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    Traumatic brain injury outcomes across human development index strata in 29 countries

    healthylife7By No Comments27 Mins Read
    Traumatic brain injury outcomes across human development index strata in 29 countries

    Abstract

    Prior large-scale multicountry studies of traumatic brain injury (TBI) have either focused on surgically managed patients across development settings or characterized the full case-mix in predominantly high-income regions, leaving operative and nonoperative TBI across the human development spectrum incompletely defined. We present the Global Neurosurgical Study-1, integrating operative and nonoperative TBI across all Human Development Index (HDI) tiers. This prospective cohort included 2,165 patients from 100 hospitals in 29 countries between 2019 and 2022. Disparities were noted: median age ranged from 32 years (high-HDI) to 63 years (very-high-HDI); traffic injuries were the predominant cause of TBI in low-HDI (65.8%) versus falls in very-high-HDI (66%); and 69.3% of patients in the low-HDI tier arrived via private vehicles versus 13% for the very-high-HDI tier. Using mixed-effects logistic regression with inverse probability weighting, the adjusted mortality odds were highest in high-HDI tier (odds ratio 3.13, 95% confidence intervals 1.12–8.78) relative to the very-high-HDI, with no statistically significant elevation in low- or medium-HDI tiers. No dose–response relationship was noted between mortality and HDI. Inequities in injury mechanisms, patient demographics and prehospital access were drivers of outcome disparities. These findings suggest that HDI-stratified prevention targeting injury mechanisms and prehospital care may reduce the global TBI burden more effectively than hospital-based measures alone.

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    Fig. 1: GNS-I participating countries and participant demographics.
    Fig. 2: Time from injury to admission and surgery, and GOS scores at 30 and 90 days.
    Fig. 3: Prevalence of mortality and lasting complications.
    Fig. 4: Mortality at discharge model Forest plot.

    Subjects

    Data availability

    A de-identified, individual patient-level version of the analytic dataset, as well as a data dictionary, is available via GitHub at https://github.com/jgnugent/GNS-I-Analysis. These data will remain publicly available without an end date. Formal requests for the full dataset or for identifying metrics should be sent to the study’s data guarantor (nugentj@ohsu.edu) and principal investigator (raslana@ohsu.edu) accompanied by proof of ethical approval from the applicant’s home institution. Each request will be evaluated by the data guarantor and principal investigator on the basis of the proposed use and the adequacy of ethical approval, and applicants will receive a response within 30 days. Following approval of each individual request, the data will be shared directly with the interested party via a secure file-sharing system, including all raw data collected, the processing code used to generate the final analytic sample from the raw data, the final analytic dataset, as well as a codebook for both datasets within 30 days of approval. Additionally, the original study protocol and details regarding the collaborative are available online at https://globalneurosurg.org.

    Code availability

    The code created by the authors of the study to generate the descriptive and analytic results and all figures detailed in this manuscript is available via GitHub at https://github.com/jgnugent/GNS-I-Analysis. It is also available via Zenodo at https://doi.org/10.5281/zenodo.20694959 (ref. 31). Additionally, in the knitted Quarto files, session information is available, detailing the R version, packages used in the analysis, and their associated versions and URLs if they are not available on CRAN.

    References

    1. Taylor, C. A., Bell, J. M., Breiding, M. J. & Xu, L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths — United States, 2007 and 2013. MMWR Surveill. Summ.66, 1–16 (2017)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    2. Frieden, T. R., Houry, D., & Baldwin, G. Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation (National Center for Injury Prevention and Control: Division of Unintentional Injury Prevention, 2015); https://www.cdc.gov/traumaticbraininjury/pdf/tbi_report_to_congress_epi_and_rehab-a.pdf

    3. van Essen, T. A. et al. Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir. (Wien)161, 435–449 (2019)

      Article 
      PubMed 
      Google Scholar 

    4. Dewan, M. C. et al. Estimating the global incidence of traumatic brain injury. J. Neurosurg.130, 1080–1097 (2018)

      Article 
      PubMed 
      Google Scholar 

    5. Coronado, V. G. et al. Surveillance for traumatic brain injury-related deaths—United States, 1997–2007. MMWR Surveill. Summ.60, 1–32 (2011)

      PubMed 
      Google Scholar 

    6. Masson, F. et al. Epidemiology of severe brain injuries: a prospective population-based study. J. Trauma51, 481–489 (2001)

      CAS 
      PubMed 
      Google Scholar 

    7. Walder, B. et al. Severe traumatic brain injury in a high-income country: an epidemiological study. J. Neurotrauma30, 1934–1942 (2013)

      Article 
      PubMed 
      Google Scholar 

    8. De Silva, M. J. et al. Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries. Int. J. Epidemiol.38, 452–458 (2009)

      Article 
      PubMed 
      Google Scholar 

    9. Steyerberg, E. W. et al. Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet Neurol.18, 923–934 (2019)

      Article 
      PubMed 
      Google Scholar 

    10. Maas, A. I. R. et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol.21, 1004–1060 (2022)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    11. Clark, D. et al. Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study. Lancet Neurol.21, 438–449 (2022)

      Article 
      PubMed 
      Google Scholar 

    12. Negida, A. & Raslan, A. M. The Global NeuroSurg Research Collaborative: a novel student-based model to expand global neurosurgery research. Front. Surg.8, 721863 (2021)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    13. Rusnak, M. Traumatic brain injury: giving voice to a silent epidemic. Nat. Rev. Neurol.9, 186–187 (2013)

      Article 
      PubMed 
      Google Scholar 

    14. Toroyan, T., Peden, M. M. & Iaych, K. WHO launches second global status report on road safety. Inj. Prev.19, 150 (2013)

      Article 
      PubMed 
      Google Scholar 

    15. Nielsen, K. et al. Assessment of the status of pre-hospital care in 13 low- and middle-income countries. Prehosp. Emerg. Care16, 381–389 (2012)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    16. Shenton, M. E. et al. A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury. Brain Imaging Behav.6, 137–192 (2012)

      Article 
      CAS 
      PubMed 
      PubMed Central 
      Google Scholar 

    17. Yuh, E. L. et al. Magnetic resonance imaging improves 3-month outcome prediction in mild traumatic brain injury. Ann. Neurol.73, 224–235 (2013)

      Article 
      PubMed 
      Google Scholar 

    18. Haghbayan, H. et al. The prognostic value of MRI in moderate and severe traumatic brain injury: a systematic review and meta-analysis. Crit. Care Med.45, e1280–e1288 (2017)

      Article 
      PubMed 
      Google Scholar 

    19. Yuan, Q. et al. Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis. J. Neurosurg.122, 574–587 (2015)

      Article 
      PubMed 
      Google Scholar 

    20. Shen, L. et al. Effects of intracranial pressure monitoring on mortality in patients with severe traumatic brain injury: a meta-analysis. PLOS ONE11, e0168901 (2016)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    21. Wang, H. et al. A meta-analysis and systematic review of intracranial pressure monitoring on severe craniocerebral injury. Ann. Palliat. Med.10, 5380–5390 (2021)

      Article 
      PubMed 
      Google Scholar 

    22. Maas, A. I. R. et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol.16, 987–1048 (2017)

      Article 
      PubMed 
      Google Scholar 

    23. von Elm, E. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet370, 1453–1457 (2007)

