Navigating Limitations and Clinical Challenges in Indonesian Tertiary Trauma Center for Penetrating Brain Injury: A Case Report and Literature Review

Abstract

Penetrating brain injury (PBI) accompanied by vascular injury is a severe trauma, often resulting in high mortality, particularly in low- and middle-income countries where many aspects of health care facilities are limited. Effective management of PBI requires efficient prehospital management, followed with advanced neurosurgical equipment, and continuous neurocritical monitoring. Delays in treatment due to inadequate transport infrastructure, scarce facilities, lack of specialized personnel, and inadequate transport infrastructure significantly elevate mortality rates. Neurointensive monitoring with radiological modalities plays significant role in detecting secondary processes in PBI, nevertheless facing significant limitations due to restricted access and resource allocation under national health insurance limit in clinical practice. Furthermore, undetected vascular complications could contribute to the high mortality observed in these environments. This case highlights the dilemmas in the neurocritical care of PBI as well as the need for improved health care policies for better health care.

Keywords

case report - penetrating brain injury - intraventricular hemorrhage - mortality rate - intensive care unit - health insurance

Introduction

A penetrating brain injury (PBI) refers to a traumatic brain injury (TBI) that results from an object, breaking the skull and dura mater and directly penetrates the brain tissue.[1] Velocity can be used to classify PBI into low, medium, and high. The mortality of PBI might vary, ranging from 20% to as much as 98.5% depending on the method of injury, prehospital management, hospital admission time, and surgery time.[1] [2] [3] [4] [5] In this case, we present a PBI as a result from fishing gun, classified into low-velocity PBI with mayor delays on numerous aspects, influencing in poor outcome of the patient postoperatively.

Prognosis in PBI is influenced by various clinical factors. The Glasgow Coma Scale (GCS) score on admission is vital for predicting the outcome in PBI.[6] [7] Timely and effective prehospital care is crucial, as delays reduce the chance for early intervention, which in turn increases the risk of mortality and negatively affects the functional outcomes of patients with brain injuries.[1] [8] [9] In advanced country, the standard time for emergency medical service (EMS) to deliver trauma patients to definitive care is 60 minutes.[10] Prolonged prehospital time significantly correlates with increased 24-hour and 30-day mortality, emphasizing that efficient evacuation and minimizing on-scene interventions could be beneficial.[11]

One of the most vital factors that influence the mortality in PBI is the trajectory. A PBI with ventricular trajectory increases the risks for creating secondary intraventricular hemorrhage (IVH) and obstructive hydrocephalus. The mortality in this scenario could reach up to 54% due to the disruption of the brain parenchyma, resulting in unreversible damage to the neurons, and allowing inflammatory responses and oxidative stress to occur resulting in mortality.[12] [13]

The chemical composition, shape, and location of an intracranial foreign body are crucial factors to evaluate when managing patients with injuries from domestic or workplace incidents.[14] [15] Surgical intervention in PBIs is indicated for cases involving retained foreign objects, dural defects, displaced bone fractures, intracranial hematomas, or direct vascular injuries. In this scenario, the extraction of foreign object could only be done approximately 72 hours after the incident, whereas surgery performed beyond 24 hours postinjury is generally discouraged due to increased risks of mortality and morbidity.[16] [17]

We present a PBI patient with fishing spear injury resulting in vascular lesion with secondary IVH, with a delayed arrival time at definitive care. On the other side, due to limitations in national health care systems, restrictions on our daily clinical practice are present from prehospital care to monitoring in the intensive care unit (ICU), hence hindering clinicians from providing optimum care.

Case Presentation

A 36-year-old man with penetrating injury to the head due to fishing accident was referred to Dr. Soetomo General Hospital, a tertiary trauma center in East Java, 10 hours after the incident. The patient received initial treatment 8 hours after the incident in a periphery hospital. Due to the assumption of vascular injury, the patient was referred from the periphery hospital, which is about 65 km from Dr. Soetomo General Hospital for advance treatment in neurosurgical field. The patient's transportation took an additional 2 hours. The patient was free from seizure activity as well as any other sign or symptom of nausea and vomiting. The patient presented with stable vital signs upon admission, including a total GCS of 15, E4V5M6. The patient showed no neurological deficits. The only significant symptoms were headache and a history of bloody rhinorrhea. The patient was transferred to the high-care unit for further observation and management.

