Impact of aspirin use on the modified brain injury guidelines for the management of mild traumatic intracranial hemorrhage

Study objective: The purpose of this study was to determine if pre-injury aspirin use increases the risk of deterioration in isolated mild traumatic intracranial hemorrhage (tICH) patients who might otherwise be safely managed without transfer to a tertiary trauma center. Methods: This was a retrospective observational analysis of isolated mild tICH patients who were transferred to a regional Level I Trauma Center between 2018 and 2023. Data abstracted from the trauma registry and electronic medical record included patient presentation, management, and outcomes. Patients were risk-stratified according to the modified Brain Injury Guidelines (mBIG) criteria, with a new fourth category, mBIG1-asa, which was defined as patients on aspirin who would otherwise be classified as mBIG1. Results: There were 575 patients with isolated mild tICH transferred to the Level I Trauma Center. Median age was 73 years, and fall was the most common mechanism of injury (74.1%). 78 patients (13.6%) were classified as mBIG1, and 47 (8.2%) were classified as mBIG1-asa. No patients in either mBIG1 or mBIG1-asa required neurosurgical intervention or died. One mBIG1-asa patient with a subarachnoid hemorrhage developed a new small focus of hemorrhage on repeat head imaging, however remained minimally symptomatic and was discharged home 4 days later after a brief ICU stay. Conclusion: We propose that the mBIG1 criteria may be expanded to include patients on pre-injury aspirin. Further prospective studies are necessary to demonstrate that these patients may be safely observed without transfer to a regional trauma center.