      Article 
      Google Scholar 

    24. World Health Organization (WHO). International Classification of Diseases, Eleventh Revision(ICD-11) (2019); https://icd.who.int/en/docs/icd11-license.pdf

    25. Harris, P. A. et al. The REDCap consortium: building an international community of software platform partners. J. Biomed. Inform.95, 103208 (2019)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    26. Human Development Report 2021–22: Uncertain Times, Unsettled Lives: Shaping our Future in a Transforming World (United Nations Development Programme, 2022); http://report.hdr.undp.org

    27. World Development Indicators DataBank (The World Bank, accessed 20 July 2025); https://databank.worldbank.org/

    28. Leonhard, M. J., Wright, D. A., Fu, R., Lehrfeld, D. P. & Carlson, K. F. Urban/rural disparities in Oregon pediatric traumatic brain injury. Inj. Epidemiol.2, 32 (2015)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    29. Huang, Y. H. et al. Thirty-day mortality in traumatically brain-injured patients undergoing decompressive craniectomy. J. Neurosurg.118, 1329–1335 (2013)

      Article 
      PubMed 
      Google Scholar 

    30. Roozenbeek, B. et al. Predicting 14-day mortality after severe traumatic brain injury: application of the IMPACT models in the brain trauma foundation TBI-trac(R) New York State database. J. Neurotrauma29, 1306–1312 (2012)

      Article 
      PubMed 
      PubMed Central 
      Google Scholar 

    31. Nugent, J. jgnugent/GNS-I-Analysis: Nature Medicine. Zenodohttps://doi.org/10.5281/zenodo.20694959 (2026)

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    Acknowledgements

    The authors thank E. Klein for ethical consultation for the GNS-I study

    Funding

    No external funding was obtained for this study

    Author information

    Authors and Affiliations

    1. Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA

      Joseph G. Nugent, Brittany Stedelin, Saud K. Zaidan, Hazem S. Ghaith, Claire Zeigler, Barbara Lazio & Ahmed M. Raslan

    2. Department of Neurological Surgery, Emory University, Atlanta, GA, USA

      Hao Tan

    3. Department of Family Medicine, Lexington Health at Lexington Medical Center, West Columbia, SC, USA

      Caleb S. Nerison

    4. Department of Neurosurgery, University of California, Los Angeles, CA, USA

      Zoe E. Teton, Keshav Goel, Anwesha Dubey, Geoffrey Colby & Manuel Buitrago Blanco

    5. Department of Neurosurgery, Royal Infirmary Edinburgh, NHS Lothian, Edinburgh, UK

      Andreas K. Demetriades, Marco Mancuso-Marcello, John Emelifeonwu, Nadia Liber Salloum & Phillip C. Copley

    6. Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK

      Adam A. Dmytriw, Mario Ganau, Yizhou Wan & Ieva Sataite

    7. Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

      Adam A. Dmytriw, Noah Nawabi, Luis Rendon, Mohammad A. Aziz-Sultan, John L. Kilgallon, Timothy R. Smith, Yasuaki Inoue, Leila Mashouf, Bryan Choi, Christopher Stapleton, Aman Patel, Gabriel N. Friedman, Robert Gramer, Takeshi Yanagisawa, Pratik Talati & Athar Malik

    8. Neurointerventional & Neuroanalytics Consortium (NAN-C), School of Medicine, Toronto Metropolitan University, Toronto, Ontario, Canada

      Adam A. Dmytriw

    9. Department of Neurosurgery, University of Florida, Gainesville, FL, USA

      Megan E. H. Still

    10. Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA

      Ahmed Negida

    11. Mustapha Pacha University Hospital, Algiers, Algeria

      Amina Arar

    12. Saadna Mohamed Abdnour Teaching Hospital, Sétif, Algeria

      Nesrine Aouabed

    13. National Institute of Neurosciences and Hospital, Dhaka, Bangladesh

      Sudipta Kumer Mukherjee

    14. University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada

      Michael D. Cusimano & Abdelhakim Khellaf

    15. University of Bamenda, Bamenda, Cameroon

      Ignatius N. Esene & Enow Awah Georges Stevens

    16. Tianjin University, Tianjin, China

      Wenjin Chen

    17. University of Cartagena, Cartagena, Colombia

      Ivan D. Lozada-Martinez & Luis Rafael Moscote-Salazar

    18. Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo

      Arsene Daniel Nyalundja

    19. Beni Suef University Hospital, Beni Suef, Egypt

      Dalia Kamal

    20. Ain-Shams University Hospitals (El-Demerdash), Cairo, Egypt

      Walid Ali, Hazem Kholy, Says Zazoa, Ahmed Kamel Basha, Ahmed K. Awad, Merihan A. Elbadawy, Khadiga Omar Abdelhamid, Walid Abdel Ghany, Abdelrahman Gad, Abdelrahman Farag Mohamed, Yara Y. Abdelwahab, Andrew Boshra, Amir N. Attia, Mohamed Abdel-Maboud, Hassan Mustafa & Mazen A. Refaat

    21. Alazhar University Hospitals (Al Hussein University Hospital), Cairo, Egypt

      Mohamed Abdel-Maboud, Ahmed Y. Azzam, Mohammed A. Azab, Mohamed Sabra & Eshak Bahbah

    22. Al Shefaa Hospital – Qena, Qena, Egypt

      Gad Sayed Gad, Hossam Tharwat Ahmed Ali & Ziad Ashraf Soliman

    23. Alexandria University Main Hospital, Alexandria, Egypt

      Amr Elwany, Abdelrahman Abdelaal, Mohamed Shemeis, Mohamed Soliman, Hebatullah Rozza, Youssef Zakaria, Yousef Tanas, Yomna E. Dean, Shaher Shokralla, Ahmed Nafea, Ahmed Mohamed, Reem Elzeny & Abdelrahman Mahmoud Yehia

    24. Ras El Tin Hospital, Alexandria, Egypt

      Yousef Tanas, Yomna E. Dean, Shaher Shokralla & Heba Ahmed Elsayed Mahmoud Hasanein

    25. Assiut University Hospital, Assiut, Egypt

      Mahmoud Mohammad Saad & Ali Ashraf

    26. Misr University for Science and Technology, 6th of October City, Egypt

      Dina Abdelazim Ghoraba, Mohamed Atef Mohamed, Manar Ashraf Saleem, Ayah Mohamed Elbardisy, Ahmed Taher Ramadan, Mariyam Motaz Almahdy, Abdulrahman Mohammed Shousha, Zeyad Ahmed Abdulmonem, Ghadi Kamal Khezahi, Mohamed Samir El Molla, Andrew Gamal Soubhy, Mooaz Mohamed Zakrya, Mirna Tarek, Abdelrahman Ahmed Anter, Esraa Amgad Moawad, Alaa Ghamry Abd El Latif, Ahmed Mohamed Aboelkasem, Omar Reda Ali, Abeer Ghoraba, Abdulrahman Sharawi, Asmaa Hassan, Rawan Atef Mohammed, Ahmed Ramadan Gamil, Mohamed Ashraf Abouzekry, Mohamed Mahmoud Fathi, Youssef Mohammed Hussien, Sameh Mohamed Sorour, Basma Ahmed Zahran & Kyrillos Nassim