Radiological investigations revealed critical findings. [Fig. 1] shows skull X-ray, which was performed before the patient was transferred to Dr. Soetomo General Hospital, a foreign object is seen originating from the left nasal cavity. A computed tomography (CT) scan without contrast revealed no soft tissue edema, midline shift, or other significant lesions in the epidural, subdural, subarachnoid, or brain parenchyma spaces as shown in [Fig. 2]. However, a hyperdense lesion in the posterior horn of the lateral ventricle indicated IVH. The CT scan also visualized a foreign body penetrating from the left nasal cavity, passing through the ethmoid bone and cribriform plate, with its tip lodged in the left inferior thalamus.

Fig. 1 Skull X-ray with Caldwell view (A) and Schaedel view (B) consecutively.

Fig. 2 Brain window of noncontrast computed tomography (CT) scan sequentially, coronal view (A), axial view (B), and sagittal view (C), showing a hyperdense foreign object in the intracranial with intraventricular hemorrhage (IVH).

[Fig. 3] illustrates CT angiography (CTA) with three-dimensional reconstruction identified a fracture of the frontal bone with splintering and depression of the inner dome of the calvarium. The study confirmed the hyperdense lesion in the lateral ventricle, consistent with IVH, and traced the foreign body penetrating through the ethmoid and cribriform regions into the left inferior thalamus. The intracranial vessels, including the anterior cerebral arteries (ACAs), anterior communicating artery, and middle cerebral arteries (MCAs), appeared normal except for the absence of the left cavernous segment of the internal carotid artery (ICA).

Fig. 3 Computed tomography (CT) angiography and three-dimensional (3D) reconstruction.

With a transfemoral catheter angiography (TFCA) no evidence of foreign object in the right ICA was found, and a complete occlusion as high as the petrous segment of the left ICA was present, as shown in [Fig. 4]. The foreign object was situated at the origin of the ACA and MCA bifurcation, near the left ICA, suggesting proximity to key vascular structures. The patient then underwent elective craniotomy with bicoronal incision, clipping of the ICA to prevent excessive bleeding, as well as backup of endovascular unit, followed with the extraction of the foreign object on the third day of care as shown in [Fig. 5]. Due to the delay of surgery, controlling intraoperative bleeding presented a significant challenge, possibly from the collateral artery. Despite these obstacles, through meticulous technique, teamwork, and the application of hemostatic measures, the bleeding was ultimately brought under control.

Fig. 4 Transfemoral cerebral angiography (TFCA) of the left internal carotid artery (ICA).

Fig. 5 Intraoperative findings and surgical approach to extract the foreign object. (A) Preservation of the olfactory nerve, (B) followed by clipping of the internal carotid artery (ICA) to prevent bleeding and cautious extraction of the foreign body. (C) An example of the foreign object.

Postoperatively, on the fourth day, the patient was intubated with sedation and intensive monitoring in the ICU. In the ICU, the patient's fluid balance was meticulously managed through the administration of intravenous crystalloids. To prevent raised intracranial pressure (ICP) and associated complications, metamizole was administered for analgesia, omeprazole for gastric ulcer prophylaxis, and metoclopramide to prevent nausea and vomiting. Antiseizure prophylaxis was provided using phenytoin, and broad-spectrum ceftriaxone was prescribed for infection prevention. Additionally, a precautionary dose of tetanus vaccine was administered due to the high risk of tetanus associated with the presence of a foreign body. From postoperative laboratory evaluation, the patient hemoglobin was low[8] [9] due to excessive intraoperative bleeding, hence transfusion of two units of whole blood was done.

On the eighth day of the patient's ICU stay, a thorough physical examination was conducted to assess his condition. During this evaluation, it became evident that the patient exhibited inadequate responses, indicating significant neurological impairment. Subsequently, further clinical assessment led to the diagnosis of brain death. Despite efforts to monitor and support the patient, his condition worsened, and eventually entered an apnea state. Given the absence of any respiratory effort, the patient was pronounced dead shortly thereafter.

