Does pneumocephalus affect the application of the pediatric brain injury guidelines?

BACKGROUND: The pediatric brain injury guidelines (kBIG) are a newly established clinical triage tool for managing pediatric traumatic brain injuries (TBIs). However, the kBIG classification does not include pneumocephalus, raising uncertainty about how to classify and manage patients with this finding. In this study, we sought to determine the risk of neurosurgical intervention, injury progression, and intensive care unit (ICU) admission in children with low- to moderate-risk TBIs and pneumocephalus. METHODS: We conducted a retrospective cohort study of pediatric trauma patients (younger than 18 years) after blunt mechanism trauma with an Abbreviated Injury Scale head score of >1 treated at a level 1 pediatric trauma center between January 2018 and April 2024. We applied the kBIG criteria to this cohort and excluded kBIG3 patients from the analysis. Demographics, presence of pneumocephalus, injury type, repeat head computed tomography, and neurosurgical intervention were extracted. Progression was defined as new or worsening bleed on repeat computed tomography. Neurosurgical treatment was defined as any operative intervention performed by a neurosurgeon. RESULTS: We included 832 pediatric trauma patients classified as kBIG0, kBIG1, and kBIG2 TBIs. Pneumocephalus was present in 143 patients (18.1%). There was no significant difference in neurosurgical intervention rates (0.2% vs. 0.7%; p = 0.5), injury progression (12% vs. 9.8%; p = 0.7), ICU admission 8.1% vs. 9.7%; p = 0.5), or ICU length of stay (1 [1-1] vs. 1 [1-1], p = 0.7) between patients with and without pneumocephalus. CONCLUSION: In this study, we found that pneumocephalus is an uncommon finding in low- to moderate-risk blunt head injuries. Patients with pneumocephalus had no increased risk of neurosurgical treatment or injury progression compared with those without. These findings suggest that pneumocephalus does not confer additional clinical risk and may be safely excluded from consideration when applying the kBIG classification to guide management in otherwise low- to moderate-risk patients. ( J Trauma Acute Care Surg . 2026;101: 437-441. Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.