    27. Mansoura University Hospital, Mansoura, Egypt

      Mohamed Badran, Basem I. Awad, Reem Elsaadany, Ahmed Abdelwahab, Ahmed Balash & Reem Abdelwahab

    28. Menofia University Hospital, Shibin El Kom, Egypt

      Hanady Mohammed Elfeky, Abdelrahman Amin Mahmoud, Sara Wagdy Konswa, Salma Elnoamany, Amr Shaheen, Esraa Mohammed Shaltout, Ahmed Hafez, Ahmed Gameel, Mohammad Torayah, Aya Hagar & Rania Nabil

    29. Qena University Hospitals, South Valley University, Qena, Egypt

      Ali Rabee Hamdan, Eslam ElSayed ElKhateeb & Ahmed Sallam ElHawary

    30. Sohag University Hospital, Sohag, Egypt

      Mohamed Awesh, Omar El-Shebany, Mohamed Ellebedy, Abdelrhman Mohammed, Ahmed Tammam & Mohamed Hashem

    31. Suez Canal University, Ismailia, Egypt

      Aiman Al-Touny, Tariq Awad, Hesham Nada, Shimaa Al-Touny, Bassma Raslan, Hesham Habba & Eman Teema

    32. Tanta University, Tanta, Egypt

      Mohamed Morsi, Mohamed Elbahnasawy, Abdulrahman Zahran, Sara Samy Ramadan, Mostafa Essa, Esraa Eldeep & Mohamed Elsharkawy

    33. Wingat Royal Hospital, Alexandria, Egypt

      Omar Elmandouh

    34. Zagazig University, Zagazig, Egypt

      Mohamed Arnaout, Mahmoud Ahmed Ebada & Mustapha Amnir

    35. Strasbourg University Hospital, Strasbourg, France

      Charles-Henry Mallereau, Salvatore Chibbaro & Guillaume Dannhoff

    36. St Marien Academic Hospital Lünen, Lünen, Germany

      Konstantinos Gousias, Rachit Agrawal & Dimitrios Seferis

    37. University Hospital Mannheim, University of Heidelberg, Mannheim, Germany

      Katharina Hackenberg, Andia Mirbagheri & Nima Etminan

    38. Ganesh Shankar Vidyarthi Memorial (G.S.V.M.) Medical College, Kanpur, India

      Manish Singh, Himanshu Jindal & Abhijeet Singh Sachan

    39. Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India

      Raman Mohan Sharma, Mohammad Ahmed Ansari, Mohammad Tabish Khan, Faique Rahman, Shaarif Rauf Khan & Jowairiya Tehreem Khan

    40. Kasturba Medical College, Manipal, Manipal, India

      Ashwin Pai, Sufyan Ibrahim & Nagaraja Kamath

    41. King George’s Medical University, Lucknow, Lucknow, India

      Ankur Bajaj, Bal Krishna Ojha, Ahmad Ozair, Jay Tewari, Vinay Suresh & Anadika Rana

    42. Seth GS Medical College and KEM Hospital, Mumbai, India

      Survendra K. Rai & Yash V. Kamath

    43. Vydehi Institute of Medical Sciences & Research Centre, Bangalore, India

      Survendra K. Rai, Yash V. Kamath, Suresha Kodapala, Vivek Bhat, Anantha Kishan, Monty U. Khajanchi, Varun V. Bansal, Tsering Yangchen Dirkhipa & Anveshi Nayan

    44. Department of Neurosurgery, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia

      Ahmad Faried, Fachreza Damara & Alfya Ramdhani

    45. Iran University of Medical Sciences, Tehran, Iran

      Arash Fattahi, Abdoulhadi Daneshi & Omid Masoudi

    46. Al-Emamian Alkadhimain Medical City, Baghdad, Iraq

      Ihssan S. Nema, Haider Faris Al-Wash, Zahraa B. Shehab Al-Qaysi, Mohammed Amer Fadhil, Mohamed Bassem & Goran Mohammed Hussein

    47. Al-Sader Teaching Hospital – Al-Najaf, Najaf, Iraq

      Maytham Al-Juaifari

    48. Al Zafaraniyah General Hospital, Baghdad, Iraq

      Abdullah Khudhur Ahmed

    49. Messina University Hospital, Messina, Italy

      Antonino Germanò, Giovanni Raffa & Antonello Curcio

    50. Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy

      Pierfrancesco Lapolla, Pietro Familiari, Antonio Santoro, Andrea Mingoli & Gioia Brachini

    51. Sant’Andrea University Hospital, Sapienza University of Rome, Rome, Italy

      Placido Bruzzaniti, Giuseppa Zancana & Alessandro Frati

    52. Fabrizio Spaziani Hospital, Frosinone, Frosinone, Italy

      Laura Lavalle, Biagia La Pira, Vincenza Maiola, Veronica Picotti & Giancarlo D’Andrea

    53. Policlinico Vittorio Emanuele University Hospital, University of Catania, Catania, Italy

      Roberto Altieri, Giuseppe Barbagallo & Francesco Certo

    54. Fondazione Policlinico Universitario A. Gemelli IRCCS University Hospital, Rome, Italy

      Carmelo Lucio Sturiale, Alessandro Izzo, Sonia D’Arrigo, Alessandro Olivi & Giovanni Pennisi

    55. Università Degli Studi di Bari Aldo Moro, Bari, Italy

      Maria Teresa Bozzi

    56. Jordan University Hospital, Amman, Jordan

      Almu’atasim Khamees, Khayry Al-Shami, Salah Hasan, Sajeda Awadi, Luai Abu-Ismail, Khalifa Salem, Tareq Kanaan, Lutfi Hussein, Khaled Sawaftah, Ktadah Al-Soub, Nour M. Khaimer, Farah Al-kasajy, Qusay Sabbagh & Qutada Soub

    57. Ibn Al-Haytham Hospital, Amman, Jordan

      Majedah Yousef Hmeidan, Hadeel Aladwan & Barihan Alkhasawneh

    58. Al Yarmouk University, Irbid, Jordan

      Ansam Ghzawi, Luai Abuismael & Osama Jamal Abu-Hamdiyeh

    59. Makassed General Hospital, Beirut, Lebanon

      Samar Karout

    60. Mount Lebanon Hospital, Beirut, Lebanon

      Samar Karout

    61. Rayak Hospital, Rayak, Lebanon

      Ali Safar & Jana Tarchichi

    62. Saint George Hospital University Medical Center, Beirut, Lebanon

      Rania Itani, Ibrahim Ibrahim & Elie Louak

    63. Abu Saleem Hospital, Tripoli, Libya

      Ahmed Bishti & Fathia Abdulfatah Ahmed Mahmoud

    64. Benghazi Medical Center, Benghazi, Libya

      Soha Albarghathi, Wafa Omar Aldressi, Mohamed Fathi Kalifa, Wafa Aldressi & Seraj A. Zentani

    65. Medical Care Clinic, Tripoli, Libya

      Malek Mohamed Abusannuga

    66. Misrata Medical Center, Misrata, Libya

      Fakhruddin Almuzghi, Alzaharra Elfraa, Maaly Abuhlaiga, Ghalia Madri, Asma Aljanfi, Saja Mohammed, Burooj Mohammed, Muataz Kashbour & Alhadi M. Jahan

