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We present a Bayesian network that predicts the probability of neurosurgical intervention after injury in children and adolescents using immediately available data upon hospital arrival. #tbi #pedsurgbestsurg @peditraumasoc @docsulli92; @childrensnatl; @vcugensurgres; @vcu_surgery; @childrenscolo BACKGROUND Timely surgical decompression improves functional outcomes and survival among children with traumatic brain injury and increased intracranial pressure. Previous scoring systems for identifying the need for surgical decompression after traumatic brain injury in children and adults have had several barriers to use. These barriers include the inability to generate a score with missing data, a requirement for radiographic imaging that may not be immediately available, and limited accuracy. To address these limitations, we developed a Bayesian network to predict the probability of neurosurgical intervention among injured children and adolescents (aged 1–18 years) using physical examination findings and injury characteristics observable at hospital arrival. METHODS We obtained patient, injury, transportation, resuscitation, and procedure characteristics from the 2017 to 2019 Trauma Quality Improvement Project database. We trained and validated a Bayesian network to predict the probability of a neurosurgical intervention, defined as undergoing a craniotomy, craniectomy, or intracranial pressure monitor placement. We evaluated model performance using the area under the receiver operating characteristic and calibration curves. We evaluated the percentage of contribution of each input for predicting neurosurgical intervention using relative mutual information (RMI). RESULTS The final model included four predictor variables, including the Glasgow Coma Scale score (RMI, 31.9%), pupillary response (RMI, 11.6%), mechanism of injury (RMI, 5.8%), and presence of prehospital cardiopulmonary resuscitation (RMI, 0.8%). The model achieved an area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI], 0.89–0.91) and had a calibration slope of 0.77 (95% CI, 0.29–1.26) with a y intercept of 0.05 (95% CI, −0.14 to 0.25). CONCLUSION We developed a Bayesian network that predicts neurosurgical intervention for all injured children using four factors immediately available on arrival. Compared with a binary threshold model, this probabilistic model may allow clinicians to stratify management strategies based on risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.