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Article

Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury

by
Shin Heon Lee
,
Jong Tae Lee
and
Yong-sook Park
*
Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06973, Republic of Korea
*
Author to whom correspondence should be addressed.
Life 2026, 16(1), 28; https://doi.org/10.3390/life16010028
Submission received: 1 December 2025 / Revised: 22 December 2025 / Accepted: 23 December 2025 / Published: 24 December 2025
(This article belongs to the Section Medical Research)
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Abstract

Background: The prognostic value of preoperative deterioration in older patients with moderate-to-mild traumatic brain injury (TBI) remains unclear. Therefore, this study aimed to evaluate the impact of preoperative neurological and radiological deterioration on clinical outcomes in this population undergoing surgery. Methods: We retrospectively reviewed patients aged ≥ 65 years with moderate-to-mild TBI (Glasgow Coma Scale (GCS) ≥ 9) who underwent surgery between 2013 and 2022. Patients were grouped based on preoperative deterioration, classified as neurological (≥2-point sustained GCS drop lasting more than 1 h) or radiological (new/aggravated imaging lesions). Study outcomes included in-hospital mortality and 6-month functional status. Multivariable logistic regression was performed to identify independent predictors of outcomes. Results: Among 58 patients, preoperative deterioration was observed in 34 (58.6%), including 14 (24.1%) with neurological and 20 (34.5%) with radiological deterioration. In-hospital mortality was significantly higher in patients with neurological deterioration than in those without (57.1% vs. 13.6%; p = 0.002). Radiological deterioration alone was not associated with increased mortality or unfavorable functional outcome at 6 months. Neurological deterioration was an independent predictor of in-hospital death (adjusted odds ratio (OR), 47.9; p = 0.004) and unfavorable 6-month outcome (adjusted OR, 35.0; p = 0.014), whereas radiological deterioration was not. A lower initial GCS was also associated with unfavorable outcomes (adjusted OR, 0.5; p = 0.013). Conclusions: Preoperative neurological deterioration is an independent predictor of in-hospital mortality and unfavorable functional outcome at 6 months in older patients undergoing surgery for moderate-to-mild TBI. These findings underscore clinical neurological decline—not radiologic progression—should guide prognostication and early intervention strategies.

1. Introduction

Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality in the older population [1,2]. The increasing incidence of moderate-to-mild TBI cases requiring neurosurgical intervention in patients aged 65 and older may be related to the aging population and increasing use of antithrombotic agents [3,4,5]. While initial neurological status and radiological findings are established prognostic indicators [6,7,8,9], the prognostic features of TBI in older adults differ from those in younger individuals [10,11].
Meanwhile, older patients presenting with moderate-to-mild TBI—defined by a Glasgow Coma Scale (GCS) score of ≥9, with mild TBI classified as GCS 13–15 and moderate TBI as GCS 9–12—are known to experience worse outcomes, including higher rates of delayed deterioration, prolonged hospitalization, and long-term disability [12,13]. Additionally, the conventional GCS-based classification may inadequately reflect clinical severity in this population, as age-related cerebral atrophy and frequent antithrombotic use can permit substantial intracranial lesion progression despite initially preserved consciousness [14,15]. Consequently, clinicoradiological dissociation may occur, and even those patients initially classified with mild TBI may require neurosurgical intervention if evolving imaging findings demonstrate significant mass effect or if neurological deterioration develops during observation [16]. Overall, the need for surgery in older patients is often determined by the dynamic neurological and radiological course rather than by initial injury severity alone.
Neurological or radiological deterioration during the preoperative period may reflect ongoing secondary injury processes such as hematoma expansion, ischemia, or evolving cerebral edema [17,18,19]. Although prior studies have highlighted the prognostic relevance of early neurological decline and radiological progression in TBI [20,21], the specific impact of these metrics in older patients with moderate-to-mild TBI—particularly those undergoing surgical intervention—remains insufficiently defined. Moreover, the clinical significance of preoperative deterioration—both neurological and radiological—remains underexplored in patients who eventually undergo surgery. Therefore, differentiating between neurological and radiological deterioration may provide further insights into prognostication and surgical decision-making.
Thus, this study aimed to evaluate the impact of preoperative neurological and radiological deterioration on in-hospital mortality and 6-month functional outcome in older patients aged 65 years or older undergoing surgical intervention for moderate-to-mild TBI. The age threshold of 65 years was selected, as this age is commonly used to define a clinically distinct older population [22]. Hence, by distinguishing between neurological and radiological deterioration before surgery, we sought to clarify the independent prognostic relevance of the type of deterioration in this vulnerable group.

2. Materials and Methods

2.1. Study Design and Patient Selection

We retrospectively evaluated a cohort of older patients (aged ≥ 65 years) who underwent neurosurgical intervention for moderate-to-mild TBI at our tertiary referral center between January 2013 and December 2022. Moderate-to-mild TBI was defined as an initial GCS score of 9 or higher upon presentation, as the GCS enables rapid, standardized, and repeated assessment of consciousness and facilitates detection of dynamic neurological deterioration in the acute preoperative period [23]. A total of 58 patients met the inclusion criteria and were included in the final analysis.
Patients were excluded upon meeting any of the following criteria: (1) initial GCS score < 9; (2) death within 72 h of admission; (3) surgical evacuation for epidural hematoma or chronic subdural hematoma; (4) presence of severe concomitant systemic injuries (e.g., major thoracoabdominal trauma requiring surgical intervention or causing hemodynamic instability). Patients who died within 72 h of admission were excluded to focus on perioperative prognostic factors among surgically managed patients and to reduce confounding from early deaths attributable to overwhelming primary injury or non-neurological causes before surgery. Only patients who underwent surgery for acute traumatic intracranial lesions such as subdural hematoma, intracerebral hemorrhage, or contusional hemorrhage were included.
This study was approved by the appropriate Institutional Review Board (IRB No. 2505-007-19573, approval date: 15 May 2025) and was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective nature of the study.