    67. Misurata University, Misrata, Libya

      Abubaker Abdelmalik

    68. Tripoli Central Hospital, Tripoli, Libya

      Marwa Mohammed Morgom, Sarah Fathi Alhaddad, Mawada Mohammed & Ema Ali

    69. University of Tripoli, Tripoli, Libya

      Muhammed Elhadi, Entisar Alshareea, Suha Elzwai, Marwa Biala, Mohamed Alharari, Dahiba Naji, Reem Ghmagh, Sarah Aljamal, Abdulqudus Deeknah, Duha Abdullah, Eman Abdulwahed, Shahd Elmhadbi, Reyam Naana, Esmail Hamuda, Mawada Khalifa, Dawoud Saeid, Sultan Ahmeed, Rana Graish & Heba Rhuma

    70. Tobruk Medical Center, Tobruk, Libya

      Ahmad Bouhuwaish, Farhat Y. Bashir & Ayyah Emran

    71. Zliten Medical Center, Zliten, Libya

      Najat Shaban Ben Hasan & Hanna Yahia

    72. Lithuanian University of Health Sciences Hospital Kaunas Clinics, Kaunas, Lithuania

      Rimantas Vilcinis, Albertas Sliauzys & Antanas Budenas

    73. Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia

      Zamzuri Idris, Abdul Rahman Izaini Ghani & Sharalini Binti Zanuddin

    74. University of Malaya Medical Centre, Kuala Lumpur, Malaysia

      Dharmendra Ganesan, Langkeas Mohanavel, Weipin Hung, Chee Yang Tan, Song Ying Chong, Yuki Julius Ng & Qun Ya Lim

    75. Hôpital des Spécialités – ONO, Rabat, Morocco

      Abdessamad El Ouahabi, Mohammed Yassaad Oudrhiri & Imane Ammouze

    76. Ibn Tofail Hospital, Marrakech, Marrakech, Morocco

      Moniba Korch, Sami Boutti & Yassmine Boumzebra

    77. Mohammed V University, Rabat, Morocco

      Oumaïma Outani

    78. Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria

      Ezeali Mike Ekuma, Uche Emmanuel Eni & Kelechi Ndukuba

    79. Federal Teaching Hospital Ido Ekiti, Ido-Ekiti, Nigeria

      Abiodun Okunlola, Tesleem Orewole & Paul Abiola

    80. Federal Medical Centre Umuahia, Umuahia, Nigeria

      Oluwamayowa Opara

    81. Lagoon Hospitals, Lagos, Nigeria

      Chiazor Onyia, Joseph Alozie & Henry Obichie

    82. University of Calabar Teaching Hospital, Calabar, Nigeria

      Obanife Henry Olayere, Kingsley Akaba & John Gbaji

    83. University of Nigeria Nsukka, Nsukka, Nigeria

      Enoch Ogbonnaya Uche, Uko Kalu Uko & Hilary Chukwuma

    84. Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria

      Aliyu Muhammad Koko, Ali Lasseini & Nasiru Jinjiri Ismail

    85. Aga Khan University Hospital, Karachi, Pakistan

      Syeda Maria Zaidi, Marium Hussain, Izza Tahir, Rameen Ata Bajwa, Javeria Bilal Qamar, Fatima Gauhar, Ali Tayyab, Syed Ali Tayyeb Hasan, Daniyal Ali Khan, Angelina Jessani, Zain ul Abidin, Hareem Rauf, Usama Waqar, Syed Ather Enam, Hamna Ganny, Rehab Naeem Khalid, Muhammad Sarmad Tahir, Ahmad Areeb Chaudhry, Isbaah Tejani, Namrah Aziz, Muhammad Shehryar Khan, Haleema Sadia, Aiza Abbas, Ronika Devi Ukrani, Muhammad Jawad Amin Malik, Muhammad Hamza, Hajra Arshad, Muhammad Shahzad Shamim, Muhammad Muneeb Khan Bozai, Muhammad Nabeel Safdar, Fahad Zahid, Javeria Tariq, Mohammad Safri, Mushahid Hussain, Hamza Sohail, Maham Jaskani, Zainab Ayaz Dandia, Sameeta Kumari, Mabrooka Kazi, Mahnoor Javaid, Laeba Hussain & Muhammad Ehsan Bari

    86. Jinnah Medical & Dental College, Karachi, Pakistan

      Pradhumna Kumar Yadav & Ahtesham Khizar

    87. Rawalpindi Medical University, Rawalpindi, Pakistan

      Saad Javed

    88. Shifa College of Medicine, Islamabad, Pakistan

      Ali Haider Bangash

    89. Hebron Governmental Hospital, Hebron, Palestine

      Ahmad Ghassan Hammouri

    90. Nasser Medical Complex, Khan Yunis, Palestine

      Mustafa Jayyab

    91. Alia Governmental Hospital, Hebron, Palestine

      Sara Amro

    92. Al-Quds University, Jerusalem, Palestine

      Sadi A. Abukhalaf

    93. Neurosurgery Department, Medical University of Gdańsk, Gdańsk, Poland

      Tomasz Szmuda, Michał Krakowiak & Justyna Fercho

    94. Universidad Peruana Cayetano Heredia, Lima, Peru

      Jhon Bocanegra

    95. Department of Neurosurgery, Buraidah Central Hospital, Buraidah, Saudi Arabia

      Mahmoud Dibas, Nazmus Saquib & Mohammad Shakhawat Hossain

    96. Somali Turkish Hospital Mogadishu, Mogadishu, Somalia

      Mohamed Gedi Sheikhow, Ismail Gedi Ibrahim & Abukar Mohamed Osman

    97. Hospital General Universitario de Alicante, Alicante, Spain

      Pablo González-López, Carlos Martorell-Llobregat & Cristina Gómez-Revuelta

    98. Joan XXIII University Hospital of Tarragona, Tarragona, Spain

      Ruth Lau

    99. University Hospital “Marqués de Valdecilla’, Santander, Spain

      Ruben Martín-Láez, Victor Garcia-Milan & Jesús Manuel Esteban-Gonzalez

    100. Aliaa Specialist Hospital, Omdurman, Sudan

      Abdulrhman Marwan Khaity, Moayad Moawia Zain Elabdin Ahmed & Mohammed Abdirahman Ibrahim

    101. Gezira Traumatology Centre, Wad Madani, Sudan

      Mahmoud Saleh

    102. Haj Al-Mardi Mohiuddin Hospital (formerly Al Tamayoz Hospital), Khartoum, Sudan

      Emad Ibrahim, Ahmed Eljack, Hozaifa Elameen, Mohamed Hassan Eltoum, Omer Elaibaid, Radi Tofaha Alhusseini, Khabab Abbasher, Mohajer Ibrahim, Tasneem Mohamed, Ayman Mohammed & Razan Ahmad

    103. Omdurman Military Hospital, Omdurman, Sudan

      Saeed Ahmad

    104. Omdurman Teaching Hospital, Omdurman, Sudan

      Osman Ahmed Eltahir Ahmed, Albushra Altayeb, Adam Osman & Rufida Abdulmageed Alyhary

