Türkiye’de Nörotravma Yönetimi ve Sağlık Politikaları: Beyin Cerrahisi Perspektifinden Sistem Analizi

Abstract

Travmatik beyin yaralanmaları başta olmak üzere nörotravmalar dünya genelinde mortalite, morbidite ve sağlık harcamalarının önde gelen nedenleri arasındadır. Nörotravmaların sonuçları yalnızca klinik tedavi yönüyle değil, prehospital bakım, sevk zinciri, travma merkezleri, nöro-yoğun bakım ve rehabilitasyon ve veri kayıt sistemlerini kapsayan bütüncül incelemeleri gerektirmektedir. Bu çalışmayla nörotravmanın yönetiminde Türkiye’nin mevcut durumu ve uluslararası kanıtlar ışığında ulusal nörotravma sistemi ihtiyacı incelenmiş ve sağlık politikası önerileri sunulmuştur. Nörotravma sistemleri, travma merkezlerinin bölgeselleştirilmesi, prehospital bakım, nörokritik bakım, rehabilitasyon ve sağlık politikalarına ilişkin uluslararası ve ulusal çalışmalar sistematik olarak taranmış ve tematik olarak analiz edilmiştir. Çalışmalar arasındaki metodolojik ve yapısal heterojenite nedeniyle nicel meta-analiz yerine sağlık sistemi bileşenlerinin bütüncül olarak değerlendirilmesine olanak sağlayan narratif sentez yaklaşımı kullanılmıştır. Yapılan literatür incelemesinde organize bir travma sisteminin bulunmasının travmatik beyin yaralanmalarının mortalitesini anlamlı düzeyde azalttığı görülmüştür. Nörotravma hastalarının önceden tanımlanmış ve uzman barındaran merkezlere doğrudan yönlendirilmesi ile mortalitede %24-28 oranında azalma bildirilmiştir. Bunun yanında ara merkezler üzerinden yapılan ikincil trasferlerin mortaliteyi %50 oranında arttırabildiği gösterilmiştir. Uluslararası nörotravma sistemleri; hastane öncesi bakım, özelleşmiş nörotravma merkezleri ve nörokritik bakım üniteleri, rehabilitasyon hizmetleri ve ulusal travma kayıt sistemlerini bir bütün olarak değerlendirmektedir. Türkiye’de mevcut veriler trafik kazalarının ağır travmatik beyin yaralanmalarının başlıca nedeni olduğunu ve yoğun bakım gereksiniminin yüksek olduğunu bunun doğal bir sonucu olarakta ekonomik yükün fazla olduğunu göstermektedir. Bununla birlikte ulusal ölçekte standartlaştırılmış bir nörotravma sevk ağı ve kapsamlı travma kayıt sistemine ilişkin yayımlanmış veriye rastlanamamıştır. Elde edilen bulgular, ulusal travma kayıt sistemi, standartlaştırılmış sevk ağları ve bölgeselleşmiş nörotravma bakım modellerinin geliştirilmesinin Türkiye'de nörotravma sonuçlarının iyileştirilmesine katkı sağlayabileceğini düşündürmektedir.

Keywords

• Travmatik beyin yaralanması
• nörotravma
• nöroşirürji
• sağlık politikası

Supporting Institution

Bu çalışma herhangi bir kurum, kuruluş veya fon sağlayıcı tarafından maddi olarak desteklenmemiştir.

Ethical Statement

Bu çalışma, herhangi bir insan veya hayvan deneyi içermemekte olup, yalnızca literatür verilerinin analizine dayanmaktadır. Bu nedenle etik kurul onayı gerektirmemektedir. Çalışmanın hazırlanması sürecinde tüm bilimsel ve etik ilkelere uyulmuştur.

Thanks

Yazarlar, çalışmanın geliştirilmesi sürecinde görüş ve önerileriyle katkı sunan tüm akademik meslektaşlara teşekkür eder. Ayrıca literatür taraması ve veri toplama aşamalarındaki teknik destekleri için ilgili birimlere minnettarız.

