Optimizing Traumatic Brain Injury Care Without Neurosurgeons: External Validation of the Brain Injury Guidelines in a Resource-Limited Trauma System

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.