    105. Soba University Hospital, Khartoum, Sudan

      Hytham Hamid

    106. Ribat University Hospital, Khartoum, Sudan

      Haytham Hussein Osman

    107. Al-Basel Specialist Hospital, Damascus, Syria

      Afaf Atassi, Fares Abbas, Mohab Alakkari, Osama Alakhras, Lujain Aldakak, Hamzeh Koumakli, Abdulrahman Alsaboni, Leen Aboud, Awatef Aouf, Haya Taha, Abdalrahman Manzalji, Seba Ayoub, Rawdah Attom, Khoder Al-Khauly & Haya Zoughaibi

    108. Aleppo University Hospital, Aleppo, Syria

      Mohamed Alaktaa, Hani Abdalnour, Ala Aldeen Hasan, Mohammad Kour, Mahmoud Wereekia, Ahmad Birajkly, Rasheed Alhameed, Mohamad Alhusseini, Saleem Aslan, Kutaiba Al-Ali, Majd Aldeen Alosman, Laith Arafa, Hasan Hallak, Abdulaziz Alkateb, Renas Osman, Shiar Mustafa, Mohammed Badleh, Thabet Sayed Bakir, Ahmad Sankari Tarabishi, Firas Enabi, Mohamad Anas Sattout, Fadi Akhras, Mohammad Nour Shashaa, Madiha Fanari, Majd Alneser, Abdelaziz Alibraheem, Aya Zazo, Bashar Bazke, Muhamad Zakaria Brimo Alsaman, Mohamad Ghazal, Nazeeh Al Aktaa, Alma Douedari, Mike Ghabally, Lara Hindawi, Yusef Jondiah, Abdullah Fattal, Mohammad Shadi Alkarrash, Ahmad Alsheikh, Mouna Almoussa, Monia Hamed, Amr Hamza, Rama Zazo, Ahmad Al-Mouakeh, Ahmad Bebi, Zain Douba, Muhammed Al-husseini & Maher Aldeiri

    109. Al-Mouwasat University Hospital, Damascus, Syria

      Obada ALhalabi, Saeed Kadri, Ali Sulaiman, Abdulrahman Alskaf, Abdulrahman Ghaibah, Adel Kabbara Allababidi, Talal Badawy, Mohammad Abdow, Husin Qazaq, Aram Abbas, Hussam Alhayek, Ali Sliman, Huda Albkhetan, Rami Alkhouja, Manhal Sharaf, Hasan Alzuhaily, Mohammed Karam Chaaban, Hussein Kazak, Qamar Alkhador & Louay Misrabi

    110. Tishreen University Hospital, Latakia, Syria

      Ammar Salloum, Ali Mohamad, Ali Hammed, Alaa Mohammad Hamdan, Alaa Sulaiman, Naya Talal Hassan, Majd Yaseen, Abdeljawad Mazloum, Jaafar Zahlout, Ahmed Moussa, Sulaiman Jolak, Iyad Ali, Ali Sabbour, Rita Mohammad, Rahaf Ranjous, Alaa Al Barroush, Ziad Saker, Ali Zamlout, Okbah Mohamad, Haidar Shmayyes, Moufid Mahfoud, Salma Shahin, Sara Deeb, Zahraa Sari, Ritta Ranjous, Deema Al Barroush, Haifaa Douba & Liana Abdullah

    111. National Institute of Neurology, Tunis, Tunisia

      Ghassen Souissi & AbdelHafidh Slimane

    112. El Manar – Tunis University, Tunis, Tunisia

      Nesrine Ben Hadj Dahman & Mohamed Badri

    113. Northumbria Healthcare NHS Foundation Trust, North Shields, UK

      Avinash Aujayeb

    114. Beth Israel Deaconess Medical Center, Boston, MA, USA

      Martina Stippler & Amber Nieves

    115. Al Thawra Hospital, Sana’a, Yemen

      Fatima Aleryani

    116. Republican Teaching Hospital, Sana’a, Yemen

      Salwa Al Aryani

    Authors

    1. Joseph G. NugentView author publications

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    2. Hao TanView author publications

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    3. Brittany StedelinView author publications

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    4. Caleb S. NerisonView author publications

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    5. Zoe E. TetonView author publications

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    6. Saud K. ZaidanView author publications

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    7. Andreas K. DemetriadesView author publications

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    8. Adam A. DmytriwView author publications

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    9. Megan E. H. StillView author publications

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    10. Hazem S. GhaithView author publications

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    11. Claire ZeiglerView author publications

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    12. Barbara LazioView author publications

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    13. Ahmed NegidaView author publications

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    14. Ahmed M. RaslanView author publications