Discussion

Effective transport and EMS have significant role to improve prehospital time and improve patient outcomes in life-threatening trauma in low- and middle-income countries (LMICs). Inefficiencies in EMS, such as poor referral systems and long distances, are among the main reasons why patients take too long to seek help in certain conditions such as nonmissile penetrating head trauma, which often require surgical intervention within 12 hours to reduce morbidity and mortality.[18] [19]

The method of transportation and the efficiency of EMS play a crucial role in reducing prehospital delays and improving patient outcomes, especially in LMICs. The poor efficiency of EMS is shown with the arrival time at tertiary trauma centers, which took more than 8 hours, in correlation to the study by Karthigeyan et al,[20] where only 17.8% trauma patients reach tertiary trauma centers within 6 hours of injury.[20] Indirect patient transport has been associated with an increased risk of short-term mortality. Although a statistically significant relationship has not been established from recent studies, mortality rates consistently remain elevated during interhospital transfer processes. Therefore, in trauma cases, it is strongly recommended to prioritize direct transfer to appropriately equipped medical facilities whenever feasible, as this approach has the potential to improve patient outcomes and reduce mortality risks.[21]

Studies show that significant number of patients rely on private transportation, such as personal vehicles, for emergency hospital visits, leading to considerable delays. For instance, in East Java, Indonesia, 67.25% of patients with neurological emergency used private transportation, resulting in delays ranging from 2.4 to 48.4 hours, while only 32.75% used ambulances with approximate transfer distance ranging from 3.5 to 18.4 km.[22] Our case highlights a longer travel distance required by the patient, since the trauma site is located in rural area, than the findings from Ningsih and Andarini,[22] due to the lack of tertiary trauma center in East Java Province. The primary destination for advanced trauma care, Dr. Soetomo General Hospital, is located approximately 80 km from the trauma site, hence creating arrival delay exceeding the golden hour, allowing secondary brain injury sequelae to progress as well as decreasing the patient's outcome. Contrary to urban settings, rural regions have demonstrated a far greater mortality risk for trauma cases. Rural trauma patients are at a two times greater risk of mortality because they have to endure the durability of the transportation and the increased distance to the trauma care centers as research shows.[23] [24] [25] Moreover, a study conducted by Caviglia et al[26] highlight that every additional minute of delay, whether during prehospital care or within the hospital, is associated with a corresponding increase in both mortality and morbidity.[26]

Alternative transportation methods, such as modified motorcycle called as motor-lances and helicopters, have been shown to reduce response times and improve patient outcomes,[27] although another study by Cunningham et al[28] suggest that the survival benefits of helicopter transport may only apply to a limited subset of patients.

These delays are further compounded in LMICs due to fragmented EMS systems, inadequate infrastructure, and a shortage of trained personnel and basic life support tools. The standard of medical services offered to citizens by the EMS providers has to be guaranteed, as one study in Cambodia and Iraq showed a 30% decreased mortality as the EMS providers were trained to provide onsite management.[29] To address these challenges, improvement of EMS provider quality, investments in structured prehospital care systems, wider adoption of advanced transportation methods, and improved access to ambulances equipped with trained personnel are essential. Such measures can significantly reduce prehospital delays and enhance patient outcomes in resource-constrained settings.

In Indonesia, this problem is exacerbated by the lack of health facilities and specialists. Studies indicate that proximity to trauma centers is directly associated with improved survival rates following traumatic injuries. Brown et al[30] highlighted that rural populations face significant barriers to accessing trauma care, resulting in higher injury-related mortality compared to urban areas. Moreover, a study by Daugherty et al[31] underlined that more than 80% rural residents were hospitalized in urban hospital, which may contribute to the higher rate of TBI-related deaths in rural areas, indicating a lack of emergency care services in those regions.

The ratio of neurosurgeons to population is still twice the ratio proposed by the Indonesian Neurosurgery Association, meaning complex cases need longer time to be referred to better facilities for definitive care as well as indicating discrepancy of trauma care in rural and urban area.[32] Another major concern worth discussing is the distributions of neurosurgeons in Indonesia since 5 out of 34 provinces are not covered by neurosurgery specialist as of 2020. Based on the data by the Indonesian Health Ministry, Southeast Asia has the lowest number and distribution of neurosurgeons compared to other parts of the world.