Neurotrauma Management and Health Policies in Türkiye: A System Analysis from a Neurosurgical Perspective

Abstract

Neurotrauma, particularly traumatic brain injury (TBI), remains a leading cause of mortality, morbidity, and healthcare expenditure worldwide. The outcomes of neurotrauma are influenced not only by clinical treatment but also by a comprehensive system encompassing prehospital care, referral pathways, trauma centers, neurocritical care, rehabilitation services, and trauma data registries. This study aimed to evaluate the current status of neurotrauma management in Türkiye, examine the need for a national neurotrauma system in light of international evidence, and propose health policy recommendations. International and national studies addressing neurotrauma systems, trauma center regionalization, prehospital care, neurocritical care, rehabilitation, and health policies were systematically reviewed and thematically analyzed. Owing to the methodological and structural heterogeneity of the included studies, a narrative synthesis approach was adopted instead of quantitative meta-analysis to facilitate a comprehensive evaluation of health system components. The literature demonstrated that the presence of organized trauma systems is associated with significant reductions in mortality following traumatic brain injury. Direct transportation of neurotrauma patients to predefined specialized centers was associated with a 24–28% reduction in mortality, whereas secondary transfers through intermediate hospitals were reported to increase mortality by approximately 50%. International neurotrauma systems integrate prehospital care, specialized neurotrauma centers, neurocritical care units, rehabilitation services, and national trauma registries within a coordinated continuum of care. Available data from Türkiye indicate that traffic-related injuries remain the leading cause of severe traumatic brain injury, resulting in substantial intensive care requirements and considerable economic burden. However, no published evidence of a nationwide standardized neurotrauma referral network or comprehensive trauma registry system was identified. The findings suggest that the development of a national trauma registry, standardized referral pathways, and regionalized neurotrauma care models may contribute to improving neurotrauma outcomes in Türkiye.

Keywords

• Traumatic brain injury
• Neurotrauma
• Neurosurgery
• Health policy

Supporting Institution

This study received no financial support from any institution, organization, or funding agency.

Ethical Statement

This study does not involve any human or animal experimentation and is based solely on the analysis of previously published literature. Therefore, ethical committee approval is not required. All scientific and ethical principles were followed throughout the development of this manuscript.

Thanks

The authors would like to thank all academic colleagues who contributed valuable insights and suggestions during the development of this study. We also express our appreciation to the relevant departments for their technical assistance in the literature review and data assessment processes.

References

1. Aras Y, Sabanci PA, Unal TC, Aydoseli A, Izgi N. Epidemiologic study in hospitalized patients with head injuries. Eur J Trauma Emerg Surg. 2017 Aug;43(4):467-473. Doi: 10.1007/s00068-016-0668-3. Epub 2016 Apr 9. PMID: 27062402.
2. Aslan N, Yıldızdaş D. Severe Pediatric Traumatic Brain Injury Treatment Approaches of Pediatric Intensivists in Turkey PICUs: National Survey Results. Turk Arch Pediatr. 2022 Jul;57(4):421-427. Doi: 10.5152/TurkArchPediatr.2022.21247. PMID: 35822474; PMCID: PMC9318421.
3. Bozkurt I, Umana GE, Deora H, Wellington J, Karakoc E, Chaurasia B. Factors Affecting Neurosurgeons’ Decisions to Forgo Life-Sustaining Treatments After Traumatic Brain Injury. World Neurosurg. 2022 Mar;159:e311-e323. Doi: 10.1016/j.wneu.2021.12.056. Epub 2021 Dec18. PMID: 34933149.
4. Brown JB, Schreiber M, Moore EE, Jenkins DH, Bank EA, Gurney JM. Commentary on gaps in prehospital trauma care: education and bioengineering innovations to improve outcomes in hemorrhage and traumatic brain injury. Trauma Surg Acute Care Open. 2024 Jan 5;9(Suppl 1):e001122. Doi: 10.1136/tsaco-2023-001122. PMID: 38196935; PMCID: PMC10773423.
5. Coburn W, Trottier Z, Villarreal RI, Paulson MW, Woodard SC, McKay JT, Bebarta VS, Flarity K, Keenan S, Schauer SG. Prehospital Pharmacotherapy in Moderate and Severe Traumatic Brain Injury: A Systematic Review. Med J (Ft Sam Houst Tex). 2023 Jan-Mar;(Per 23-1/2/3):47-56. PMID: 36607298. Fakhry SM, Shen Y, Garland JM, Wilson NY, Wyse RJ, Morse JL, Hunt DL, Acuna D, Dunne J, Kurek SJ, Gordy SD, Watts DD. The burden of geriatric traumatic brain injury on trauma systems: Analysis of 348,800 Medicare inpatient claims. J Am Geriatr Soc. 2023 Feb;71(2):516-527. Doi: 10.1111/jgs.18114. Epub 2022 Nov 4. PMID: 36330687.
6. Fuller G, Pallot D, Coats T, Lecky F. The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review. Br J Neurosurg. 2014 Aug;28(4):452-60. Doi: 10.3109/02688697.2013.865708. Epub 2013 Dec 9. PMID: 24313333.
7. Ghajar J. Traumatic brain injury. Lancet. 2000 Sep 9;356(9233):923-9. Doi: 10.1016/S0140-6736(00)02689-1. PMID: 11036909.
8. Gilmartin S, Brent L, Hanrahan M, Dunphy M, Deasy C. A retrospective review of patients who sustained traumatic brain injury in Ireland 2014-2019. Injury. 2022 Nov;53(11):3680-3691. Doi: 10.1016/j.injury.2022.09.013. Epub 2022 Sep 13. PMID: 36167689.

