).

Coagulopathy is a frequent event in traumatic injury due to blood loss. The guideline for field management of combat-related head trauma is the application of early detection and prevention of coagulopathy and hypotension in bTBI.12 In our experience, intraabdominal injury and basilar skull fracture were common sources of bleeding that should be concerning. Bleeding from a basilar skull fracture influxed massively into the oropharynx, whereas intraabdominal bleeding will accumulate in the peritoneal cavity. The prevalence of coagulopathy is significantly higher in patients with TBI and is associated with a poor clinical outcome.6,11,24,25

After injuries, various molecules and pathways such as platelet-activating factors, tissue factors, microparticles, and brain phospholipids are activated, causing a hypocoagulable state.31 Also, coagulopathy should be reversed immediately with the transfusion of blood products such as fresh frozen plasma, platelets, and cryoprecipitate to improve clinical outcome.

The present study may be limited by the size of the sample, which resulted in a wide confidence interval. This paper presents initial research on the clinical outcomes of patients with bTBI and the analysis of factors predicting outcome according to our knowledge. Additional multivariable analyses were used to control confounding factors arising from limitations of our research methodology.

Conclusions

Blast injury causes TBI ranging from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, reversing an abnormal coagulogram is required immediately to improve outcomes, but the management of brain shift needs further study.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Tunthanathip. Acquisition of data: Tunthanathip, Khocharoen. Analysis and interpretation of data: Tunthanathip. Drafting the article: Tunthanathip. Critically revising the article: Tunthanathip. Reviewed submitted version of manuscript: Tunthanathip, Khocharoen. Approved the final version of the manuscript on behalf of all authors: Tunthanathip. Statistical analysis: Tunthanathip. Administrative/technical/material support: Tunthanathip, Khocharoen. Study supervision: Phuenpathom.

References

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    Arul GSReynolds JDiRusso SScott ABree STempleton P: Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan. Ann R Coll Surg Engl 94:52–572012

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    Brazinova AMauritz WLeitgeb JWilbacher IMajdan MJanciak I: Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old. J Neurotrauma 27:154915552010

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    Cernak I: Blast-induced neurotraumaWinn HR (ed): . Philadelphia: WB Saunders2017429342942

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    Chaiphrom NKanchanaroek KKhumwattana M: Characteristics and distribution of blast and firearm injuries in Thai military personnel during conflict in southern Thailand. J Med Assoc Thai 92 (Suppl 1):S47S522009

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    Eisenberg HMGary HE JrAldrich EFSaydjari CTurner BFoulkes MA: Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 73:6886981990

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    Franschman GBoer CAndriessen TMvan der Naalt JHorn JHaitsma I: Multicenter evaluation of the course of coagulopathy in patients with isolated traumatic brain injury: relation to CT characteristics and outcome. J Neurotrauma 29:1281362012

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    Freeman JLWinston KRByers JTBeauchamp K: Damage-control neurosurgery: packing to halt relentless intracranial bleeding. J Trauma Acute Care Surg 79:8658692015

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    Lipper MHKishore PREnas GGDomingues da Silva AAChoi SCBecker DP: Computed tomography in the prediction of outcome in head injury. AJR Am J Roentgenol 144:4834861985

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    Nanuam W: Engagement of Malaysia and Indonesia on Counterinsurgency in the South of Thailand. Honolulu: Asia Pacific Center for Security Studies2015 (http://apcss.flywheelsites.com/wp-content/uploads/2015/08/AP-Wassana-counterinsurgency-Aug2015.pdf

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    Risling MDavidsson J: Experimental animal models for studies on the mechanisms of blast-induced neurotrauma. Front Neurol 3:302012

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    Rosenfeld JV: Damage control neurosurgery. Injury 35:6556602004

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Article Information

Correspondence Thara Tunthanathip: Prince of Songkla University, Songkhla, Thailand. tsus4@hotmail.com.