This imbalance is due to the lower number of surgeons trained in the discipline of neurosurgery, leading to poor coverage and underserved health services for the population. [32] [33] Regional distribution and resource shortages lead to an estimated 2.5 million unaddressed primary neurosurgical operations each year in Southeast Asia.[33] [34] [35] Additional time needed to reach facilities with neurosurgeon takes time, hence delaying patients to get immediate intervention. Addressing these systemic challenges requires substantial investments in EMS infrastructure, equitable distribution of specialists, and improved referral systems to ensure timely and efficient access to specialized care, ultimately reducing delays and improving outcomes for trauma patients in Indonesia.

The study provides insights into how health care systems influence delays in managing TBIs, which correlated with the National Insurance System, referred to as BPJS (Badan Penyelenggara Jaminan Sosial) in Indonesia, which uses a single-payer health system (SPHS). A study by Shakir et al,[19] compare the prehospital and intrahospital delays of SPHS and multi-payer health system (MPHS) where the SPHS exhibits shorter prehospital delays compared to the MPHS but has prolonged intrahospital delays.

In our daily practice, the National Insurance System has been linked to longer interhospital delays in Indonesia. This paradox may arise due to specific implementation challenges of the National Insurance System in resource-limited settings, such as the bureaucratic processes for claim approvals, lack of adequate emergency transport infrastructure, and delays caused by administrative checks before patient transfer. In comparison, the SPHS framework in other countries highlights that centralized coordination and equitable access can reduce prehospital delays. In Indonesia, these theoretical advantages are overshadowed by systemic inefficiencies in execution. Furthermore, as seen in SPHS globally, intrahospital delays under the National Insurance System could also be prolonged due to resource limitations and patient volume, mirroring the longer intrahospital delay (mean = 309.37 minutes, confidence interval [CI] = −21.95 to 640.69), which also contributed to the patient's arrival time delay at the tertiary trauma center.[19]

The verification process for the National Insurance System health claims is significantly slow, creating inefficiencies that deviate from the guidelines of the National Insurance System Health Regulation Number 3 of 2017, which mandates a maximum of 15 working days for claim processing. In practice, hospitals face challenges in meeting this timeline, especially when dealing with traumatized patients who often struggle to categorize their cases under the category of Health or Employment insurance in the National Insurance System, as observed in the Taluk Kuantan Regional Hospital.[36] This issue aligns with the findings from Allahabadi et al,[37] who noted that public or government insurance contributes to substantial treatment delays. Their study revealed that adult patients with public insurance experience approximately 6 times longer wait times for clinical evaluation, 5.5 times longer for radiological scans, and 4.5 times longer for surgery compared to those with private insurance. Such delays negatively affect patient care, prolonging access to critical medical procedures and increasing the risk of complications. These inefficiencies in the National Insurance System highlight the broader challenges faced by public insurance schemes and emphasize the urgent need for reforms to streamline claim verification processes, ensuring timely medical interventions and reducing disparities between public and private health care services.[37] Financial barriers further exacerbate the situation, preventing many patients in LMICs from affording critical investigations and essential surgical procedures.[38]

Delays in diagnostic imaging also pose significant challenges, with median waiting times for CT scans in LMICs ranging from 37 minutes to 7 hours, creating detrimental variations for patient care.[38] CT scan is the most readily available and reliable radiological modality for patients with PBIs, offering rapid and detailed evaluation of both bony structures and soft tissues.[39] These findings are linear with our case findings, where the patient needed to travel for 80 km to acquire CT scan as the primary radiological modality in TBI.

