Outcomes of Moderate-to-Severe Traumatic Brain Injury in a Low-Resource Setting.

Importance: No study from a low- and middle-income country (LMIC) has reported long-term mortality and quality of life (QOL) after moderate to severe traumatic brain injury (msTBI), highlighting its burden and recovery trajectories. Objectives: To measure short- and long-term mortality and QOL among patients in an LMIC with msTBI and to identify factors associated with outcomes. Design, Setting, and Participants: This cohort study analyzed prospectively collected data of patients with msTBI from December 1, 2021, to May 31, 2024, from a multicenter trauma registry of all injured patients from 2 tertiary care centers in Karachi, Pakistan. Adult patients (aged ≥18 years) with a diagnosis of msTBI (Glasgow Coma Scale [GCS] score of ≤12) enrolled in the registry and had recorded outcomes at 1, 3, 6, and 12 months. Exposure: Moderate TBI (GCS score of 9-12) or severe TBI (GCS score ≤8 or intubated patients with recorded GCS). Main Outcomes and Measures: The primary outcome was mortality (inpatient, follow-up, and cumulative), and the secondary outcome was QOL. Results: Of the 819 patients (median age, 38 years [IQR, 26-54 years]; 689 men [84.1%]), 368 (44.9%) had moderate TBI and 451 (55.1%) had severe TBI; 158 patients (19.3%) were lost to follow-up at 12 months. Road traffic crashes were the most common cause of TBI (607 [74.1%]). Inpatient mortality was 22.9% among patients with moderate TBI (80 of 349) and 68.9% among those with severe TBI (295 of 428). For patients discharged alive, 8.2% with moderate TBI (30 of 368) and 5.8% with severe TBI (26 of 451) died within 1 month. Cumulative mortality at 12 months was 59.4% among patients with moderate TBI and 87.8% among those with severe TBI. Older age (adjusted hazard ratio [AHR], 1.01 [95% CI, 1.01-1.02] per additional year of age), TBI severity (AHR, 2.67 [95% CI, 2.24-3.18]), and having no surgical intervention (AHR, 1.43 [95% CI, 1.18-1.74]) were significantly associated with higher 12-month mortality. Patients with severe TBI had poor QOL reported across all domains compared with those with moderate TBI. Conclusions and Relevance: In this cohort study of patients in Pakistan with msTBI, mortality was high, particularly among those with severe TBI, and most posthospital deaths occurred within the first month after hospital discharge. Older age, no surgical intervention, and greater injury severity were associated with higher mortality, highlighting the need for improved acute and postdischarge care in resource-limited settings.