BACKGROUND: Substantial practice variation exists in the management of children with complicated mild traumatic brain injury (mTBI), defined as a Glasgow Coma Scale score of 13 to 15 with intracranial injury on neuroimaging. Accurate risk stratification can aid clinicians with decisions after intracranial injuries are identified on initial neuroimaging. Our objective was to derive and validate a clinical risk score to predict critical interventions and clinically significant neurologic deterioration in children with complicated mTBI. METHODS: We conducted a 12-center, retrospective, cohort study of children younger than 18 years with complicated mTBI evaluated in participating emergency departments between May 2014 and March 2021. Our primary outcome was a composite of traumatic brain injury–related critical medical or neurosurgical intervention, mortality, and/or clinically important neurologic deterioration within 96 hours of emergency department arrival. We split the sample into 70% derivation and 30% validation cohorts and used multivariable logistic regression β coefficients to weight each clinical and neuroradiographic predictor and generate a clinical risk score. RESULTS: Among 870 children included, 16.4% experienced the primary outcome. Variables included in the final, reduced multivariable model were age 2 years or older, Glasgow Coma Scale (13 or 14 vs. 15), multiple hemorrhages, hemorrhage size ≥5 mm, depressed skull fracture, holohemispheric or chronic-appearing hemorrhage, epidural hemorrhage, mass effect, and high-risk imaging findings (midline shift, herniation, diffuse axonal injury, or diffuse cerebral edema). The area under the curve of the final model was 0.894 (95% confidence interval, 0.849–0.939) in the validation cohort. A clinical risk score of ≤3 was found in 49.6% of the validation cohort, which had a negative predictive value of 96.9 (92.3–99.2). CONCLUSION: We developed and internally validated a clinical risk score that accurately stratifies children with complicated mTBI by risk of critical interventions and deterioration. This tool can aid postneuroimaging decisions in pediatric trauma patients. ( J Trauma Acute Care Surg . 2026;00: 00–00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) LEVEL OF EVIDENCE: Prognostic; Level III.
Chaudhari et al. (Tue,) studied this question.