CT scan is usually performed in emergency situations due to its time efficiency and provides detailed findings on brain structures. CT scan is essential for the diagnosis of acute as well as chronic intracranial lesion, such as intracranial hemorrhagic lesion and infarct.[1] [40] The usage of CT scan in PBI cases is not only to visualize the injury that caused it but also to evaluate the associated soft tissue as well as vascular damage. In cases where a penetrating vascular injury following PBI is suspected, CTA is highly recommended to assess the vascular architecture and rule out any vascular injury such as pseudoaneurysm or vascular occlusion.[41] [42] [43] Another radiological modality, digital subtraction angiography (DSA) is considered the gold standard for diagnosing vascular lesions due to its superior accuracy compared to CTA, highlighting DSA's higher sensitivity, specificity, positive predictive value, and negative predictive value, emphasizing the need for DSA when vascular injury is suspected.[44]

However, requirement to advanced diagnostic facilities, such as CT scan, CTA, and DSA, is often not met promptly in LMICs, including in East Java province. A study by Zimmerman et a,l[45] recorded one-fourth of TBI patients do not receive adequate radiological imaging in the emergency unit, although there is indications for radiological imaging in LMICs. This is vital, since vascular injury complicate the treatment and strategy to manage PBI, and the involvement of vascular injury requires rapid intervention as well as resulting in different strategy for surgical intervention.[46] These studies align with our case presentation, where a difficulty to obtain adequate radiological imaging is present in the periphery hospital emergency room, hence raising the risk of mortality and morbidity by delaying diagnosis and detection of related complications. In the end, due to this burden, the neurosurgery team faces vivid difficulties in implementing the right strategy for handling head trauma cases, especially PBI in Indonesia.

Seelig et al[47] found that patients who underwent surgery within the first 4 hours had a significantly lower mortality rate of 30%, compared to a staggering 90% for those treated after 4 hours (p < 0.0001). Similarly, research by Okada et al[48] analyzed 1,169 trauma patients who received definitive care within 4 hours and survived beyond that period. Of these, 33% (386 patients) ultimately died, with the median time to care being 137 minutes. However, only 5.2% (61 patients) were treated within 60 minutes of injury. Due to multifactorial limitations as explained above, the foreign object extraction could only be done approximately 72 hours postinjury, hence, we highlight this phenomenon as one of the contributing factors related to the patients' mortality.

Following TBI, patients often experience global and localized changes in cerebral blood flow (CBF). During the first 12 hours postinjury, reduced perfusion is typically observed, followed by hyperperfusion and potential vasospasms, which may eventually normalize. Hyperperfusion can lead to premature capillary structures that are prone to disruption during surgical interventions, resulting in secondary bleeding.[49] [50] This may have correlation with the finding of excessive bleeding intraoperatively, and might be the cause of the patient's deterioration.

In addition, up to 40% of cases of PBI report vascular complications such as secondary intracranial hemorrhage, pseudoaneurysm, traumatic aneurysms, and vasospasm. Timely treatment of these complications is critical and recent evidence supports the universal application of CT scanning and CTA during the 24 hours after the surgical approach for effective and early surveillance for any complication process.[51] [52] [53]

Cerebral vasospasm is a significant complication following subarachnoid hemorrhage (SAH) and TBI, necessitating routine postoperative imaging for early detection. Radiological modalities such as CTA and CT perfusion imaging are highly effective in identifying vascular changes and detecting ischemia associated with vasospasm.[54] [55] This is particularly critical for TBI patients, where maintaining cerebral perfusion pressure (CPP) is vital to avoid secondary brain injury.[56] Robust monitoring through transcranial Doppler as well as CT scan facilitates proactive management strategies, including fluid resuscitation and vasodilator intervention, that help mitigate the progression of vasospasm to ischemic lesions. Vasospasm, characterized by the narrowing of cerebral arteries due to smooth muscle contraction and inflammatory infiltration, significantly diminishes cerebral perfusion and results in the failure of cerebral autoregulation, microthrombosis, and cerebral ischemic injury.[57] [58]

Cerebral vasospasm and delayed cerebral ischemia (DCI) are significant complications following TBI, contributing to increased morbidity and mortality by disrupting CBF and leading to secondary brain injury. On the third day after the accident, the patient had undergone TFCA and the total occlusion in the ICA was as high as the petrous level. Since the arrival time to the tertiary trauma center is prolonged, vasospasm is neglected, creating total occlusion of the ICA and as a consequence might proceed to cerebral ischemia.