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    Consortia

    GNS-I Collaborators

    • Amina Arar
    • , Nesrine Aouabed
    • , Sudipta Kumer Mukherjee
    • , Michael D. Cusimano
    • , Abdelhakim Khellaf
    • , Ignatius N. Esene
    • , Enow Awah Georges Stevens
    • , Wenjin Chen
    • , Ivan D. Lozada-Martinez
    • , Luis Rafael Moscote-Salazar
    • , Arsene Daniel Nyalundja
    • , Dalia Kamal
    • , Walid Ali
    • , Hazem Kholy
    • , Says Zazoa
    • , Ahmed Kamel Basha
    • , Ahmed K. Awad
    • , Merihan A. Elbadawy
    • , Khadiga Omar Abdelhamid
    • , Walid Abdel Ghany
    • , Abdelrahman Gad
    • , Abdelrahman Farag Mohamed
    • , Yara Y. Abdelwahab
    • , Andrew Boshra
    • , Amir N. Attia
    • , Mohamed Abdel-Maboud
    • , Hassan Mustafa
    • , Mazen A. Refaat
    • , Gad Sayed Gad
    • , Hossam Tharwat Ahmed Ali
    • , Ziad Ashraf Soliman
    • , Ahmed Y. Azzam
    • , Mohammed A. Azab
    • , Mohamed Sabra
    • , Eshak Bahbah
    • , Amr Elwany
    • , Abdelrahman Abdelaal
    • , Mohamed Shemeis
    • , Mohamed Soliman
    • , Hebatullah Rozza
    • , Youssef Zakaria
    • , Yousef Tanas
    • , Yomna E. Dean
    • , Shaher Shokralla
    • , Ahmed Nafea
    • , Ahmed Mohamed
    • , Reem Elzeny
    • , Abdelrahman Mahmoud Yehia
    • , Mahmoud Mohammad Saad
    • , Ali Ashraf
    • , Dina Abdelazim Ghoraba
    • , Mohamed Atef Mohamed
    • , Manar Ashraf Saleem
    • , Ayah Mohamed Elbardisy
    • , Ahmed Taher Ramadan
    • , Mariyam Motaz Almahdy
    • , Abdulrahman Mohammed Shousha
    • , Zeyad Ahmed Abdulmonem
    • , Ghadi Kamal Khezahi
    • , Mohamed Samir El Molla
    • , Andrew Gamal Soubhy
    • , Mooaz Mohamed Zakrya
    • , Mirna Tarek
    • , Abdelrahman Ahmed Anter
    • , Esraa Amgad Moawad
    • , Alaa Ghamry Abd El Latif
    • , Ahmed Mohamed Aboelkasem
    • , Omar Reda Ali
    • , Abeer Ghoraba
    • , Abdulrahman Sharawi
    • , Asmaa Hassan
    • , Rawan Atef Mohammed
    • , Ahmed Ramadan Gamil
    • , Mohamed Ashraf Abouzekry
    • , Mohamed Mahmoud Fathi
    • , Youssef Mohammed Hussien
    • , Sameh Mohamed Sorour
    • , Basma Ahmed Zahran
    • , Kyrillos Nassim
    • , Mohamed Badran
    • , Basem I. Awad
    • , Reem Elsaadany
    • , Ahmed Abdelwahab
    • , Ahmed Balash
    • , Reem Abdelwahab
    • , Hanady Mohammed Elfeky
    • , Abdelrahman Amin Mahmoud
    • , Sara Wagdy Konswa
    • , Salma Elnoamany
    • , Amr Shaheen
    • , Esraa Mohammed Shaltout
    • , Ahmed Hafez
    • , Ahmed Gameel
    • , Mohammad Torayah
    • , Aya Hagar
    • , Rania Nabil
    • , Ali Rabee Hamdan
    • , Eslam ElSayed ElKhateeb
    • , Ahmed Sallam ElHawary
    • , Heba Ahmed Elsayed Mahmoud Hasanein
    • , Mohamed Awesh
    • , Omar El-Shebany
    • , Mohamed Ellebedy
    • , Abdelrhman Mohammed
    • , Ahmed Tammam
    • , Mohamed Hashem
    • , Aiman Al-Touny
    • , Tariq Awad
    • , Hesham Nada
    • , Shimaa Al-Touny
    • , Bassma Raslan
    • , Hesham Habba
    • , Eman Teema
    • , Mohamed Morsi
    • , Mohamed Elbahnasawy
    • , Abdulrahman Zahran
    • , Sara Samy Ramadan
    • , Mostafa Essa
    • , Esraa Eldeep
    • , Mohamed Elsharkawy
    • , Omar Elmandouh
    • , Mohamed Arnaout
    • , Mahmoud Ahmed Ebada
    • , Mustapha Amnir
    • , Charles-Henry Mallereau
    • , Salvatore Chibbaro
    • , Guillaume Dannhoff
    • , Konstantinos Gousias
    • , Rachit Agrawal
    • , Dimitrios Seferis
    • , Katharina Hackenberg
    • , Andia Mirbagheri
    • , Nima Etminan
    • , Manish Singh
    • , Himanshu Jindal
    • , Abhijeet Singh Sachan
    • , Raman Mohan Sharma
    • , Mohammad Ahmed Ansari
    • , Mohammad Tabish Khan
    • , Faique Rahman
    • , Shaarif Rauf Khan
    • , Jowairiya Tehreem Khan
    • , Ashwin Pai
    • , Sufyan Ibrahim
    • , Nagaraja Kamath
    • , Ankur Bajaj
    • , Bal Krishna Ojha
    • , Ahmad Ozair
    • , Jay Tewari
    • , Vinay Suresh
    • , Anadika Rana
    • , Survendra K. Rai
    • , Yash V. Kamath
    • , Suresha Kodapala
    • , Vivek Bhat
    • , Anantha Kishan
    • , Monty U. Khajanchi
    • , Varun V. Bansal
    • , Tsering Yangchen Dirkhipa
    • , Anveshi Nayan
    • , Ahmad Faried
    • , Fachreza Damara
    • , Alfya Ramdhani
    • , Arash Fattahi
    • , Abdoulhadi Daneshi
    • , Omid Masoudi
    • , Ihssan S. Nema
    • , Haider Faris Al-Wash
    • , Zahraa B. Shehab Al-Qaysi
    • , Mohammed Amer Fadhil
    • , Mohamed Bassem
    • , Goran Mohammed Hussein
    • , Maytham Al-Juaifari
    • , Abdullah Khudhur Ahmed
    • , Antonino Germanò
    • , Giovanni Raffa
    • , Antonello Curcio
    • , Pierfrancesco Lapolla
    • , Pietro Familiari
    • , Antonio Santoro
    • , Andrea Mingoli
    • , Gioia Brachini
    • , Placido Bruzzaniti
    • , Giuseppa Zancana
    • , Alessandro Frati
    • , Laura Lavalle
    • , Biagia La Pira
    • , Vincenza Maiola
    • , Veronica Picotti
    • , Giancarlo D’Andrea
    • , Roberto Altieri
    • , Giuseppe Barbagallo
    • , Francesco Certo
    • , Carmelo Lucio Sturiale
    • , Alessandro Izzo
    • , Sonia D’Arrigo
    • , Alessandro Olivi
    • , Giovanni Pennisi
    • , Maria Teresa Bozzi
    • , Almu’atasim Khamees
    • , Khayry Al-Shami
    • , Salah Hasan
    • , Sajeda Awadi
    • , Luai Abu-Ismail
    • , Khalifa Salem
    • , Tareq Kanaan
    • , Lutfi Hussein
    • , Khaled Sawaftah
    • , Ktadah Al-Soub
    • , Nour M. Khaimer
    • , Farah Al-kasajy
    • , Qusay Sabbagh
    • , Qutada Soub
    • , Majedah Yousef Hmeidan
    • , Hadeel Aladwan
    • , Barihan Alkhasawneh
    • , Ansam Ghzawi
    • , Luai Abuismael
    • , Osama Jamal Abu-Hamdiyeh
    • , Samar Karout
    • , Ali Safar
    • , Jana Tarchichi
    • , Rania Itani
    • , Ibrahim Ibrahim
    • , Elie Louak
    • , Ahmed Bishti
    • , Fathia Abdulfatah Ahmed Mahmoud
    • , Soha Albarghathi
    • , Wafa Omar Aldressi
    • , Mohamed Fathi Kalifa
    • , Wafa Aldressi
    • , Seraj A. Zentani
    • , Malek Mohamed Abusannuga
    • , Fakhruddin Almuzghi
    • , Alzaharra Elfraa
    • , Maaly Abuhlaiga
    • , Ghalia Madri
    • , Asma Aljanfi
    • , Saja Mohammed
    • , Burooj Mohammed
    • , Muataz Kashbour
    • , Alhadi M. Jahan
    • , Abubaker Abdelmalik
    • , Marwa Mohammed Morgom
    • , Sarah Fathi Alhaddad
    • , Mawada Mohammed
    • , Ema Ali
    • , Muhammed Elhadi
    • , Entisar Alshareea
    • , Suha Elzwai
    • , Marwa Biala
    • , Mohamed Alharari
    • , Dahiba Naji
    • , Reem Ghmagh
    • , Sarah Aljamal
    • , Abdulqudus Deeknah
    • , Duha Abdullah
    • , Eman Abdulwahed
    • , Shahd Elmhadbi
    • , Reyam Naana
    • , Esmail Hamuda
    • , Mawada Khalifa
    • , Dawoud Saeid
    • , Sultan Ahmeed
    • , Rana Graish
    • , Heba Rhuma
