February 17, 2026 — The Brain Trauma Foundation has updated the 2001 evidence-based guidelines for the care of patients with penetrating traumatic brain injury (pTBI) . A working group of more than 30 expert panelists developed over 30 new evidence-based recommendations. To provide a bridge between these recommendations and complexities of care at the bedside, panelists also used a rigorous Delphi process to develop consensus statements as well as treatment algorithms for the guidelines. The guidelines and algorithms are published together as a supplement to the March 2026 issue of Neurosurgery , the official publication of the Congress of Neurological Surgeons (CNS), which is part of the Lippincott portfolio by Wolters Kluwer .
The guidelines were reviewed for evidence-based integrity and endorsed by the American Association of Neurological Surgeons and Congress of Neurological Surgeons.
Saving lives requires combating nihilism with information
“There are many misconceptions in medicine, and the idea that all penetrating brain injury is uniformly non-survivable is certainly one of them,” say Gregory W. J. Hawryluk, MD, PhD, of the Cleveland Clinic; Randy Bell, MD, CAPT (ret), MC, USN, of the University of South Dakota; and colleagues. They emphasize two main points: Patients with pTBI who survive to reach a trauma center, in whom care is not considered futile, often have the same or better outcomes than comparably injured patients with closed TBI, and in nearly every circumstance pTBI is a surgical disease.
The new care pathways address the needs of diverse pTBI patients
The algorithms include a master pathway relevant to all patients and “toolkits” to address care issues that affect only some patients. The master care pathway discusses the pre-hospital or field setting, then lays out steps for patient care at the hospital:
Immediately re-apply advanced trauma life support (ATLS) principles, with simultaneous laboratory and image-based analysis. Immediate neurosurgical consultation is recommended. Follow ATLS protocols strictly, as the striking nature of pTBI can be distracting. It is crucial to identify the entry and, if present, exit wound, keeping in mind the potential for multiple penetrating injuries and multiple injured organ systems. Beware that nail gun injuries are often occult, as are stab wounds where the implement has been removed. If significant skull disruption is encountered, avoid compressive dressings and do not probe the wound or debride brain tissue or other damaged tissue at this point.
When the patient is sufficiently resuscitated, send them for immediate CT and CT angiography (CTA) of the head and neck. Because CT images can be subject to scatter, skull x-rays may have a role in demonstrating the presence and location/trajectory of radio-opaque foreign bodies. Some foreign bodies (e.g., glass, wood, and some rocks) are radiolucent and require MRI if it is felt that can be done safely. Strongly consider additional imaging, including cerebral angiography, at this point if traumatic vascular injury including traumatic aneurysms are noted on CTA or otherwise suspected.
The algorithms portion of the supplement includes a toolkit for assessing futility in cases of pTBI, as well as toolkits for surgical management in general, managing a protruding foreign body, managing severe injury (multiple injured lobes, mass lesion, midline shift, or edema), managing penetrating skull base injury, and managing traumatic vascular injury.
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Neurosurgery
Treatment Algorithms From the Brain Trauma Foundation Guidelines for the Management of Penetrating Traumatic Brain Injury, Second Edition
17-Feb-2026