Modified brain injury guideline (mBIG) - Revision history

Ostermayer: Retarget anticoagulation reversal link to existing page Anticoagulant reversal for life-threatening bleeds

2026-04-28T04:37:31Z

Retarget anticoagulation reversal link to existing page Anticoagulant reversal for life-threatening bleeds

← Older revision		Revision as of 04:37, 28 April 2026
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	===Anticoagulation and antiplatelet considerations===		===Anticoagulation and antiplatelet considerations===
	*Standard mBIG criteria assume no significant coagulopathy; anticoagulated patients require independent coagulopathy assessment and [[anticoagulation reversal]] prior to applying the guideline		*Standard mBIG criteria assume no significant coagulopathy; anticoagulated patients require independent coagulopathy assessment and [[Anticoagulant reversal for life-threatening bleeds\|anticoagulation reversal]] prior to applying the guideline
	*Even mBIG 1 patients on antiplatelet therapy should have a lower threshold for neurosurgical consultation and repeat imaging		*Even mBIG 1 patients on antiplatelet therapy should have a lower threshold for neurosurgical consultation and repeat imaging

Ostermayer: Add explicit Exclusion: not applicable to spontaneous/aneurysmal ICH

2026-04-28T04:10:59Z

Add explicit Exclusion: not applicable to spontaneous/aneurysmal ICH

← Older revision		Revision as of 04:10, 28 April 2026
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	==Exclusion criteria==		==Exclusion criteria==
			*'''Spontaneous (non-traumatic) intracranial hemorrhage''' — mBIG is '''not''' applicable to aneurysmal/spontaneous [[subarachnoid hemorrhage]] or spontaneous [[hemorrhagic stroke\|intracerebral hemorrhage]]
	*GCS <13		*GCS <13
	*Penetrating head trauma		*Penetrating head trauma

Ostermayer at 03:50, 28 April 2026

2026-04-28T03:50:28Z

@@ Line 23: / Line 23: @@
 ==mBIG tiers==
+{{mBig}}
 ==Management==
@@ Line 97: / Line 65: @@
 *[[Elevated intracranial pressure]]
 *[[Clinical decision rules for head CT in trauma]]
 ==References==

Ostermayer at 03:48, 28 April 2026

2026-04-28T03:48:00Z

← Older revision		Revision as of 03:48, 28 April 2026
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	==Background==		==Background==
	The modified Brain Injury Guidelines (mBIG) is a clinical decision tool that stratifies patients with [[mild traumatic brain injury]] and traumatic intracranial hemorrhage on CT into three tiers to guide neurosurgical consultation, ICU admission, and safe discharge decisions. It was derived to reduce unnecessary neurosurgical consultations and ICU admissions without compromising safety in low-risk patients.<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</ref>		The modified Brain Injury Guidelines (mBIG) is a clinical decision tool that stratifies patients with [[mild traumatic brain injury]] and traumatic intracranial hemorrhage on CT into three tiers to guide neurosurgical consultation, ICU admission, and safe discharge decisions. It was derived to reduce unnecessary neurosurgical consultations and ICU admissions without compromising safety in low-risk patients.<ref name="joseph2022">Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</ref>

	*Validated for adults with [[mild traumatic brain injury]] (GCS 13–15) and traumatic intracranial hemorrhage identified on CT		*Validated for adults with [[mild traumatic brain injury]] (GCS 13–15) and traumatic intracranial hemorrhage identified on CT
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	===Repeat imaging===		===Repeat imaging===
	*mBIG 1: Repeat CT generally not required if patient remains neurologically intact and asymptomatic at 4–6 hours<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</~~ref~~>		*mBIG 1: Repeat CT generally not required if patient remains neurologically intact and asymptomatic at 4–6 hours<ref name="joseph2022"/>
	*mBIG 2: Repeat CT at 4–6 hours recommended		*mBIG 2: Repeat CT at 4–6 hours recommended
	*mBIG 3: Repeat CT urgently; neurosurgery to guide imaging cadence		*mBIG 3: Repeat CT urgently; neurosurgery to guide imaging cadence
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	\|}		\|}

	*mBIG 1 patients may be safely discharged with a reliable caregiver and clear return precautions if all clinical parameters remain stable after 4–6 hours of ED observation<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</~~ref~~>		*mBIG 1 patients may be safely discharged with a reliable caregiver and clear return precautions if all clinical parameters remain stable after 4–6 hours of ED observation<ref name="joseph2022"/>

	==See also==		==See also==

Ostermayer: Created mBIG page - clinical decision tool for mild TBI with intracranial hemorrhage

2026-04-28T03:46:44Z

Created mBIG page - clinical decision tool for mild TBI with intracranial hemorrhage

New page

==Background==
The modified Brain Injury Guidelines (mBIG) is a clinical decision tool that stratifies patients with [[mild traumatic brain injury]] and traumatic intracranial hemorrhage on CT into three tiers to guide neurosurgical consultation, ICU admission, and safe discharge decisions. It was derived to reduce unnecessary neurosurgical consultations and ICU admissions without compromising safety in low-risk patients.<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</ref>