9. Härtl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma. 2006 Jun;60(6):1250-6; discussion 1256. Doi: 10.1097/01.ta.0000203717.57821.8d. PMID:16766968.
10. Irdesel J, Aydiner SB, Akgoz S. Rehabilitation outcome after traumatic brain injury. Neurocirugia (Astur). 2007 Feb;18(1):5-15. Doi: 10.1016/s1130-1473(07)70303-2. PMID: 17393041.
11. Kahveci K, Dinçer M, Doger C, Yaricı AK. Traumatic brain injury and palliative care: a retrospective analysis of 49 patients receiving palliative care during 2013-2016 in Turkey. Neural Regen Res. 2017 Jan;12(1):77-83. Doi: 10.4103/1673-5374.198987. PMID: 28250751; PMCID: PMC5319246.
12. Kelly ML, Banerjee A, Nowak M, Steinmetz M, Claridge JA. Decreased mortality in traumatic brain injury following regionalization across hospital systems. J Trauma Acute Care Surg. 2015 Apr;78(4):715-20. Doi: 10.1097/TA.0000000000000590. PMID: 25807401.
13. Kelly ML, Roach MJ, Banerjee A, Steinmetz MP, Claridge JA. Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system. J Trauma Acute Care Surg. 2015 Sep;79(3):372-7. Doi: 10.1097/TA.0000000000000762. PMID: 26307868.
14. Kesinger MR, Nagy LR, Sequeira DJ, Charry JD, Puyana JC, Rubiano AM. A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country. Injury. 2014 Sep;45(9):1350-4. Doi: 10.1016/j.injury.2014.04.037. Epub 2014 Apr 28. PMID: 24861416.
15. Kilinc S, Aydogan MS, Duran M, Yucetas CS. Incidence, microbiology, and clinical impact of ventilator-associated pneumonia in traumatic brain injury: a single-center retrospective study. Brain Inj. 2026 May;40(7):614-618. Doi: 10.1080/02699052.2026.2638955. Epub 2026 Mar 2. PMID: 41771661.
16. Lepard J, Ammar A, Shlobin NA, Boyke AE, Berger C, Vital A, Rolle M, Corley J, Barthélemy EJ, Park KB. An Assessment of Global Neurotrauma Prevention and Care Delivery: The Provider Perspective. World Neurosurg. 2021 Dec;156:e183-e191. Doi: 10.1016/j.wneu.2021.09.025. Epub 2021 Sep 21. PMID: 34560295.
17. Ozyurt E, Goksu E, Cengiz M, Yilmaz M, Ramazanoglu A. Retrospective Analysis of Prognostic Factors of Severe Traumatic Brain Injury in a University Hospital in Turkey. Turk Neurosurg. 2015;25(6):877-82. Doi: 10.5137/1019-5149.JTN.9181-13.0. PMID: 26617136.
18. Öner Ö, Hanci V, Gürkok MÇ, Ergan B, Yaka E, Gökmen AN. The effect of amantadine treatment on neurological outcome and mortality in mechanically ventilated severe head trauma patients in intensive care unit. Medicine (Baltimore). 2024 May 17;103(20):e38172. Doi: 10.1097/MD.0000000000038172. PMID: 38758901; PMCID: PMC11098193.
19. Pélieu I, Kull C, Walder B. Prehospital and Emergency Care in Adult Patients with Acute Traumatic Brain Injury. Med Sci (Basel). 2019 Jan 21;7(1):12. Doi: 10.3390/medsci7010012. PMID: 30669658; PMCID: PMC6359668.
20. Pitts LH. Neurotrauma and trauma systems. New Horiz. 1995 Aug;3(3):546-8. PMID: 7496766.
21. Prabhakar H, Lele AV, Kapoor I, Mahajan C, Shrestha GS, Rao CV, Suarez JI, Livesay SL, Shafiq F, Popugaev K, Santosa D, Zada ON, Yang W, Nisha HA, Mijangos-Mendez JC, Agaba PK, Portilla JLP, Tuahir YH, Shanmugam P, Arruebarrena YP, Videtta W, Vásquez-García S, Raheem MSA, Yimer F, Padayachy LC, Naranjo LS, Arriaga P, Myei C, Matuja SS, Fadalla T, Viarasilpa T, Lundeg G, Salisu-Kabara HM, Tsan SEH, Gutierrez SP, Yankae LP, Konkayev A, Chaikittisilpa N, Sampaio G, Van Bui T, Mariano GSL, Sabillon GA, Blanco P, Ortiz W, Gallardo AJL, Arun O, Mani K. Neurocritical Care Organization in the Low-Income and Middle-Income Countries. Neurocrit Care. 2025 Aug;43(1):141-156. Doi: 10.1007/s12028-025-02210-7. Epub 2025 Feb 7. PMID: 39920547.
