Applying brain injury guidelines to patients with traumatic brain injury: A contemporary, consecutive series

Traumatic brain injury (TBI) is a significant contributor to long-term disability and imposes substantial costs, which may include excess, duplicative, or unnecessary imaging, hospitalizations or transfers, and superfluous consultations. We examined the use of the Brain Injury Guidelines (BIG) in 144 consecutive patients presenting with TBI.

Patients with TBI evaluated consecutively between April 2024 and September 2024 were prospectively classified into BIG 1, 2, and 3 categories and retrospectively assessed. The primary outcome measure was neurosurgical intervention. Secondary outcome measures included: admission; post-presentation neurologic deterioration; new or progressive hemorrhage on repeat head computed tomography (RHCT); discharge modified Rankin Scale (mRS) score; and 30-day re-presentation or subsequent admission.

Of the 144 patients studied, 29 were BIG1 (20.1 %), 29 BIG2 (20.1 %), and 86 were BIG3 (59.7 %). None of the 58 BIG1 or BIG 2 patients (0 %) required a neurosurgical intervention. In BIG3, 21 (24.4 %) patients had a change in neurological exam, and 14 (16.3 %) had progression of hemorrhage on repeat head CT (RHCT) scans. Fourteen patients (16.3 %) in the BIG3 category received some type of neurosurgical intervention; none of the BIG 1 or BIG patients did. BIG3 patients who did not receive anti-platelet or anti-coagulant agents (identified as "BIG3-solo") had a neurological deterioration roughly three times more commonly than any other BIG3 subgroup and were more likely to have an invasive neurosurgical procedure than patients in BIG1, BIG 2 or non-BIG3 solo patients. Nearly half of the patients in BIG1 were discharged from the ED (41 %), compared with only three (10.3 %) in BIG2 and one (1.2 %) in BIG3. Four BIG1 (13.8 %), 6 BIG2 patients (20.7 %) and 12 BIG3 patients (14 %) re-presented to an ED within 30 days of discharge.

The BIG are a valuable tool to stratify clinical risk and guide resource utilization, including repeat imaging, consultation, need for admission, level of admission, and, potentially to determine the need for transfer among facilities based on BIG group.