Traumatic brain injury (TBI) looks likely
 to remain the largest global contributor to neurological disability until at least 2030,an international commission has forecast.

The predicted burden of disabilitysurrounding TBI across the world “far exceeds” that related to dementia and cerebrovascular disease, says the Lancet Neurology Commission’s extensive report.

The paper estimates that the global annual cost of TBI could be as high as US$400bn (£296bn), or around 0.5 per cent of gross world product.

The report aims to pave the way for what it calls a “long overdue”, concerted effort to tackle the global TBI problem, which is a “public health challenge of vast, but insufficiently recognised, proportions”.

It sets out priorities and expert recommendations for all parties involved in TBI, including healthcare professionals, researchers, funders and decision-makers.

Over 70 expert authors representing institutions spanning the globe contributed to the report, with a further 250 contributors via the International Initiative for Traumatic Brain Injury Research (InTBIR).

A lack of uniformity in the characterisation and management of TBI in different countries around the world is a continual theme throughout the report.

Among several recommendations, the report urges an international consensus on definitions and standardised epidemiological monitoring of TBI, to allow accurate measurement of key factors such as incident rates and access to care.

The report also underlines the value of centralised care, explaining: “There is growing evidence of a relationship between management in high-volume centres and improved outcomes, which suggests that care for the most critically ill patients should be centralised.

“Substantial gains could be made from provision of adequate prehospital care, appropriate referral and continuity along the chain of care, with early access to effective rehabilitation,” it adds.

The commission also calls for:
• More research into links between TBI and increased risk of later neurological diseases, such as stroke and dementia

• Better strategies for TBI prevention to deliver cost savings that could fund improved access to care and research

• Professional sporting organisations to lead by example by immediately removing anyone with a suspected concussion from play

• Healthcare policies which improve access to acute and post-acute care, reducing the burden of TBI on patients, families and society

• More “robust evidence” on potential medical, surgical and rehabilitation interventions to inform guidelines and improve outcomes

• Studies aimed at improving the precision of diagnosis, classification and characterisation of TBI

• The development of a “validated set of quality indicators” to enable the benchmarking of care quality

• Greater collaboration between public and private funding bodies – as well as industrial partners –to support the development of national and global biorepositories and databases which could foster vital TBI research

• The introduction of validated outcome measures which factor in the overall burden of disability caused by TBI, driving better clinical management and aiding the high-quality research needed to take TBI treatments forward

A dearth in TBI-relevant drug treatments is particularly concerning to the commission. It states: “Despite investment of many billions of dollars by pharmaceutical companies, no effective drugs exist for treatment in the acute setting – a failing due, in part, to insufficient targeting of therapies to patients in whom the relevant mechanism is active.

“We need better methods to characterise TBI to allow identification of patient sub-groups with a common dominant disease mechanism, who are more likely to respond to specific treatments – a concept now being popularised as precision medicine.”

It continues: “Huge opportunities exist for improvements in characterisation of initial severity, outcome and prognosis, and for more accurate tracking of disease processes, by building on the current scientific advances in modern neuroimaging, genomics, disease biomarker development, and pathophysiological monitoring.

 in these technologies could facilitate the goals of precision medicine in TBI.”

The commission comes amid rising levels of TBI in countries of all economic status. High-income nations like the UK, with its ageing population, are experiencing more TBI caused by falls among the elderly.

In low and middle-income countries, TBIs as a result of traffic accidents are increasing, according to the report. International conflict and sports-related concussions are also adding to growing worldwide TBI rates.

The report concludes: “Clinicians and researchers, in consultation with patients and their families, need to play their part in taking these recommendations forward.

“Collaboration between funding agencies will be required to coordinate the strategy and conduct of research, and commitment from policymakers will be essential to facilitate research and ensure timely implementation of research outputs.

“Implementation of prevention strategies and provision of optimum clinical care in different settings should be a priority for clinicians and policymakers alike. Integration of all these e orts should deliver rich dividends in terms of better and more cost-effective care, with huge benefits for patients, their families, and society as a whole.”

Global TBI in numbers

US$400bn: Estimated global financial burden of TBI each year
50 to 60 million: Approximate annual number of TBIs internationally
6.5 years: The typical gap between clinical research and its translation into improvements in care (or between study publication and systematic review)
5 to 15 per cent: The possible attributable risk of dementia as a result of TBI – an area which needs more investigation, saysthe commission
30 to 40 per cent: Mortality rate of severe TBI (according to observational studies on unselected populations)
1 million: number of deaths caused by TBI each year