Retrospective analysis of small intracranial hemorrhage in trauma: Is acute care surgery team management alone safe?

The Brain Injury Guidelines (BIG) provide a validated framework for categorizing patients with small intracranial haemorrhages (ICH) who could be managed by acute care surgery without neurosurgical consultation or repeat head computed tomography in the absence of neurological deterioration. This replication study retrospectively applied BIG criteria to ICH subjects and only included BIG1 and BIG2 subjects. The trauma registry was queried from 2014 to 2019 for subjects with a traumatic ICH <1 cm, Glasgow Coma Scale score of 14/15 and not on anticoagulation therapy. Patients were then categorized under BIG 1 or BIG2 and outcomes were evaluated. Two hundred fourteen subjects were reviewed (88 BIG1 and 126 BIG2). Twenty-three subjects had worse repeat imaging, but only one had worsening exam that resolved spontaneously. None required neurosurgical intervention. One died of non-neurological causes. Retrospective analysis supported our hypothesis that patients categorized as BIG1 or BIG2 could have been safely managed by acute care surgeons without neurosurgical consultation or repeat head imaging. A review of minor worsening on repeat imaging without changes in neurological exams and no need for neurosurgical interventions supports this evidence-based approach to the management of small intracranial haemorrhages.