INCLUDE WHEN CITING DOI: 10.3171/2018.8.FOCUS18311.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Map showing the southern conflict region, composed of three southern border provinces (gray) and four districts of the Songkhla province.

  • View in gallery

    A 29-year-old military person with a primary blast injury. A: Axial CT scan showed diffuse brain swelling with an obliterated basal cistern. B: Sagittal CT scan showed focal hemorrhages at the parasagittal white matter. C: Coronal CT scan showed microhemorrhage at the gray and white matter located in both parasagittal areas. Acute subdural hematoma along the left convexity was observed.

  • View in gallery

    A 32-year-old military person with a secondary blast injury. Axial (A) and coronal (B) CT scans showed a bone fragment that penetrated into the deep parietal lobe.

  • View in gallery

    A 27-year-old military person with a tertiary blast injury. A: Axial CT scan showed a coup scalp hematoma at the impact site and contracoup left temporal contusion. B: Coronal CT scan showed a compound depressed left parietal bone fracture at the impact site and contracoup temporal contusion.

  • View in gallery

    Forest plot of univariate and multivariable analysis of factors associated with an unfavorable outcome. BE = both eyes; Di = diameter; EDH = epidural hematoma; fx = fracture; MLS = midline shift; SDH = subdural hematoma; SSI = surgical site infection; TSAH = traumatic subarachnoid hemorrhage.

References

1

Arul GSReynolds JDiRusso SScott ABree STempleton P: Paediatric admissions to the British military hospital at Camp Bastion, Afghanistan. Ann R Coll Surg Engl 94:52–572012

2

Brazinova AMauritz WLeitgeb JWilbacher IMajdan MJanciak I: Outcomes of patients with severe traumatic brain injury who have Glasgow Coma Scale scores of 3 or 4 and are over 65 years old. J Neurotrauma 27:154915552010

3

Cernak I: Blast-induced neurotraumaWinn HR (ed): . Philadelphia: WB Saunders2017429342942

4

Chaiphrom NKanchanaroek KKhumwattana M: Characteristics and distribution of blast and firearm injuries in Thai military personnel during conflict in southern Thailand. J Med Assoc Thai 92 (Suppl 1):S47S522009

5

Eisenberg HMGary HE JrAldrich EFSaydjari CTurner BFoulkes MA: Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 73:6886981990

6

Franschman GBoer CAndriessen TMvan der Naalt JHorn JHaitsma I: Multicenter evaluation of the course of coagulopathy in patients with isolated traumatic brain injury: relation to CT characteristics and outcome. J Neurotrauma 29:1281362012

7

Freeman JLWinston KRByers JTBeauchamp K: Damage-control neurosurgery: packing to halt relentless intracranial bleeding. J Trauma Acute Care Surg 79:8658692015

8

Funston J: . Carlton, Victoria: Melbourne Law School2008 (https://www.webcitation.org/query.php?url=http://www.law.unimelb.edu.au/files/dmfile/funstonfinalforwebsite2.pdf

9

Gean AD (ed): Brain Injury: Applications from War and Terrorism. Philadelphia: Lippincott Williams & Wilkins2014

10

Jennett BBond M: Assessment of outcome after severe brain damage. Lancet 1:4804841975

11

Kim YJ: A systematic review of factors contributing to outcomes in patients with traumatic brain injury. J Clin Nurs 20:151815322011

12

Knuth TLetarte PBLing GMoores LERhee PTauber D: Guidelines for Field Management of Combat-Related Head Trauma. New York: Brain Trauma Foundation2005 (https://braintrauma.org/uploads/02/09/btf_field_management_guidelines_2.pdf

13

Lipper MHKishore PREnas GGDomingues da Silva AAChoi SCBecker DP: Computed tomography in the prediction of outcome in head injury. AJR Am J Roentgenol 144:4834861985

14

Magnuson JLeonessa FLing GS: Neuropathology of explosive blast traumatic brain injury. Curr Neurol Neurosci Rep 12:5705792012

15

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