Highlight
- Patients with mild traumatic brain injury (TBI) and small intracranial hemorrhages are often transferred to higher-level trauma centers despite low intervention rates.
- A retrospective cohort study showed that selected mild TBI patients could be safely managed locally at level III trauma centers using standardized monitoring protocols.
- No locally managed patients required neurosurgical intervention, with similar mortality and shorter hospital stays compared to transferred patients.
- This supports risk-based transfer protocols, reducing unnecessary strain on level I centers and aligning with updated regional trauma system standards.
Study Background
Mild traumatic brain injury (Glasgow Coma Scale [GCS] scores 14-15) with traumatic intracranial hemorrhage presents a frequent clinical dilemma in trauma systems, particularly in regions where level III and IV trauma centers lack on-site neurosurgical coverage. Traditionally, many patients with such injuries are transferred to higher-level trauma centers (level I) for close monitoring and possible neurosurgical intervention. However, these transfers often place a logistical and financial burden on patients and healthcare systems despite the generally low risk of neurological deterioration and the rarity of operative interventions in this subgroup. Recognizing which patients can be safely managed locally is paramount for efficient trauma care resource utilization and avoiding unnecessary patient transfers.
Study Design
This retrospective cohort study included adult patients treated from 2015 to 2025 with isolated mild TBI (GCS 14-15) and traumatic intracranial hemorrhage. Patients met strict clinical and radiographic inclusion criteria designed to identify low-risk hemorrhages suitable for conservative management. Two cohorts were evaluated: (1) patients managed locally at a level III trauma center using a standardized monitoring and escalation protocol, and (2) patients transferred to a regional level I trauma center following standard practice. Primary outcomes included rates of neurosurgical intervention and in-hospital mortality. Secondary outcomes included length of hospital stay and discharge disposition.
Key Findings
A total of 335 patients were analyzed—48 managed at the level III center and 287 transferred to level I centers. Importantly, none of the locally managed patients required neurosurgical intervention, whereas only one transferred patient (0.4%) required surgery. In-hospital mortality was nearly identical between groups (2.1% in level III vs 2.2% in level I centers). Median hospital length of stay was 2 days for both cohorts. Notably, a greater proportion of the local management group were discharged directly home (81.3%) compared to transferred patients (72.5%).
The standardized protocol at the level III center included close neurological monitoring with predefined escalation criteria, ensuring that any clinical changes prompting neurosurgical evaluation triggered immediate transfer if needed. This risk-adapted approach preserved patient safety while minimizing potentially unnecessary transfers.
Expert Commentary
This study provides compelling real-world evidence supporting risk-stratified management strategies in mild TBI with intracranial hemorrhage. It challenges the paradigm that all such patients require transfer to level I centers, especially when strict clinical and imaging criteria are applied for local care suitability. The findings highlight the capacity of level III centers to safely monitor select patients under a structured protocol, which may result in cost savings, enhanced patient convenience, and more efficient trauma system utilization.
However, the study’s retrospective design and single regional system may limit generalizability. Future prospective studies could strengthen evidence for protocol standardization and clarify the subsets of patients who would most benefit from local management. Additionally, the implementation of tele-neurosurgery consultations might further enhance decision-making in rural or resource-limited settings.
Conclusion
Selective local management of patients with isolated mild traumatic brain injury and traumatic intracranial hemorrhage is feasible and safe, with comparable outcomes to transfer to higher-level trauma centers. This approach can reduce unnecessary patient transfers, alleviate resource burdens on level I centers, and comply with updated trauma system policies such as those from the Pennsylvania Trauma Systems Foundation. Refining risk-based transfer criteria extends benefits across clinical, operational, and economic domains, promoting patient-centered trauma care.
Ongoing research to validate these protocols in diverse settings and incorporate emerging technologies is necessary to optimize mild TBI pathways further.
Funding and ClinicalTrials.gov
The study was supported by institutional funds from participating trauma centers. Specific funding details were not provided. The study was retrospective without registered clinical trial identifiers.
References
- German A, White K, Broadwin M, et al. Safe local management of mild traumatic brain injury: Reducing unnecessary transfers to higher-level trauma centers. Surgery. 2026 Jun 8;197:110372. PMID: 42361533.
- Stein SC, Georgoff P, Meghan S, et al. Mild traumatic brain injury: pathophysiology and clinical management. Neurosurg Focus. 2015;38(2): E5.
- Ditty BJ, Rivera S, Locke CJ, et al. Neurosurgical consultations and mild traumatic brain injuries: Reducing unnecessary transfers. Am J Emerg Med. 2019 Jul;37(7):1191-1195.
- Pennsylvania Trauma Systems Foundation. 2024 Update: Guidelines for Trauma Care Levels III and IV. Available at: https://www.ptsf.org/standards (accessed June 2026).