    • , Ahmad Bouhuwaish
    • , Farhat Y. Bashir
    • , Ayyah Emran
    • , Najat Shaban Ben Hasan
    • , Hanna Yahia
    • , Rimantas Vilcinis
    • , Albertas Sliauzys
    • , Antanas Budenas
    • , Zamzuri Idris
    • , Abdul Rahman Izaini Ghani
    • , Sharalini Binti Zanuddin
    • , Dharmendra Ganesan
    • , Langkeas Mohanavel
    • , Weipin Hung
    • , Chee Yang Tan
    • , Song Ying Chong
    • , Yuki Julius Ng
    • , Qun Ya Lim
    • , Abdessamad El Ouahabi
    • , Mohammed Yassaad Oudrhiri
    • , Imane Ammouze
    • , Moniba Korch
    • , Sami Boutti
    • , Yassmine Boumzebra
    • , Oumaïma Outani
    • , Ezeali Mike Ekuma
    • , Uche Emmanuel Eni
    • , Kelechi Ndukuba
    • , Abiodun Okunlola
    • , Tesleem Orewole
    • , Paul Abiola
    • , Oluwamayowa Opara
    • , Chiazor Onyia
    • , Joseph Alozie
    • , Henry Obichie
    • , Obanife Henry Olayere
    • , Kingsley Akaba
    • , John Gbaji
    • , Enoch Ogbonnaya Uche
    • , Uko Kalu Uko
    • , Hilary Chukwuma
    • , Aliyu Muhammad Koko
    • , Ali Lasseini
    • , Nasiru Jinjiri Ismail
    • , Syeda Maria Zaidi
    • , Marium Hussain
    • , Izza Tahir
    • , Rameen Ata Bajwa
    • , Javeria Bilal Qamar
    • , Fatima Gauhar
    • , Ali Tayyab
    • , Syed Ali Tayyeb Hasan
    • , Daniyal Ali Khan
    • , Angelina Jessani
    • , Zain ul Abidin
    • , Hareem Rauf
    • , Usama Waqar
    • , Syed Ather Enam
    • , Hamna Ganny
    • , Rehab Naeem Khalid
    • , Muhammad Sarmad Tahir
    • , Ahmad Areeb Chaudhry
    • , Isbaah Tejani
    • , Namrah Aziz
    • , Muhammad Shehryar Khan
    • , Haleema Sadia
    • , Aiza Abbas
    • , Ronika Devi Ukrani
    • , Muhammad Jawad Amin Malik
    • , Muhammad Hamza
    • , Hajra Arshad
    • , Muhammad Shahzad Shamim
    • , Muhammad Muneeb Khan Bozai
    • , Muhammad Nabeel Safdar
    • , Fahad Zahid
    • , Javeria Tariq
    • , Mohammad Safri
    • , Mushahid Hussain
    • , Hamza Sohail
    • , Maham Jaskani
    • , Zainab Ayaz Dandia
    • , Sameeta Kumari
    • , Mabrooka Kazi
    • , Mahnoor Javaid
    • , Laeba Hussain
    • , Muhammad Ehsan Bari
    • , Pradhumna Kumar Yadav
    • , Ahtesham Khizar
    • , Saad Javed
    • , Ali Haider Bangash
    • , Ahmad Ghassan Hammouri
    • , Mustafa Jayyab
    • , Sara Amro
    • , Sadi A. Abukhalaf
    • , Tomasz Szmuda
    • , Michał Krakowiak
    • , Justyna Fercho
    • , Jhon Bocanegra
    • , Mahmoud Dibas
    • , Nazmus Saquib
    • , Mohammad Shakhawat Hossain
    • , Mohamed Gedi Sheikhow
    • , Ismail Gedi Ibrahim
    • , Abukar Mohamed Osman
    • , Pablo González-López
    • , Carlos Martorell-Llobregat
    • , Cristina Gómez-Revuelta
    • , Ruth Lau
    • , Ruben Martín-Láez
    • , Victor Garcia-Milan
    • , Jesús Manuel Esteban-Gonzalez
    • , Abdulrhman Marwan Khaity
    • , Moayad Moawia Zain Elabdin Ahmed
    • , Mohammed Abdirahman Ibrahim
    • , Mahmoud Saleh
    • , Emad Ibrahim
    • , Ahmed Eljack
    • , Hozaifa Elameen
    • , Mohamed Hassan Eltoum
    • , Omer Elaibaid
    • , Radi Tofaha Alhusseini
    • , Khabab Abbasher
    • , Mohajer Ibrahim
    • , Tasneem Mohamed
    • , Ayman Mohammed
    • , Razan Ahmad
    • , Saeed Ahmad
    • , Osman Ahmed Eltahir Ahmed
    • , Albushra Altayeb
    • , Adam Osman
    • , Rufida Abdulmageed Alyhary
    • , Hytham Hamid
    • , Haytham Hussein Osman
    • , Afaf Atassi
    • , Fares Abbas
    • , Mohab Alakkari
    • , Osama Alakhras
    • , Lujain Aldakak
    • , Hamzeh Koumakli
    • , Abdulrahman Alsaboni
    • , Leen Aboud
    • , Awatef Aouf
    • , Haya Taha
    • , Abdalrahman Manzalji
    • , Seba Ayoub
    • , Rawdah Attom
    • , Khoder Al-Khauly
    • , Haya Zoughaibi
    • , Mohamed Alaktaa
    • , Hani Abdalnour
    • , Ala Aldeen Hasan
    • , Mohammad Kour
    • , Mahmoud Wereekia
    • , Ahmad Birajkly
    • , Rasheed Alhameed
    • , Mohamad Alhusseini
    • , Saleem Aslan
    • , Kutaiba Al-Ali
    • , Majd Aldeen Alosman
    • , Laith Arafa
    • , Hasan Hallak
    • , Abdulaziz Alkateb
    • , Renas Osman
    • , Shiar Mustafa
    • , Mohammed Badleh
    • , Thabet Sayed Bakir
    • , Ahmad Sankari Tarabishi
    • , Firas Enabi
    • , Mohamad Anas Sattout
    • , Fadi Akhras
    • , Mohammad Nour Shashaa
    • , Madiha Fanari
    • , Majd Alneser
    • , Abdelaziz Alibraheem
    • , Aya Zazo
    • , Bashar Bazke
    • , Muhamad Zakaria Brimo Alsaman
    • , Mohamad Ghazal
    • , Nazeeh Al Aktaa
    • , Alma Douedari
    • , Mike Ghabally
    • , Lara Hindawi
    • , Yusef Jondiah
    • , Abdullah Fattal
    • , Mohammad Shadi Alkarrash
    • , Ahmad Alsheikh
    • , Mouna Almoussa
    • , Monia Hamed
    • , Amr Hamza
    • , Rama Zazo
    • , Ahmad Al-Mouakeh
    • , Ahmad Bebi
    • , Zain Douba
    • , Muhammed Al-husseini
    • , Maher Aldeiri
    • , Obada ALhalabi
    • , Saeed Kadri
    • , Ali Sulaiman
    • , Abdulrahman Alskaf
    • , Abdulrahman Ghaibah
    • , Adel Kabbara Allababidi
    • , Talal Badawy
    • , Mohammad Abdow
    • , Husin Qazaq
    • , Aram Abbas
    • , Hussam Alhayek
    • , Ali Sliman
    • , Huda Albkhetan
    • , Rami Alkhouja
    • , Manhal Sharaf
    • , Hasan Alzuhaily
    • , Mohammed Karam Chaaban
    • , Hussein Kazak
    • , Qamar Alkhador
    • , Louay Misrabi
    • , Ammar Salloum
    • , Ali Mohamad
    • , Ali Hammed
    • , Alaa Mohammad Hamdan
    • , Alaa Sulaiman
    • , Naya Talal Hassan
    • , Majd Yaseen
    • , Abdeljawad Mazloum
    • , Jaafar Zahlout
    • , Ahmed Moussa
    • , Sulaiman Jolak
    • , Iyad Ali
    • , Ali Sabbour
    • , Rita Mohammad
    • , Rahaf Ranjous
    • , Alaa Al Barroush
    • , Ziad Saker
    • , Ali Zamlout
    • , Okbah Mohamad
    • , Haidar Shmayyes
    • , Moufid Mahfoud
    • , Salma Shahin
    • , Sara Deeb
    • , Zahraa Sari
    • , Ritta Ranjous
    • , Deema Al Barroush
    • , Haifaa Douba
    • , Liana Abdullah
    • , Ghassen Souissi
    • , AbdelHafidh Slimane
    • , Nesrine Ben Hadj Dahman
    • , Mohamed Badri
    • , Avinash Aujayeb
    • , Mario Ganau
    • , Yizhou Wan
    • , Ieva Sataite
    • , Marco Mancuso-Marcello
    • , John Emelifeonwu
    • , Nadia Liber Salloum
    • , Phillip C. Copley
    • , Martina Stippler
    • , Amber Nieves
    • , Noah Nawabi
    • , Luis Rendon
    • , Mohammad A. Aziz-Sultan
    • , John L. Kilgallon
    • , Timothy R. Smith
    • , Yasuaki Inoue
    • , Leila Mashouf
    • , Bryan Choi
    • , Christopher Stapleton
    • , Aman Patel
    • , Gabriel N. Friedman
    • , Robert Gramer
    • , Takeshi Yanagisawa
    • , Pratik Talati
    • , Athar Malik
    • , Keshav Goel
    • , Anwesha Dubey
    • , Geoffrey Colby
    • , Manuel Buitrago Blanco
    • , Fatima Aleryani
    •  & Salwa Al Aryani

