Risk factors associated with significant posttraumatic brain hemorrhage as per the QueBIC categories: A retrospective multicenter study.

BACKGROUND

Among adults with mild traumatic brain injury (mTBI), only a minority develop clinically significant intracranial hemorrhage requiring neurosurgical intervention or causing death. The Quebec Brain Injury Categories (QueBIC) stratifies risk based on computed tomography (CT) morphology, with complications occurring mainly in moderate/high-risk categories. Identifying pre-CT clinical predictors of these categories could help prioritize imaging and monitoring. We aimed to identify such predictors in complicated mTBI and assess concordance between QueBIC and the Canadian CT Head Rule (CCHR).

METHODS

We conducted a retrospective multicenter cohort study of adults ≥18 years with complicated mTBI (GCS 13-15 plus intracranial hemorrhage and/or skull fracture) who underwent head CT between January 2020 and December 2022. QueBIC categories were assigned from radiology reports by two radiologists and two emergency physicians. Multivariable logistic regression identified independent pre-CT predictors of moderate/high QueBIC risk. Diagnostic performance metrics were estimated, and QueBIC-CCHR concordance was described.

RESULTS

Among 2,253 patients (median age 66.3 y [IQR: 47.9-80.6]; 65.6% male), 42.6% were classified as moderate/high by QueBIC. Antithrombotic medication independently increased the risk of moderate/high QueBIC: antiplatelet therapy, OR: 1.41 (95% CI: 1.06-1.88); anticoagulants, OR: 2.25 (1.40-3.60); and dual therapy, OR: 2.49 (1.11-5.55). Older age was associated with higher risk: 65-74 years, OR: 1.52 (1.11-2.08); ≥75 years, OR: 1.66 (1.24-2.22). Confusion was the strongest clinical correlate, with an OR of 18.67 (13.06-27.33). Suspected skull vault fracture was also associated, OR: 2.09 (1.61-2.72). CCHR frequently assigned high risk where QueBIC remained low or moderate: among CCHR-high patients, 48.5% were QueBIC-low, 36.3% QueBIC-moderate, and 15.2% QueBIC-high. Conversely, among CCHR-low patients, 79.6% were QueBIC-low.

CONCLUSIONS

In complicated mTBI, pre-CT risk per QueBIC is mainly driven by antithrombotic exposure, older age, confusion, and suspected skull fracture. CCHR shows moderate concordance and tends to overestimate risk compared with morphology-based stratification. These findings support using QueBIC-informed pathways to guide imaging and monitoring. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

LEVELS OF EVIDENCE: Prognostic and Epidemiological Study, Level III.