Posttraumatic vasospasm (PTV) has been closely linked to unfavorable outcomes in TBI patients, especially with low-velocity PBIs. A study by Almojuela et al[59] found that only 35.7% of patients with vasospasm achieved a favorable Glasgow Outcome Score, compared to 47.4% of patients without vasospasm, although this difference did not reach statistical significance (p = 0.12) . Similarly, Prasad et al[60] reported that vasospasm is associated with a 20% incidence of morbidity and mortality in patients with SAH, underscoring its critical role in the development of secondary injuries.

Vasospasm significantly reduces neurological outcomes, with less than 20% of head trauma patients exhibiting clinical deficits experiencing poor prognoses. The reported incidence of PTV ranges from 19 to 68%, and it is often associated with decreased likelihood of routine discharge, extended hospital stays, and reduced overall survival rates.[61] [62] The pathophysiology of vasospasm includes mechanisms such as reduced nitric oxide production, direct calcium channel activation, inflammation, and oxidative stress, which collectively impair cerebral autoregulation and promote microthrombosis and ischemic injury.[58]

Several factors contribute to PTV, including SAH, low GCS scores, and metabolic factors, such as hypoalbuminemia, which impairs blood–brain barrier (BBB) integrity and exacerbates cerebral edema.[63] [64] Metabolic complications such as anemia and thrombocytopenia further contribute to cerebral ischemia by reducing oxygen-carrying capacity and inhibiting angiogenic responses.[65] [66] Hypoalbuminemia exacerbates BBB disruption, leading to vascular leakage, increased cerebral edema, and secondary hemorrhages, which amplify the risk of ischemia and infarction.[67] These complications are compounded by logistical challenges, such as delays in diagnostic imaging, insurance system issue, travel distance, and inadequacy of advance care facilities.[20] [22] [38] [46]

The management of PTV following TBI in the ICU remains ambiguous due to the lack of definitive guidelines. Research by Ha et al[68] and Francoeur and Mayer[69] emphasizes the importance of monitoring vessel caliber over time using transcranial Doppler and CTA, particularly during the 3rd to 7th days postinjury, to manage vasospasm. Early identification of vasospasm allows for timely therapeutic interventions, such as vasopressor therapy and fluid resuscitation, aimed at optimizing CPP and preventing further secondary brain injury. A different outcome is found in a similar case reported by Almojuela et al.[59] The diagnosis of vasospasm took shorter time than ours, resulting in different strategy implementation mainly to focus on managing PTV with pharmacological therapy and balloon angioplasty, given its potential reversibility. This study also highlights the importance of repeat CTA to ensure the resolution of vasospasm as well as the presence of possible postoperative complications. The patient survived and was discharged from hospital 6 weeks postadmission.

In this patient, we evaluated the IVH as a posttraumatic complication to the PBI, whereas IVH stands as a risk factor for secondary intracranial arterial lesion, hence resulted in several vascular complications.[70] [71] The course of PBI is one of the determinants of patients' outcome. Similar researches show that PBIs that penetrate through the ventricle significantly increase the chances of developing secondary IVH and obstructive hydrocephalus in which mortality rates can be as high as 54%.[12] [13]

One of the acceptable laboratory and radiology monitoring by the national health insurance (BPJS) is routine blood test. Routine blood tests are widely used for patient monitoring in Indonesia due to insurance limitations, and unfortunately, it does not provide a complete picture of the patient's condition. Before the clinical deterioration, anemia (8.9) and thrombocytopenia (112,000) were identified, followed by hypoalbuminemia. While these findings are valuable, they may not capture the nuanced progression of a patient's clinical condition. This limitation calls for enhanced diagnostic strategies to monitor patients more comprehensively. Integrating advanced imaging techniques or frequent neurological assessments could complement routine blood tests and improve early detection of complications. Expanding monitoring protocols is essential to bridge the gap in patient care and ensuring timely interventions.

