External retrospective validation of Brain Injury Guidelines criteria and modified guidelines for improved care value in the management of patients with low-risk neurotrauma

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Conventional management of patients with neurotrauma frequently consists of routine, repeat head CT at preordained intervals with ICU-level monitoring, regardless of injury severity. The Brain Injury Guidelines (BIG) are a classification tool for stratifying patients into injury severity and risk-of-progression categories based on presenting clinical and radiographic findings. In the present study, the authors aimed to validate BIG criteria at a single level 1 trauma center.


Patients were classified according to BIG criteria and evaluated for subsequent radiographic progression or development of neurological decline. A 2-year retrospective cohort review of consecutive patients with neurotrauma (n = 590) was undertaken. The authors then developed a modified BIG algorithm for use at their institution and followed its implementation prospectively over 555 consecutive patients.


In the retrospective analysis, no patient in the BIG 1 category (n = 88, 14.9%) demonstrated progression or neurological decline, and 7.5% of BIG 2 patients (n = 107, 18.1%) demonstrated mild radiographic progression without any decline or need for additional neurosurgical or medical intervention, whereas 15.4% of BIG 3 patients (n = 395, 66.9%) underwent additional neurosurgical procedures. In the prospective analysis, no BIG 1 (n = 105, 18.9%) or BIG 2 (n = 48, 8.6%) patients demonstrated a clinical decline or required any further neurosurgical intervention. By contrast, 12.9% of BIG 3 patients (n = 402, 72%) required immediate neurosurgical intervention, and a further 2.0% required delayed intervention based on clinical and/or radiographic evidence of injury progression.


Application of the BIG criteria in a single large level 1 trauma center reliably sorted patients into appropriate risk categories that accurately guided ongoing management.

ABBREVIATIONS BIG = Brain Injury Guidelines; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ICP = intracranial pressure; mBIG = modified BIG; mTBI = mild traumatic brain injury.
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Contributor Notes

Correspondence Justin S. Cetas: Oregon Health & Science University, Portland, OR. cetasj@ohsu.edu.INCLUDE WHEN CITING Published online November 8, 2019; DOI: 10.3171/2019.6.JNS19584.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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