*Validated for adults with [[mild traumatic brain injury]] (GCS 13–15) and traumatic intracranial hemorrhage identified on CT
*Originally the Brain Injury Guidelines (BIG) were developed at Banner University Medical Center; the mBIG refined and validated this tool<ref>Joseph B, Aziz H, Pandit V, et al. Prospective validation of the Brain Injury Guidelines: managing traumatic brain injuries without neurosurgical consultation. J Trauma Acute Care Surg. 2014;77(6):984-988. PMID 25423543.</ref>

==Inclusion criteria==
*Adult patient (age ≥18)
*[[Mild traumatic brain injury]] (GCS 13–15)
*Traumatic intracranial hemorrhage on head CT (any of the following):
**[[Subdural hemorrhage]]
**[[Epidural hemorrhage]]
**[[Subarachnoid hemorrhage]]
**[[Traumatic intracerebral hemorrhage]]
**Intraventricular hemorrhage
**Cerebral contusion

==Exclusion criteria==
*GCS <13
*Penetrating head trauma
*Coagulopathy (INR >1.5, platelets <100k, on therapeutic anticoagulation)
*Age <18

==mBIG tiers==

===mBIG 1 (lowest risk)===
All of the following must be true:
*GCS 15
*No loss of consciousness (LOC)
*No [[seizure]]
*No [[vomiting|emesis]]
*Isolated [[subdural hemorrhage|SDH]] ≤4 mm, isolated [[epidural hemorrhage|EDH]] ≤4 mm, isolated [[subarachnoid hemorrhage|tSAH]] ≤4 mm, cerebral contusion ≤2 cm, or intraventricular hemorrhage ≤2 mm
*No herniation or significant mass effect on CT
*Neurologically intact

Disposition: No neurosurgical consultation required; observation in non-monitored setting acceptable; repeat CT imaging not required if clinically stable; may be appropriate for discharge with reliable follow-up.

===mBIG 2 (intermediate risk)===
Meets any of the following (but does not meet mBIG 3 criteria):
*GCS 13–14, OR
*LOC, OR
*Isolated [[seizure]], OR
*Emesis, OR
*CT findings larger than mBIG 1 thresholds but without herniation/significant mass effect

Disposition: Neurosurgical consultation warranted; admission to step-down or monitored unit; repeat head CT in 4–6 hours or per neurosurgical guidance.

===mBIG 3 (highest risk)===
Any of the following:
*GCS <13 (note: if GCS <13, patient may not strictly qualify as "mild TBI" — manage per [[moderate-to-severe traumatic brain injury]] pathway)
*Any herniation on CT
*Significant mass effect (midline shift >5 mm, cisternal effacement)
*Bilateral or mixed intracranial hemorrhage pattern with neurologic decline
*Neurovascular injury identified

Disposition: Emergent neurosurgical consultation; ICU admission; operative intervention frequently required.

==Management==

===Anticoagulation and antiplatelet considerations===
*Standard mBIG criteria assume no significant coagulopathy; anticoagulated patients require independent coagulopathy assessment and [[anticoagulation reversal]] prior to applying the guideline
*Even mBIG 1 patients on antiplatelet therapy should have a lower threshold for neurosurgical consultation and repeat imaging

===Repeat imaging===
*mBIG 1: Repeat CT generally not required if patient remains neurologically intact and asymptomatic at 4–6 hours<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</ref>
*mBIG 2: Repeat CT at 4–6 hours recommended
*mBIG 3: Repeat CT urgently; neurosurgery to guide imaging cadence

===Neurosurgical consultation===
*mBIG 1: Not required
*mBIG 2: Recommended
*mBIG 3: Emergent

==Disposition==

{| class="wikitable"
|-
! Tier !! Neuro consult !! Admission level !! Repeat CT
|-
| mBIG 1 || Not required || Observation or discharge || Not required if stable
|-
| mBIG 2 || Recommended || Step-down/monitored || 4–6 hours
|-
| mBIG 3 || Emergent || ICU || Urgent/per neurosurgery
|}

*mBIG 1 patients may be safely discharged with a reliable caregiver and clear return precautions if all clinical parameters remain stable after 4–6 hours of ED observation<ref>Joseph JM, Shiber JR, Meskill K, Joseph GJ, Sai-Sudhakar CB. Modified Brain Injury Guidelines: A Prospective Study of Safety, Efficacy, and Resource Utilization. J Emerg Med. 2022;63(4):490-498. PMID 36117061.</ref>

==See also==
*[[Head trauma (main)]]
*[[Mild traumatic brain injury]]
*[[Traumatic intracerebral hemorrhage]]
*[[Subdural hemorrhage]]
*[[Epidural hemorrhage]]
*[[Subarachnoid hemorrhage]]
*[[Moderate-to-severe traumatic brain injury]]
*[[Elevated intracranial pressure]]
*[[Clinical decision rules for head CT in trauma]]
*[[Anticoagulation reversal]]

==References==
<references/>

[[Category:Neurology]][[Category:Trauma]][[Category:Radiology]]