Combined intracranial hemorrhage subtypes should not change modified Brain Injury Guidelines criteria

The modified Brain Injury Guidelines (mBIG) are an established protocol to triage traumatic brain injury with intracranial hemorrhage (ICH) while reducing resource utilization. However, mBIG do not differentiate between isolated and combined intracranial hemorrhage (cICH). This study evaluated whether patients with multiple ICH subtypes require different triage.

We performed a retrospective study of adult patients classified as mBIG 1 or mBIG 2 at two Level I trauma centers January 1, 2017, to June 30, 2023. Patients with cICH (≥2 subtypes) were compared with isolated ICH. Primary outcome was clinical deterioration, defined as new focal neurologic findings, pupillary examination changes or Glasgow Coma Scale score of <13 as compared with initial presentation. Secondary outcomes included radiographic progression, neurosurgical consultation, neurosurgical intervention, number of head computed tomography, hospital and intensive care unit length of stay, and readmission.

Among 844 patients, 251 (29.7%) had cICH. Compared with isolated, cICH patients had higher Injury Severity Score (14.3 vs. 11.8, p < 0.001), longer intensive care unit length of stay (1 vs. 0, p < 0.001), and greater radiographic progression (20.3% vs. 11.3%, p = 0.002). However, clinical deterioration (1.0% vs. 2.6%, p = 0.252), neurosurgical intervention (0.4% vs. 0.2% p = 0.507), and readmission (5.2% vs. 3.7%, p = 0.413) were rare and did not differ between groups.

While cICH is associated with more radiographic progression and resource utilization compared with isolated ICH, it is not associated with higher occurrence of clinical deterioration or neurosurgical intervention. These findings support continued use of mBIG for isolated and cICH with escalation of care reserved for neurological deterioration or other high-risk features.

Therapeutic/Care Management; Level IV.