22. Rubiano AM, Puyana JC, Mock CN, Bullock MR, Adelson PD. Strengthening neurotrauma care systems in low and middle income countries. Brain Inj. 2013;27(3):262-72. Doi: 10.3109/02699052.2012.750742. PMID: 23438347.
23. Safaz I, Alaca R, Yasar E, Tok F, Yilmaz B. Medical complications, physical function and communication skills in patients with traumatic brain injury: a single centre 5-year experience. Brain Inj. 2008 Sep;22(10):733-9. Doi: 10.1080/02699050802304714. PMID: 18720099.
24. Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE; CENTER TBI Participants and Investigators. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med. 2021 Aug 4;29(1):113. Doi: 10.1186/s13049-021-00930-1. PMID: 34348784; PMCID: PMC8340517.
25. Shammassian BH, DiGiorgio A, Manley G. Systems of Neurotrauma HealthCare. Neurosurg Clin N Am. 2025 Jul;36(3):459-465. Doi: 10.1016/j.nec.2025.03.015. PMID: 40543954.
26. Shammassian BH, Wooster L, Wright JM, Kelly ML. Systematic review of trauma system regionalization and implementation on outcomes in traumatic brain injury patients. Neurol Res. 2021 Feb;43(2):87-96. Doi: 10.1080/01616412.2020.1824391. Epub 2020 Sep 24. PMID:32967585.
27. Shrestha GS, Goffi A, Aryal D. Delivering neurocritical care in resource-challenged environments. Curr Opin Crit Care. 2016 Apr;22(2):100-5. Doi: 10.1097/MCC.0000000000000285. PMID: 26828423.
28. Shrestha GS, Prabhakar H, Mahajan C, Kapoor I, Livesay SL, Rajajee V, Zirpe K, Videtta W, Hossain S, Silva GS, Rubiano AM, Raheem MSA, Pina Y, Wanchoo J, Shukla U, Tripathy S, Singhal V, Margaretha RE, Tsan S, Yimer FT, Lamsal R, Salisu-Kabara H, Pinedo JL, Soliven JAR, Popugaev K, Padayachy LC, Shanmugam P, Viarasilpa T, Arun O, Van Bui T. Consensus statement on standards for neurocritical care units in low-income and middle-income countries (LMICs). J Crit Care. 2026 Feb;91:155296. Doi: 10.1016/j.jcrc.2025.155296. Epub 2025 Oct18. PMID: 41110431.
29. Süt N, Memiş D. Intensive care cost and survival analyses of traumatic brain injury. Ulus Travma Acil Cerrahi Derg. 2010 Mar;16(2):149-54. PMID: 20517770.
30. Tazarourte K, Cesaréo E, Sapir D, Atchabahian A, Tourtier JP, Briole N, Vigué B. Update on prehospital emergency care of severe trauma patients. Ann Fr Anesth Reanim. 2013 Jul-Aug;32(7-8):477-82. Doi: 10.1016/j.annfar.2013.07.005. Epub 2013 Jul 31. PMID: 23916517.
31. The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Trauma systems. J Neurotrauma. 2000 Jun-Jul;17(6-7):457-62. Doi: 10.1089/neu.2000.17.457. PMID: 10937887.
32. Trauma systems and the neurosurgeon. Brain Trauma Foundation. J Neurotrauma. 1996 Nov;13(11):647-51. Doi: 10.1089/neu.1996.13.647. PMID: 8941881.
33. Zhang Q, Tang D, Chen T, Ai Y, Chen Z, Liu G, Liu J, Chen X, Liu J, Xia Y. Global, regional, and national burden of transport-related moderate/severe traumatic brain injury, 1992-2021: a cross-sectional time-trend analysis of GBD 2021. Int J Surg. 2026 Feb 1;112(2):2360-2373. Doi: 10.1097/JS9.0000000000003693. Epub 2025 Oct 16. PMID: 41092434.