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728 www.thelancet.com/neurology Vol 7 August 2008ReviewModerate and severe traumatic brain injury in adultsAndrew I R Maas, Nino Stocchetti, Ross BullockTraumatic brain injury (TBI) is a major health and socioeconomic problem that aff ects all societies. In recent years, patterns of injury have been changing, with more injuries, particularly contusions, occurring in older patients. Blast injuries have been identifi ed as a novel entity with specifi c characteristics. Traditional approaches to the classifi cation of clinical severity are the subject of debate owing to the widespread policy of early sedation and ventilation in more severely injured patients, and are being supplemented with structural and functional neuroimaging. Basic science research has greatly advanced our knowledge of the mechanisms involved in secondary damage, creating opportunities for medical intervention and targeted therapies; however, translating this research into patient benefi t remains a challenge. Clinical management has become much more structured and evidence based since the publication of guidelines covering many aspects of care. In this Review, we summarise new developments and current knowledge and controversies, focusing on moderate and severe TBI in adults. Suggestions are provided for the way forward, with an emphasis on epidemiological monitoring, trauma organisation, and approaches to management. IntroductionTraumatic brain injury (TBI) constitutes a major health and socioeconomic problem throughout the world.1,2 It is the leading cause of mortality and disability among young individuals in high-income countries, and globally the incidence of TBI is rising sharply, mainly due to increasing motor-vehicle use in low-income and middle-income countries. WHO has projected that, by 2020, traffi c accidents will be the third greatest cause of the global burden of disease and injury.3 In higher income countries, traffi c safety laws and preventive measures have reduced the incidence of TBI due to traffi c accidents,4 whereas the incidence of TBI caused by falls is increasing as the population ages, leading to a rise in the median age of TBI populations (table 1). This has consequences for the type of brain damage currently seen, and contusions (falls in older patients) are becoming more frequent than diff use injuries (high-velocity traffi c accidents in younger patients).Violence is now reported as the cause of closed head injury in approximately 7–10% of cases,9,10 a substantial increase from earlier studies. The incidence of penetrating brain injury is also increasing, particularly in the USA, due to the use of fi rearms in violence-related injuries. Worldwide, armed confl icts and terrorist activities are causing more brain injuries, often due to improvised explosive devices, to the extent that blast injuries of the brain are now recognised as a specifi c entity. The changing patterns of injury and treatment approaches have challenged current concepts of classifi cation. Moreover, basic research has greatly advanced our knowledge of what happens in the brain after TBI, off ering opportunities to limit processes involved in secondary brain damage. However, translating advances from basic research into clinical benefi t has proven complex. Here, we discuss current knowledge and novel insights and controversies in the study of adults with moderate and severe TBI, with the aim of integrating basic science and clinical research to provide guidelines on the epidemiological monitoring of TBI, trauma organisation, and management at the acute stage. Epidemiology and costIn the USA, monitoring by the Centers for Disease Control and Prevention shows the annual incidence of emergency department visits and hospital admissions for TBI to be 403 per 100 000 and 85 per 100 000, respectively.11 Epidemiological data on TBI from the European Union are scarce, but do indicate an annual aggregate incidence of hospitalised and fatal TBI of approximately 235 per 100 000,12 similar to that found in Australia,13 although substantial variation exists between European countries. Most patients with TBI have milder injuries, but residual defi cits in these patients are not infrequent.14 Approximately 10–15% of patients with TBI have more serious injuries, requiring specialist care.TBI is more common in young adults, particularly men (75%), which causes high costs to society because of life years lost due to death and disability. In Europe, TBI accounts for the greatest number of total years lived with disability resulting from trauma, and is among the top three causes of injury-related medical Lancet Neurol 2008; 7: 728–41Department of Neurosurgery, University Hospital Antwerp, Antwerp, Belgium (A I R Maas MD); Neuroscience Intensive Care Unit, Ospedale Maggiore Policlinico, Milan University, Milan, Italy (N Stocchetti MD); and Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA (R Bullock MD)Correspondence to: Andrew I R Maas, Department of Neurosurgery, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgiumandrew.maas@uza.be Year of studynMedian age (years)Proportion aged >50 yearsTraumatic Coma Data Bank5UK four centre study61986–1988European Brain Injury Consortium Core Data Survey7Rotterdam cohort study*Austrian Severe TBI study81984–19877462515%988847293827%33%19951999–20037744239%1999–20044154845%*Unpublished (Maas, AIR). Table 1: Increasing age in TBI studies