Battlefield Lessons, Global Standards: USU Co-Authors Landmark Update to Penetrating TBI Care

USU’s MTBI² co-authored the first update in 25 years to penetrating TBI care, moving treatment from watchful waiting to immediate surgery.

U.S. Army Capt. Alex Yang operates during a brain tumor removal at Walter Reed National Military Medical Center in Bethesda, Md., March 4, 2026. (DoW photo by Ricardo J. Reyes)

August 25, 2026 by Hadiyah Brendel

The Brain Trauma Foundation’s Guidelines for the Management of Penetrating Traumatic Brain Injury, Second Edition — the first revision in 25 years — urge surgeons to treat gunshot and blast wounds to the brain with immediate intervention rather than the long-standing wait-and-see approach. Published as a supplement in the journal Neurosurgery, the guidelines drew on two decades of U.S. military trauma data and required collaboration among more than 35 international experts. 

Dr. Bradley Dengler, director of the Military Traumatic Brain Injury Initiative (MTBI²) and associate professor of Surgery at the Uniformed Services University of the Health Sciences (USU), served as one of the co-authors. Much of the evidence behind the new edition came from USU and MTBI² data gathered across two decades of conflict in Iraq and Afghanistan.

A Shift From Pessimism to Action

With the information available at the time, medical professionals approached penetrating brain injuries with what Dengler calls “medical nihilism,” a wait-and-see approach that viewed penetrating head injuries as largely fatal. This conservative, observation-based approach delayed surgery.

The new guidelines challenge that perspective, calling for rapid, early surgical intervention. That includes immediate decompressive craniectomies (temporarily removing a section of the skull to give a bruised, swelling brain room to expand) and hematoma evacuations (surgically draining pooled blood clots that press on the brain) to control brain swelling.

Dengler said the first edition leaned heavily on predicting outcomes the field could not yet predict, and that the new edition sets a different course.

“The first edition focused extensively on prognosis, which we couldn’t predict at the time,” Dengler said. “A primary goal of the new edition is to move away from the nihilism historically associated with penetrating brain injury.”

Short of specific catastrophic signs, such as a projectile passing directly through the brainstem, he said, these patients should receive aggressive treatment from the start.

Registered nurse Alonzo Malcolm updates patient charts in the Department of Emergency Medicine at Brooke Army Medical Center, Fort Sam Houston, Texas, Oct. 13, 2022. (U.S. Army photo by Jason W. Edwards)

Dengler noted that while the update specifically targets wounds that pierce the skull, insights can be drawn from broader, non-penetrating traumatic brain injuries (TBIs). Clinical practice in blunt trauma shows it takes an average of 14 days for a patient with a severe TBI to begin following commands. The average time to withdraw life-sustaining care in civilian settings, however, is just three days.

“We cannot reliably predict long-term outcomes during that initial window,” Dengler said. “Early, aggressive intervention prevents a premature prognosis from becoming a self-fulfilling prophecy.”

Two decades of military tracking in Iraq and Afghanistan showed that patients achieve the best neurotrauma outcomes when they reach the operating room within a strict six-hour window. Translating a rigid timeline from a controlled military evacuation system into a global medical reality, though, requires balancing the realities of civilian trauma infrastructure.

To encourage wide adoption and allow for the differences among hospital systems, the committee focused on securing institutional support. The authors emphasize the clinical need for rapid intervention while preserving the operational flexibility diverse trauma networks require. That consensus-building process led to endorsements from major medical bodies, including the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

Screening for Vascular Damage

The second edition structures its clinical recommendations across seven distinct parameters, outlining specific treatment algorithms for each management pathway. Chief among them is an overhaul in how neurosurgeons identify and treat vascular complications.

The guidelines outline three major advances in addressing vascular complications in the brain:

1. Identifying which patients require immediate screening.
2. Determining an exact timeframe for repeat imaging to catch delayed damage.
3. Establishing protocols for definitive treatments such as endovascular surgery to repair blood vessels.

These advances target traumatic pseudoaneurysms, structural weaknesses in the arterial walls of the brain caused by passing projectiles. Because these weak spots can appear days after the initial injury and often form near the base of the skull, standard initial computed tomography (CT) scans can’t always detect them through the surrounding bone.

A patient may appear stable at first, then suffer a late-onset, life-threatening brain bleed days later. To counter this, new protocols direct teams to transfer patients to a specialized endovascular suite for direct, repeated vascular mapping throughout the first week of care.

“An initial CT angiogram provides an immediate assessment, but injuries near the skull base are often obscured by bone artifacts on the scan,” Dengler said. “The second edition strongly recommends a formal diagnostic angiography in an endovascular suite during admission to evaluate the vessels clearly.”

Because these structural weaknesses can develop within the first seven days, he said, the guidelines call for strict, protocol-driven monitoring.

The Unique Value of Military Data

The clinical foundation of these guidelines rests heavily on the research and operational data USU and MTBI² sustained through two decades of conflict in Iraq and Afghanistan. Because MTBI² maintains a direct connection to high volumes of penetrating brain trauma data, the initiative holds a concentration of expertise that is rare in the wider medical community and central to military medicine.

Dengler said that deep pool of military data sets the university’s research apart, with few peers in the civilian sector.

“Very few places see this type of trauma,” Dengler said. “Aside from the military, only institutions like the University of Maryland Shock Trauma Center in Baltimore, the University of Chicago, or Ryder Trauma Center in Miami manage a comparable volume of penetrating brain injuries.”

USU led the advances in these areas, he said, because it has the clinical volume and expertise to do so. The closed nature of the military healthcare system also let researchers track patients through the entire evacuation pipeline, from the battlefield to long-term rehabilitation.

In forward-deployed surgical units, neurosurgeons treated fragment and blast wounds with immediate intervention. Dengler credits that unwritten baseline, captured in the phrase “no one dies in the tent,” with driving much of the advancement in how these injuries are managed.

The outcomes Dengler witnessed reshaped his sense of what counts as survivable.

“We observed individuals with devastating fragment injuries who ultimately recovered, returned to independent living, married, and raised families,” he said.

Facilitating Global Adoption

To promote global use, the Brain Trauma Foundation published the 300-page guideline document as a fully open-access resource, making it immediately available to any practitioner worldwide. The organization is also distributing mobile-friendly management algorithms and partnering with Global Neuro to conduct free international webinars. The aim is to carry this proactive treatment philosophy into emergency rooms worldwide, so that the next service member who arrives with a penetrating head wound has a better chance of going home.