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Open Access Research article

Predicting intracranial hemorrhage after traumatic brain injury in low and middle-income countries: A prognostic model based on a large, multi-center, international cohort

Saleena Subaiya1*, Ian Roberts2, Edward Komolafe3 and Pablo Perel2

Author Affiliations

1 Department of Emergency Medicine, New York Presbyterian, New York, NY, USA

2 CRASH Trials Coordinating Center, The London School of Hygiene and Tropical Medicine, London, UK

3 Department of Neurosurgery, Obafemi Awolowo University, Ife Ife, Nigeria

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BMC Emergency Medicine 2012, 12:17  doi:10.1186/1471-227X-12-17

Published: 19 November 2012



Traumatic brain injury (TBI) affects approximately 10 million people annually, of which intracranial hemorrhage is a devastating sequelae, occurring in one-third to half of cases. Patients in low and middle-income countries (LMIC) are twice as likely to die following TBI as compared to those in high-income countries. Diagnostic capabilities and treatment options for intracranial hemorrhage are limited in LMIC as there are fewer computed tomography (CT) scanners and neurosurgeons per patient as in high-income countries.


The Medical Research Council CRASH-1 trial was utilized to build this model. The study cohort included all patients from LMIC who received a CT scan of the brain (nā€‰=ā€‰5669). Prognostic variables investigated included age, sex, time from injury to randomization, pupil reactivity, cause of injury, seizure and the presence of major extracranial injury.


There were five predictors that were included in the final model; age, Glasgow Coma Scale, pupil reactivity, the presence of a major extracranial injury and time from injury to presentation. The model demonstrated good discrimination and excellent calibration (c-statistic 0.71). A simplified risk score was created for clinical settings to estimate the percentage risk of intracranial hemorrhage among TBI patients.


Simple prognostic models can be used in LMIC to estimate the risk of intracranial hemorrhage among TBI patients. Combined with clinical judgment this may facilitate risk stratification, rapid transfer to higher levels of care and treatment in resource-poor settings.

Neurosurgery; Trauma; Developing countries; Intracranial hemorrhage; Traumatic brain injury