Anemia is a critical systemic factor that exacerbates secondary brain injury in patients with TBI. Anemia compromises the oxygen-carrying capacity of the blood, leading to inadequate cerebral oxygenation, which worsens ischemia in brain-injured patients.[72] [73] Following TBI, the brain enters a hypermetabolic and hypercatabolic state that heightens the demand for oxygen and nutrients. This state accelerates the depletion of red blood cells and hemoglobin, further compounding the effects of anemia.[74] A retrospective study on 1,150 TBI patients found that anemia, defined as hemoglobin levels below 9 g/dL, was significantly associated with increased mortality (odds ratio = 3.67; 95% CI = 1.13–2.24).[65] The hypermetabolic state of the injured brain, combined with anemia, creates a mismatch between oxygen supply and demand, worsening ischemia and leading to poorer outcomes.

Thrombocytopenia and hypoalbuminemia are critical systemic factors that exacerbate secondary brain injury in patients with TBI, significantly contributing to poorer outcomes. Postoperative thrombocytopenia is associated with poor short-term prognosis in TBI patients, as it inhibits the angiogenic response, leading to brain tissue ischemia.[75] [76] Moreover, 50% of moderate-to-severe TBI patients with thrombocytopenia develop new or progressive lesions visible on follow-up cerebral CT scans, highlighting its role in worsening secondary injuries.[76] Similarly, hypoalbuminemia disrupts the integrity of the BBB, promoting plasma leakage into the extravascular space and intensifying cerebral edema.[77]

Thrombocytopenia diminishes platelet count, impairing angiogenesis, which is essential for restoring vascular stability and perfusion to ischemic brain tissue after TBI. This impairment promotes tissue ischemia, further compounding the severity of secondary brain damage. On the other hand, hypoalbuminemia exacerbates the breakdown of the BBB, leading to increased vascular permeability, plasma leakage, and cerebral edema. This leakage heightens ICP and contributes to secondary brain injury.

The cause of death in this patient is likely multifactorial, with DCI being a significant contributor. In Indonesia, routine radiological monitoring in the neuro-ICU, such as CTA or transcranial Doppler, is often limited due to insurance constraints, leaving patients vulnerable to undetected complications. The ICA occlusion on the third day after the incident suggests a high likelihood of DCI, as the blockage would severely impair cerebral perfusion, particularly in regions without sufficient collateral circulation. The absence of adequate vasospasm treatment, such as nimodipine therapy in the neuro-ICU, further exacerbates ischemic risk, as unmitigated vasospasm can compromise CBF. Additionally, the hypermetabolic and hypercatabolic state of the injured brain, combined with systemic factors like anemia and thrombocytopenia, likely worsened the oxygen supply–demand mismatch, intensifying ischemic damage and contributing to secondary brain injury.

Another probable cause of death could be rebleeding, particularly given the postoperative thrombocytopenia and the presence of IVH. Low platelet levels hinder clot stabilization, raising the risk of vascular rupture, especially in fragile, newly formed vascular structures. Complication of the foreign object's trajectory, in this case IVH, points to a hemorrhagic process that could raise ICP, leading to herniation or further compromising cerebral perfusion. The delayed extraction of the foreign object, occurring past the golden hour for intervention, also significantly increased the risk of mortality by allowing ischemic and hemorrhagic processes to advance. The limited monitoring and therapeutic options available in the ICU setting due to financial and systemic barriers likely prevented timely identification and management of these complications, resulting in poor outcomes. Together, DCI, rebleeding, and systemic factors like anemia, thrombocytopenia, and hypoalbuminemia culminated in a fatal progression of secondary brain injury, hence, decreasing the patient's survival chance.

This case report offers a comprehensive analysis of the factors influencing mortality in PBI, with a particular focus on socioeconomic determinants, such as the National Insurance System. It highlights the challenges faced in accessing tertiary trauma centers, compounded by inadequate facilities, particularly radiological resources, in peripheral hospitals. Additionally, the report addresses the limitations of neuromonitoring in the management of PBI patients, emphasizing its critical role within the context of the National Insurance System.

This study has several limitations that must be considered. First, the cause of death in our case remains undetermined due to the limitations in radiological monitoring, which hindered a more comprehensive assessment of critical conditions. Second, minimal data regarding the reasons for delayed arrival at trauma centers restricts our understanding of prehospital factors impacting patient outcomes. Third, there is a paucity of studies reporting PBI cases with similar outcomes, limiting the generalizability of our findings. Furthermore, few studies have explored the relationship between insurance systems and mortality in PBI patients, particularly within the context of Indonesia, an area that warrants further investigation. Lastly, the interhospital referral system, particularly its interaction with national health insurance, remains understudied, and its potential impact on trauma patient outcomes requires more focused research.

