Highlights
Increasing Mortality
Between 2009 and 2024, hospital mortality for critically ill patients with traumatic brain injury (TBI) in England, Wales, and Northern Ireland increased from 25.6% to 35.0%.
Withdrawal of Therapy
The proportion of withdrawal of life-sustaining therapy (WLST) decisions rose significantly from 7.5% to 19.7%, a trend not mirrored in other ICU cohorts such as sepsis or vascular brain injury.
Secondary Brain Insults
Exposure to early secondary brain insults remains high, with hypoxaemia rates nearly doubling from 36.9% to 61.2% over the study period.
Background: The Evolving Landscape of TBI Care
Traumatic brain injury (TBI) remains a primary cause of death and long-term disability worldwide. While advancements in neurocritical care, such as intracranial pressure monitoring and standardized protocols for managing cerebral perfusion, were expected to improve outcomes, recent epidemiological data have provided conflicting signals. In many high-income countries, the demographics of TBI are shifting toward an older population with more comorbidities, often resulting from low-fall mechanisms rather than high-velocity motor vehicle accidents.
Despite these shifts, there is a lack of long-term longitudinal data regarding how mortality and clinical decision-making—specifically the withdrawal of life-sustaining therapy (WLST)—have evolved over the last decade. Understanding these trends is critical for clinicians and policy makers to determine whether changes in outcomes are due to shifting patient profiles, variations in care quality, or evolving ethical perspectives on end-of-life care in the neuro-ICU.
Study Design and Methodology
This large-scale observational cohort study utilized data from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP), covering 235 adult ICUs in England, Wales, and Northern Ireland. The study period spanned 15 years, from April 1, 2009, to March 31, 2024.
Population and Comparators
The researchers identified 45,684 unique TBI patients admitted to the ICU. To determine if the observed trends were specific to TBI or representative of broader ICU shifts, the study included three comparator cohorts: general trauma, sepsis, and vascular brain injury (such as stroke or subarachnoid hemorrhage).
Endpoints
The primary outcome was hospital mortality. Secondary outcomes included the incidence of WLST decisions and the prevalence of predefined early secondary brain insults, including hypotension, hypoxaemia, hypocapnia, hypercapnia, and hyperglycaemia, within the first 24 hours of ICU admission.
Key Findings: Mortality and WLST Trends
The study revealed a stark divergence in TBI outcomes compared to other critically ill populations. While mortality rates for sepsis and general trauma have generally stabilized or improved in recent years, TBI mortality showed a significant upward trajectory.
A Significant Rise in Mortality
In 2009, the hospital mortality rate for TBI patients stood at 25.6%. By 2024, this figure had climbed to 35.0%. Multivariable analyses, which adjusted for age, comorbidities, and injury severity, confirmed that this was a robust trend rather than a mere reflection of an aging population.
The Tripling of WLST Decisions
Perhaps the most provocative finding was the dramatic increase in decisions to withdraw life-sustaining therapy. In the early part of the study, WLST was recorded in 7.5% of cases. By the end of the study period, this had surged to 19.7%. This suggests that nearly one-fifth of all TBI patients in the ICU now undergo a formal decision to limit or cease life-prolonging interventions. Crucially, this trend was unique to the TBI cohort; similar escalations were not observed in patients with sepsis or non-TBI trauma.
Early Secondary Brain Insults: A Growing Concern
The study also highlighted the persistent challenge of preventing secondary brain injury. Early secondary insults are known to exacerbate the primary mechanical injury and are associated with poorer outcomes.
Prevalence of Physiological Insults
Among the TBI cohort:
49.8% experienced hypotension.
29.9% were exposed to hypocapnia.
33.6% were exposed to hypercapnia.
29.2% suffered from hyperglycaemia.
The Hypoxaemia Paradox
Most concerning was the trend in hypoxaemia (low blood oxygen). The proportion of patients exposed to hypoxaemia rose markedly from 36.9% in 2009 to 61.2% in 2024. Given that oxygenation is a cornerstone of neurocritical care management, this nearly two-fold increase suggests either a change in the physiological fragility of patients or a potential gap in the consistent application of oxygenation targets across ICUs.
Expert Commentary: Interpreting the Data
The findings of this study raise critical questions for the neurosurgical and intensivist communities. The simultaneous rise in mortality and WLST decisions suggests a shift in the clinical approach to TBI.
Ethical Frameworks and Nihilism
One possible interpretation is that clinicians and families are increasingly prioritizing quality of life over survival at any cost. However, there is a risk of “therapeutic nihilism,” where the perception of a poor prognosis becomes a self-fulfilling prophecy if life-sustaining care is withdrawn prematurely. The study authors emphasize the need to examine the ethical frameworks and decision-making processes that underpin WLST to ensure they are evidence-based and free from bias.
The Role of Secondary Insults
The rise in hypoxaemia and the high prevalence of hypotension indicate that physiological stabilization remains a hurdle. If nearly half of TBI patients are experiencing hypotension and over 60% are experiencing hypoxaemia, these secondary factors may be driving the increased mortality rates. Improving the adherence to “Brain Trauma Foundation” guidelines or similar neuro-protective protocols could potentially mitigate some of these trends.
Limitations
While the study is robust due to its large sample size and long duration, it is observational. It cannot definitively prove that increased WLST is the cause of increased mortality, nor can it account for every possible confounder, such as changes in pre-hospital care or the specific nuances of family-clinician discussions.
Conclusion
This 15-year study provides a sobering look at the current state of TBI care in the UK. With hospital mortality and WLST rates on the rise, and a significant increase in early secondary insults like hypoxaemia, the medical community must re-evaluate the trajectory of neurocritical care. Future research should focus on the drivers of WLST decisions and the implementation of more aggressive strategies to prevent secondary brain injury in the crucial early hours of admission.
Funding and References
This research was supported by funding from UKRI, NIHR, the UK Ministry of Defence, Alzheimer’s Research UK, the French Society of Anaesthesiology and Critical Care, the Gueules Cassées Foundation, and the INNOVEO donation fund.
References
Chapalain X, Huet O, Rowan KM, Mouncey PR, Langeron O, Menon DK, Harrison DA. Hospital mortality, withdrawal of life-sustaining therapy decisions and early secondary brain insults for critically ill traumatic brain injury patients in England, Wales and Northern Ireland (2009-2024): an observational cohort study. Lancet Reg Health Eur. 2025 Nov 20;61:101538. doi: 10.1016/j.lanepe.2025.101538.