Neuroworsening in traumatic brain injury: A consensus of the Latin American Brain Injury Consortium (LABIC) and the Latin American Federation of Neurosurgical Societies (FLANC) expert group

Neuroworsening (NW) after traumatic brain injury (TBI) is a life-threatening complication affecting at least one in five patients. The current definition remains heterogeneous and does not integrate contemporary neuromonitoring tools that could help reduce this variability. Current diagnostic approaches are predominantly reactive, identifying deterioration only after brain herniation has occurred. To establish an expert consensus to update the definition of NW in TBI by proposing a stratified diagnostic framework aligned with precision and personalized medicine principles, aiming to shift a paradigm that has been in use for the past 50 years. A formal Delphi consensus process was conducted involving 25 experts from the Latin American Brain Injury Consortium (LABIC) and the Latin American Federation of Neurosurgical Societies (FLANC). A pre-consensus systematic literature review was performed, followed by structured electronic surveys with Likert-scale and multiple-choice items. Consensus was predefined as ≥80% agreement for establishing a statement. A 95.2% response rate was achieved in the first Delphi round, with 100% of statements reaching the consensus threshold. The panel agreed on a stratified three phenotype NW framework: Established NW, Subclinical NW and High-Risk Phenotype, including patients with pre-existing anatomical or systemic conditions that affect cerebral compliance or oxygenation reserve. This consensus proposes integrating clinical, imaging, and multimodal neuromonitoring parameters to update the definition of NW, thereby reducing heterogeneity in the current concept. Seven statements were established with >80% agreement. The new definition promotes a preventive approach to this critical condition, in contrast to the traditional reactive model.