Predictors of Neurosurgical Intervention in Mild Traumatic Brain Injury Patients Presenting to the Emergency Department: A Systematic Review
DOI:
https://doi.org/10.65759/a9zb1v02Keywords:
mild traumatic brain injury, emergency department, neurosurgical intervention, Glasgow Coma Scale, computed tomographyAbstract
Background: Mild traumatic brain injury (TBI) represents a large share of emergency department head trauma presentations, although a smaller subgroup has intracranial injury that requires neurosurgical treatment. Early identification is central to safe imaging, admission, transfer, and specialist consultation decisions. Objective: This systematic review synthesized original studies evaluating clinical, demographic, physiologic, and radiologic predictors of neurosurgical intervention in emergency department patients with mild TBI. Methods: A PRISMA-based review framework was used. PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library were searched for adult studies of mild TBI, Glasgow Coma Scale 13–15, emergency presentation, and neurosurgical intervention or equivalent acute neurosurgical outcome. Original cohort, validation, registry, and decision-rule studies were prioritized. Results: Ten main original studies and additional validation studies were included in the narrative synthesis. The most consistent predictors were acute intracranial hemorrhage pattern, subdural hematoma thickness, midline shift, epidural hematoma, depressed or basal skull fracture signs, failure to normalize Glasgow Coma Scale, vomiting, older age, coagulopathy or anticoagulant exposure, and early neurologic worsening. Decision instruments achieved high sensitivity for ruling out intervention, although specificity varied widely. Conclusion: Neurosurgical intervention after mild TBI is uncommon overall, although risk increases sharply with specific radiologic and neurologic features. Risk stratification that combines computed tomography findings with serial neurologic assessment provides the most clinically useful approach for emergency disposition and transfer decisions.
References
1. Stiell IG, Wells GA, Vandemheen K, Clement CM, Lesiuk H, Laupacis A, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391–1396. doi:10.1016/S0140-6736(00)04561-X.
2. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100–105. doi:10.1056/NEJM200007133430204.
3. Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005;294(12):1511–1518. doi:10.1001/jama.294.12.1511.
4. Bouida W, Marghli S, Souissi S, Ksibi H, Methammem M, Haguiga H, et al. Prediction value of the Canadian CT Head Rule and the New Orleans Criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma. Ann Emerg Med. 2013;61(5):521–527.
5. Foks KA, van den Brand CL, Lingsma HF, van der Naalt J, Jacobs B, de Jong E, et al. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ. 2018;362:k3527. doi:10.1136/bmj.k3527.
6. Mower WR, Gupta M, Rodriguez R, Hendey GW. Validation of the sensitivity of the NEXUS Head CT decision instrument for selective imaging of blunt head injury patients: an observational study. PLoS Med. 2017;14(7):e1002313. doi:10.1371/journal.pmed.1002313.
7. Nishijima DK, Haukoos JS, Newgard CD, Staudenmayer K, White N, Slattery D, et al. Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage. Ann Emerg Med. 2013;61(5):509–517.e4.
8. Sweeney TE, Salles A, Harris OA, Spain DA, Staudenmayer KL. Prediction of neurosurgical intervention after mild traumatic brain injury using the National Trauma Data Bank. World J Emerg Surg. 2015;10:23. doi:10.1186/s13017-015-0017-6.
9. Joseph B, Pandit V, Aziz H, Kulvatunyou N, Zangbar B, Green DJ, et al. Mild traumatic brain injury defined by Glasgow Coma Scale: is it really mild? Brain Inj. 2015;29(1):11–16. doi:10.3109/02699052.2014.945959.
10. Nishijima DK, Sena MJ, Galante JM, Shahlaie K, London J, Melnikow J, et al. Derivation of a clinical decision instrument to identify adult patients with mild traumatic intracranial hemorrhage at low risk for requiring ICU admission. Ann Emerg Med. 2014;63(4):448–456.
11. Lessard J, Cournoyer A, Chauny JM, Piette É, Paquet J, Daoust R. Can the “important brain injury criteria” predict neurosurgical intervention in mild traumatic brain injury? A validation study. Am J Emerg Med. 2020;38(3):521–525. doi:10.1016/j.ajem.2019.05.043.
12. Tourigny JN, Paquet V, Fortier É, Malo C, Mercier É, Chauny JM, et al. Predictors of neurosurgical intervention in complicated mild traumatic brain injury patients: a retrospective cohort study. Brain Inj. 2021;35(10):1267–1274. doi:10.1080/02699052.2021.1972147.
13. Yue JK, Upadhyayula PS, Avalos LN, Cage TA, Cooper SR, Dams-O’Connor K, et al. Neuroworsening in the emergency department is a predictor of traumatic brain injury intervention and outcome: a TRACK-TBI pilot study. J Clin Med. 2023;12(5):2024. doi:10.3390/jcm12052024.
14. Joseph B, Obaid O, Dultz L, Gerdik C, Khalil M, Mahmoud A, et al. Validating the Brain Injury Guidelines: results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022;93(2):157–165. doi:10.1097/TA.0000000000003554.
15. Orlando A, Panchal RR, Mellor L, Dhakal L, Hamilton D, Quan G, et al. Risk factors for neurosurgical intervention within 48 hours of admission for patients with mild traumatic brain injury and isolated subdural hematoma. J Neurosurg. 2025;142(2):547–560. doi:10.3171/2024.5.JNS232476.
16. Harnan SE, Pickering A, Pandor A, Goodacre SW. Clinical decision rules for adults with minor head injury: a systematic review. J Trauma. 2011;71(1):245–251. doi:10.1097/TA.0b013e31820d090f.
17. American College of Emergency Physicians Clinical Policies Subcommittee. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with mild traumatic brain injury. Ann Emerg Med. 2023;81(5):e63–e105.
18. Kannan S, Gillespie CS, Lee KS, Phang I, McMahon CJ. Diagnostic utility of Brain Injury Guidelines: systematic review and meta-analysis for prediction of neurosurgical intervention in traumatic brain injury. Brain Inj. 2024;38(13):1093–1100. doi:10.1080/02699052.2024.2375593.
