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Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce
Shea P Gallagher1, Benedict A Capacio, Alexandra S Rooney
1From the Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., B.A.C., A.S.R., R.Y.C., C.B.S., A.K., M.J.S., V.B., M.J.M.), Scripps Mercy Hospital, San Diego, California; Division of Trauma and Acute Care Surgery, Department of Surgery (S.P.G., M.J.M.), Los Angeles General Medical Center, Los Angeles, California; and Division of Trauma and Acute Care Surgery, Department of Surgery (K.B.S., W.L.B.), Scripps Memorial Hospital La Jolla, La Jolla, California.
Insights
Modified Brain Injury Guidelines (BIG) may safely reduce healthcare costs for patients on anticoagulation (AC) with traumatic brain injury (TBI). Lower-risk TBI patients on AC did not require neurosurgical intervention, suggesting potential resource savings.
Area of Science:
- Neurosurgery
- Traumatology
- Geriatric Medicine
Background:
- The Brain Injury Guidelines (BIG) stratify traumatic brain injury (TBI) severity to guide management and reduce healthcare burden.
- Current BIG protocols mandate that all patients on anticoagulation (AC) are classified into the highest severity tertile (BIG 3).
- This classification may lead to over-utilization of healthcare resources for TBI patients on AC.
Purpose of the Study:
- To analyze TBI patients on AC using a modified BIG model.
- To determine if a modified BIG approach can safely reduce healthcare resource utilization in this population.
- To assess the safety and efficacy of stratifying TBI patients on AC into lower risk tertiles.
Main Methods:
- Retrospective analysis of 221 patients aged 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers.
- Patients were stratified into modified BIG 1 to 3 risk groups, excluding AC as a primary criterion.
- Outcomes analyzed included intracranial hemorrhage progression, neurosurgical intervention (NSI), mortality, and discharge status.
Main Results:
- 23%, 29%, and 48% of patients were classified as BIG 1, BIG 2, and BIG 3, respectively.
- BIG 3 patients had higher rates of AC reversal agents, ICH progression, NSI (16%), and mortality (26%) compared to BIG 1 and 2.
- No patients in BIG 1 or 2 required NSI, and mortality was significantly lower (15x odds for BIG 3 vs. BIG 1).
Conclusions:
- Higher ICH progression rates in AC patients did not translate to increased NSI or mortality in lower modified BIG tertiles.
- Applying modified BIG criteria could potentially reduce neurosurgical consultations by up to 52%.
- Modified BIG criteria offer a safe opportunity for healthcare resource and cost savings in the TBI population on AC.
Introduction:
The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization.
Methods:
Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared.
Results:
A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01).
Conclusion:
The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population.
Level Of Evidence:
Prognostic and Epidemiological; Level IV.
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