Clinical progression in patients with concomitant blunt cerebrovascular injury and traumatic brain injury classified using the Brain Injury Guidelines.

Abstract

The Brain Injury Guidelines (BIG) provide neurosurgical consultation and imaging protocols by stratifying patients with traumatic brain injury (TBI) according to injury severity. However, the effect of concomitant blunt cerebrovascular injury (BCVI) on clinical progression and surgical intervention within this framework has not been investigated. The aim of this study was to determine whether the Biffl grade for BCVI evaluation should be incorporated into the BIG criteria to help determine clinical care, follow-up imaging, and treatment decisions for these patients. Adult patients (age ≥ 18 years) with TBI who were transferred to a level 1 trauma center from 2019 to 2023 were retrospectively analyzed. For analysis, patients were stratified by BIG category and propensity matched (1:1) by age, sex, BIG classification, and frailty index. Clinical outcomes were compared between patients with and without BCVI. Multivariable logistic regression analysis was performed to identify predictors of clinical progression (radiographic injury progression or clinical neurological deterioration) or the need for neurosurgical intervention, both in the overall cohort and in the BCVI subgroup. Overall, 999 patients (648 male, mean age 53.5 years) were included in this analysis, and 103 patients (10.3%) presented with BCVI in addition to TBI. The presence of BCVI was not independently associated with progression or the need for neurosurgical intervention in the overall cohort of patients with TBI or the matched cohort (103 patients with BCVI and 103 patients without BCVI). However, among patients with BCVI, both the presence of intracranial hemorrhage (OR 3.04, 95% CI 1.01-9.37) and an injury classified as Biffl grade > I (OR 4.00, 95% CI 1.46-10.96) significantly predicted progression or the need for intervention. For patients with TBI, BCVI alone did not predict clinical progression or the need for neurosurgical intervention. However, higher Biffl grades and intracranial hemorrhage among patients with BCVI were associated with a greater risk of clinical progression or the need for neurosurgical intervention. These findings support the integration of BCVI-specific factors into triage models and highlight the need for refined clinical pathways that supplement BIG classification when BCVI is present.