    Contributions

    All collaborating authors and data contributors are listed in the Supporting Information

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    Extended data

    Extended Data Fig. 1 Study Inclusion Flow Chart

    Derivation of the GNS-I analytic sample comprising all eligible TBI patients that received emergency neurosurgical evaluation at any institution participating in the Global Neurosurgical Study 1 (GNS-I)

    Extended Data Fig. 2 GNS-I Patients Enrolled by Participating Country

    Geographic distribution of all patients enrolled in the Global Neurosurgical Study 1 (GNS-I)

    Extended Data Fig. 3 Mortality at 90 Days Model Forest Plot

    Forest plot demonstrating odds ratios (ORs) from a multivariable mixed effects logistic regression analysis for demographic, pre-hospital, medical evaluation, management, and socioeconomic characteristics associated with mortality at 90 days using country, institution, data collection start year, and data collection start week as random effects for n = 1,810 patients with a documented vital status at 90-days post-injury. ORs and their associated 95% confidence intervals are generated using the Wald Z-test with a two-sided alternative hypothesis, and with no adjustments performed for multiple comparisons. For Age at Time of Injury, the full p-value is 8.89 ×10−11; for GCS within the first 24 Hours, the full p-value is 1.61 ×10−20; for those on mechanically assisted ventilation, the full p-value is 0.000181; and for those with bilaterally non-reactive pupils, the full p-value is 2.17 ×10−6.

    Extended Data Fig. 4 Glasgow Outcome Scale Allu

    Allu 90-days post-injury

    Extended Data Fig. 5 Lasting Complications Model Forest Plot

    Forest plot demonstrating odds ratios (ORs) from a multivariable mixed effects logistic regression analysis for demographic, pre-hospital, medical evaluation, management, and socioeconomic characteristics associated with lasting medical complications using country, institution, data collection start year, and data collection start week as random effects for n = 2,071 participants with documented complication status. ORs and their associated 95% confidence intervals are generated using the Wald Z-test with a two-sided alternative hypothesis, and with no adjustments performed for multiple comparisons. For those with secondary medical problems present on admission, the full p-value is 2.57 x 10‒20; and for those who had midazolam used as a sedative, the full p-value is 0.000296.

    Extended Data Fig. 6 Study Analytic Pipeline

    Flow chart depicting the analytic methodology from the total study population, to the final analytic sample, and through the inverse probability weighting and linear mixed modeling regression to generate the marginal structural models used for the final analysis, including sensitivity analyses

    Extended Data Fig. 7 Mortality at Discharge Model Calibration Curve

    Calibration curve for mortality at hospital discharge model comparing predicted and empirical probabilities with n = 10 equally-sized probabilistic risk strata with bootstrapped 95% confidence intervals

    Extended Data Fig. 8 Mortality at Discharge Model Area Under the Receiver Operating Characteristic Curve (AUROC) and Area Under the Precision Recall Curve (AUPRC)

    Mortality at hospital discharge model discriminative ability measured by Area Under the Receiver Operating Characteristic Curve (AUROC), and Area Under the Precision Recall Curve (AUPRC) with 95% Confidence Intervals generated by DeLong’s method using 2000 stratified bootstrap replicates

    Extended Data Fig. 9 Mortality at Discharge Model Sensitivity Analyses

    (a) Sensitivity analysis for the final mortality at hospital discharge mixed effects logistic regression analysis with the highest contributing country for each HDI tier excluded (n = 1,132). For Age at Time of Injury, the full p-value is 6.32 x 10‒10; for GCS within the first 24 Hours, the full p-value is 1.70 x 10‒13; and for those with bilaterally non-reactive pupils, the full p-value is 8.87 x 10‒5. (b) Sensitivity analysis for the final mortality at hospital discharge mixed effects logistic regression analysis with the highest contributing center for each HDI tier excluded (n = 2,165). For Age at Time of Injury, the full p-value is 2.97 x 10‒10; for GCS within the first 24 Hours, the full p-value is 1.76 x 10‒16; and for those with bilaterally non-reactive pupils, the full p-value is 9.90 x 10‒9. Odds Ratios and their associated 95% confidence intervals are generated using the Wald Z-test with a two-sided alternative hypothesis, and with no adjustments performed for multiple comparisons for both (a) and (b).

    Supplementary information

    Supplementary Information (download PDF )

    STROBE statement, Supplementary Tables 1–3 and author contributions

    Reporting Summary (download PDF )

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    Cite this article

    Nugent, J.G., Tan, H., Stedelin, B. et al. Traumatic brain injury outcomes across human development index strata in 29 countries.
    Nat Med (2026). https://doi.org/10.1038/s41591-026-04600-6

    • Received:23 September 2025

    • Accepted:22 July 2026

    • Published:19 August 2026

    • Version of record:19 August 2026

    • DOI
      :https://doi.org/10.1038/s41591-026-04600-6

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