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Validating the Brain Injury Guidelines in a Pediatric Population with Mild Traumatic Brain Injury and Intracranial
Nina Yu1, Jose Castillo2, Jonathan E Kohler3
1School of Medicine, University of California, Davis, Sacramento, California, USA.
Insights
The Brain Injury Guidelines (BIG) effectively identify children with mild traumatic brain injury (mTBI) who may need further evaluation, reducing unnecessary imaging and hospital admissions. This tool aids in optimal triage for pediatric TBI patients.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Emergency Medicine
Background:
- Mild traumatic brain injury (mTBI) and intracranial injury (ICI) in children often lead to overuse of imaging and hospital admissions.
- Identifying children at risk for critical neurological injury is crucial for appropriate emergency care and resource allocation.
Purpose of the Study:
- To validate the Brain Injury Guidelines (BIG) algorithm in pediatric patients (0-17 years) with mTBI and ICI.
- To assess the BIG's accuracy in identifying critical neurosurgical injuries in children.
- To compare the BIG's predictive capability against the Glasgow Coma Scale (GCS) alone.
Main Methods:
- Retrospective review of 804 pediatric TBI admissions (2017-2023) with initial head CT and GCS 14-15.
- Classification of patients into BIG categories (1, 2, 3) and identification of clinically important TBI (ciTBI).
- Evaluation of imaging progression and 6-month outcomes (GOS-E).
Main Results:
- BIG categories showed significant differences in ciTBI incidence (0.6% BIG 1, 1.0% BIG 2, 26.0% BIG 3, p < 0.0001).
- Imaging progression requiring further evaluation occurred in 0% BIG 1, 0.5% BIG 2, and 18.0% BIG 3 injuries (p < 0.001).
- 98% of patients with available outcomes had a GOS-E ≥5, with no significant difference between BIG categories.
Conclusions:
- The BIG algorithm demonstrates reasonable accuracy in stratifying pediatric mTBI patients who develop ciTBI.
- BIG classification can assist in triage decisions, including the need for neurosurgical consultation and repeat imaging.
- While effective for risk stratification, higher BIG scores did not correlate with worse long-term patient outcomes in this cohort.
Abstract:
Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017-2023) using an institutional registry. Patients included (0-17 years) had an initial head computerized tomography scan with ICI and a GCS of 14-15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome.
