Optimizing Traumatic Brain Injury Care Without Neurosurgeons: External Validation of the Brain Injury Guidelines in a...

Background/Objectives: Access to neurosurgical care remains limited in many trauma systems worldwide, particularly in low- and middle-income countries (LMICs). The Brain Injury Guidelines (BIG) were developed to guide the management of traumatic brain injury (TBI) and optimize resource utilization; however, their applicability in resource-limited environments without on-site neurosurgical coverage remains unclear. The aim of this study was to evaluate the performance and applicability of the BIG in a trauma center without neurosurgical support. Methods: We performed a retrospective analysis of adult patients with TBI admitted to a trauma center without neurosurgical support in São Paulo, Brazil, between 2013 and 2017. Patients were classified according to the BIG criteria (BIG 1-3) based on clinical and radiological findings. Primary outcomes were clinical and radiological deterioration and mortality; secondary outcomes included neurosurgical transfer, repeat computed tomography (CT) utilization, and length of stay. Results: A total of 178 patients were included: 12 (6.7%) BIG 1, 53 (29.8%) BIG 2, and 113 (63.5%) BIG 3. No patient classified as BIG 1 or BIG 2 experienced clinical or radiological deterioration, required neurosurgical intervention, or died; adverse outcomes were confined to the BIG 3 cohort, with a mortality rate of 11.5%. The combined BIG 1-2 group showed a sensitivity and negative predictive value (NPV) of 100% for identifying patients without deterioration or need for neurosurgical intervention. Despite the absence of adverse events in the BIG 1-2 group, 76.4% of patients underwent transfer for neurosurgical evaluation, and repeated CT imaging was frequently performed. Conclusions: In this single-center retrospective cohort, the BIG demonstrated excellent discriminatory ability for identifying low-risk TBI patients in a setting without neurosurgical coverage. BIG 1 and BIG 2 categories reliably ruled out the need for neurosurgical intervention, supporting selective non-transfer strategies to optimize resource utilization.