This study highlights the need for more research on PBI in Indonesia. Increasing publications and studies on PBI will improve local understanding and management. It is also crucial to raise awareness of vascular complications in PBI and encourage research in related fields such as vascular surgery and trauma care. Future studies should examine how the National Health Insurance (BPJS) system affects neuromonitoring practices in PBI cases, aiming to improve health care delivery. Additionally, analyzing factors affecting patient outcomes—from prehospital care to management and intensive care monitoring—will help develop recommendations to optimize PBI care in Indonesia.

Strength

This case report offers a comprehensive analysis of the factors influencing mortality in PBI, with a particular focus on socioeconomic determinants, such as the National Insur- ance System. It highlights the challenges faced in accessing tertiary trauma centers, compounded by inadequate facili- ties, particularly radiological resources, in peripheral hospi- tals. Additionally, the report addresses the limitations of neuromonitoring in the management of PBI patients, em- phasizing its critical role within the context of the National Insurance System.

Limitations

This study has several limitations that must be considered. First, the cause of death in our case remains undetermined due to the limitations in radiological monitoring, which hindered a more comprehensive assessment of critical conditions. Sec- ond, minimal data regarding the reasons for delayed arrival at trauma centers restricts our understanding of prehospital factors impacting patient outcomes. Third, there is a paucity of studies reporting PBI cases with similar outcomes, limiting the generalizability of our findings. Furthermore, few studies have explored the relationship between insurance systems and mortality in PBI patients, particularly within the context of Indonesia, an area that warrants further investigation. Lastly, the interhospital referral system, particularly its interaction with national health insurance, remains understudied, and its potential impact on trauma patient outcomes requires more focused research.

Future studies

This study highlights the need for more research on PBI in Indonesia. Increasing publications and studies on PBI will improve local understanding and management. It is also crucial to raise awareness of vascular complications in PBI and encourage research in related fields such as vascular surgery and trauma care. Future studies should examine how the National Health Insurance (BPJS) system affects neuromonitoring practices in PBI cases, aiming to improve health care delivery. Additionally, analyzing factors affecting patient outcomes—from prehospital care to management and intensive care monitoring—will help develop recommendations to optimize PBI care in Indonesia.

Conclusion

Reducing the mortality of PBIs requires a multifaceted approach focused on improving timely access to high-quality trauma care. First, enhancing the quality of EMS is essential to minimize prehospital delays and ensure rapid transport of patients to definitive care facilities. Direct patient transport to trauma centers equipped with neurosurgical services within the golden hour is crucial for improving outcomes. In Indonesia, this necessitates addressing the inadequate distribution of trauma centers as well as neurosurgeons by ensuring their equitable placement across regions to provide geographic coverage and timely access to life-saving interventions. Additionally, addressing financial barriers imposed by the National Insurance System (BPJS) is critical to enabling comprehensive neurointensive care monitoring. Efforts to streamline interhospital transport, reduce administrative delays, and simplify national health insurance claim processes will further improve care efficiency.

Conflict of Interest

None declared.

Authors' Contributions

T.A. was responsible for patient care, designing and formulating the paper, supervising the manuscript writing and editing process, and revising the paper. A.A.-F. performed the evacuation of the foreign object, contributed to the conceptual framework of the paper, supervised the writing and editing, provided critical feedback, and revised the manuscript. N.S.S. contributed to the conceptual framework, led the paper discussions, supervised manuscript preparation, provided critical feedback, and participated in revising the manuscript. A.R.A. and M.R.P. were involved in data collection, expanding the conceptual framework into a case report, writing the report, and revising the paper.

Ethical Approval

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Institutional Review Board (IRB) approval was obtained from Soetomo General Hospital Ethics Board, ensuring that all protocols met the necessary ethical standards for research involving human participants. Informed consent was obtained from the participant and family involved.

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Publication History

Article published online:
19 May 2025