Traumatic brain injury is taking a far heavier toll in Pakistan than hospital statistics alone suggest. Two new studies led by Weill Cornell Medicine researchers have found that patients can face a substantial risk of death, disability and declining quality of life for months after an injury that may initially appear mild or moderate. The findings, published in JAMA Network Open, offer one of the most detailed examinations to date of long-term traumatic brain injury outcomes in a resource-limited setting. They also challenge the assumption that patients who survive the first critical hours are necessarily on a safe path to recovery.
The research team analyzed records from a trauma registry covering injured patients treated at two care centers in Karachi between December 2021 and May 2024. The patients were followed for a full year after their injuries, allowing the investigators to examine what happened after emergency treatment and hospital discharge. Most traumatic brain injuries in low- and middle-income countries are linked to road traffic accidents, where delayed transport, limited emergency services and overcrowded hospitals can all influence survival. Yet long-term outcomes in these settings remain poorly documented. The Karachi registry provided an opportunity to track mortality and recovery beyond the hospital, when many patients are no longer visible to formal healthcare systems.
The first study examined 819 patients with moderate or severe traumatic brain injury, classified using the Glasgow Coma Scale, or GCS. This clinical tool assigns scores from 3 to 15 according to a patient’s eye opening, verbal responses and motor responses. A score of 3 to 8 generally indicates severe injury, while a score of 9 to 12 indicates moderate injury. The scale is useful for rapidly assessing consciousness, but it does not capture every factor that determines recovery, including hidden brain damage, complications after discharge, access to rehabilitation or a patient’s ability to return for follow-up care. In the Karachi cohort, 45% of patients had moderate injuries and 55% had severe injuries.
As expected, patients with severe injuries experienced the greatest danger. However, the researchers were particularly concerned by the outcomes among those with moderate traumatic brain injury, who would normally be expected to have a considerably better prognosis than patients with severe damage. Many deaths occurred during the first month after discharge, pointing to a dangerous gap between hospital treatment and continued medical supervision at home. By 12 months, mortality had reached nearly 60% among patients with moderate injury and almost 88% among those with severe injury. These figures were dramatically higher than mortality rates reported in a previous study from high-income countries, where the corresponding rates were about 9% and 30%.
The pattern suggests that the biological effects of brain injury are only part of the explanation. Patients may leave the hospital before complications are recognized, particularly when families face financial pressure, transportation difficulties or a lack of nearby specialists. Seizures, infections, worsening brain swelling, blood clots, impaired swallowing and untreated neurological decline can become life-threatening after discharge. Cognitive and physical disabilities may also prevent survivors from working, managing medication or caring for themselves. The researchers found that older age, greater injury severity and the absence of surgical intervention were associated with a higher risk of death. They also argue that the first month at home should be treated as a critical phase of recovery rather than the end of acute care.
The second study focused on 602 patients with mild traumatic brain injury, defined as a GCS score of 13 to 15. These patients are typically awake and able to follow commands, although they may experience confusion, memory loss or other neurological symptoms. The study found that “mild” injury was not a single, predictable condition. Patients at the lower end of the mild range had substantially worse outcomes than those who scored 15, including higher mortality and poorer quality of life during recovery. This difference raises questions about whether some injuries are being classified as mild when they are clinically more serious. It also suggests that a single consciousness score may not be enough to determine who can safely leave the hospital.
Patients in the mild-injury study stayed in the hospital for approximately two days, and the authors said premature discharge may have contributed to poor outcomes. A patient who appears alert can still have an intracranial hemorrhage, diffuse microscopic damage or evolving swelling that is difficult to detect without appropriate imaging and observation. Even when no immediate surgical emergency is present, symptoms such as headaches, dizziness, memory problems, sleep disruption and mood changes can interfere with daily life. Across the mild traumatic brain injury groups, the 12-month mortality rate was 14%, a level the researchers described as relatively high compared with published findings from wealthier countries.
The social consequences can amplify the medical ones. In Pakistan and other countries where many families live close to the poverty line, even a modest neurological disability can eliminate a person’s ability to work or perform basic tasks. Lost income may reduce access to food, transportation and follow-up care, while caregivers may have to leave employment to provide support. This creates a feedback loop in which injury worsens poverty, and poverty makes recovery more difficult. Dr. Junaid Razzak, the senior author and a professor of emergency medicine at Weill Cornell Medicine, said that patients can fall through gaps before reaching a hospital, during emergency treatment and especially after they return home.
The researchers describe this as a broken “chain of survival.” At the scene of an accident, bystanders may not know how to protect an injured person’s airway or neck. Ambulance drivers may lack reliable information about which hospitals have available beds or neurosurgical services. Emergency departments may have limited resources while staff race to stabilize patients during the first 48 hours, a period that can be decisive for preventing secondary brain injury. After discharge, structured monitoring and rehabilitation may be unavailable. The investigators suggest that stronger trauma networks could connect emergency responders, hospitals, surgeons, rehabilitation specialists and community health workers so that patients receive the right care at the right time.
Telehealth and routine remote follow-up could provide one practical solution, especially for families who cannot easily return to major medical centers. Scheduled calls or video visits could help clinicians identify worsening headaches, seizures, confusion, weakness, depression or problems with medication. Simple rehabilitation guidance and caregiver education might also reduce complications. The researchers emphasize that these approaches would not replace emergency treatment, brain imaging or surgery when needed. Instead, they could extend clinical oversight into the vulnerable weeks and months after hospitalization. Their findings underscore that traumatic brain injury should be treated as a long-term disease process, not merely an event that ends when a patient leaves the emergency department.
The studies were supported by the Fogarty International Center of the U.S. National Institutes of Health through the Aga Khan University Trauma and Injury Research Training Program, with funding used solely for data collection. Dr. Razzak and his colleagues plan to investigate how trauma systems can be redesigned to move patients more efficiently to appropriate facilities and close the gaps in post-discharge care. Their results from Karachi point to a wider global problem: in countries where road injuries are common and medical resources are limited, the true burden of traumatic brain injury may remain hidden long after the crash. Better early transport, careful assessment of apparently mild injuries, longer observation, organized follow-up and accessible rehabilitation could prevent many deaths while giving survivors a better chance to return to independent lives.
Web References:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2852614
https://jamanetwork.com/journals/jamaneurology/fullarticle/2781523
References:
Two studies published in JAMA Network Open by researchers led by Weill Cornell Medicine, examining one-year outcomes after moderate-to-severe and mild traumatic brain injury in Karachi, Pakistan.
Image Credits: Weill Cornell Medicine
Keywords: traumatic brain injury, brain injuries, Pakistan, Karachi, emergency medicine, trauma care, road traffic accidents, Glasgow Coma Scale, mortality, rehabilitation, telehealth, global health, Junaid Razzak