2.2. Neurological and Radiological Monitoring Protocol

Neurological status was continuously assessed using the GCS at hourly intervals from the time of admission to the emergency department. This hourly monitoring protocol was maintained in the intensive care unit and step-down wards by trained nursing staff.
Follow-up brain imaging was performed in accordance with institutional protocol. High-energy trauma was defined as injury mechanisms involving substantial kinetic force, such as motor vehicle collisions or falls from height, whereas low-energy trauma referred to ground-level falls or minor blunt impacts. For patients with high-energy trauma or those receiving antithrombotic therapy, an initial follow-up scan was routinely obtained within 3–6 h after the first emergency imaging, and another scan was performed the following day. In patients with lower-energy trauma who were not receiving antithrombotic therapy, follow-up imaging was conducted on the day after admission. Additional imaging was scheduled for all patients on postoperative days 5–7, or earlier if specific clinical changes, such as new neurological deficits or unexplained neurological deterioration, were observed. This imaging protocol was applied as standard institutional practice throughout the study period. Minor variations in imaging timing occurred in a limited number of cases due to clinical circumstances; however, all patients underwent sufficient preoperative follow-up imaging to evaluate the radiological deterioration. No systematic deviations from the institutional imaging protocol were identified.

2.3. Definition of Preoperative Deterioration

Preoperative deterioration was categorized as neurological or radiological based on clinical examination and neuroimaging findings obtained between emergency department admission and surgery. This definition encompassed both deterioration that occurred during the observation period before the surgical decision and after the decision for surgery, but before the operation. Neurological deterioration was defined as a sustained decrease of ≥2 points in the GCS persisting for more than 1 h, as observed between any two consecutive neurological evaluations, irrespective of setting, including the emergency department, intensive care unit, or ward. Radiological deterioration was defined as either radiographical progression of pre-existing lesions (e.g., hematoma expansion or increased midline shift) or the emergence of new intracranial abnormalities (e.g., new hematoma formation, hydrocephalus, or ischemic lesions) on follow-up computed tomography (CT) or magnetic resonance imaging (MRI) performed before surgery.
Based on these criteria, patients were categorized into three groups according to preoperative deterioration status: no deterioration (n = 24), neurologic deterioration (n = 14), and radiologic deterioration (n = 20). In cases where both neurological and radiological deteriorations were observed, patients were classified into the neurological deterioration group, as neurological deterioration represents a clinically overt manifestation, thereby ensuring mutually exclusive group classification.

2.4. Data Collection

For each patient, we retrospectively collected demographic and clinical data, including age, sex, comorbid conditions (hypertension, diabetes mellitus, cardiac disease, and prior cerebrovascular events), and pre-injury use of antithrombotic agents. Detailed radiological findings on initial brain CT scans were reviewed, including the presence of subdural hemorrhage, intracerebral hemorrhage, subarachnoid hemorrhage, and the Rotterdam CT score. The mechanism of injury was categorized as either high-energy or low-energy. The timing of deterioration was documented for each patient. Information regarding the type of surgical procedure—craniotomy or craniectomy—was also recorded. All data were obtained through a comprehensive review of electronic medical records and imaging archives and were independently verified by two investigators to ensure consistency and accuracy.

2.5. Outcome Measures

The primary outcomes of this study were in-hospital mortality and functional outcome at 6 months following surgery. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) and was dichotomized into favorable (GOS 4–5) and unfavorable (GOS 1–3) categories for analysis. The 6-month time point was selected as it is generally considered to represent a relatively stable phase of neurologic recovery [24], while limiting the influence of aging-related functional decline, comorbidities, and intercurrent events that may confound longer-term outcome assessment in older patients [25]. GOS scores were determined through outpatient clinic follow-up by the clinical staff.

2.6. Statistical Analysis

Statistical analyses were performed using Python software (version 3.8.10; Python Software Foundation, Wilmington, DE, USA). Continuous variables are presented as the mean ± standard deviation or median with interquartile range (IQR), depending on data distribution; categorical variables are expressed as frequencies and percentages. Normality was assessed using the Shapiro–Wilk test, and homogeneity of variances was evaluated using Levene’s test; parametric or nonparametric tests were applied accordingly. Between-group comparisons of continuous variables were performed using Student’s t-test or the Mann–Whitney U test, and categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. Multivariable logistic regression analyses were conducted to identify independent predictors of in-hospital mortality and unfavorable functional outcome at 6 months, with variables selected a priori based on clinical relevance, and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Multicollinearity was assessed using variance inflation factors, and model calibration was evaluated using the Hosmer–Lemeshow goodness-of-fit test. A two-tailed p-value of <0.05 was considered statistically significant.

3. Results

3.1. Patient Characteristics

We analyzed data for 58 older patients with moderate-to-mild TBI who underwent surgical intervention. Among these patients, 34 (58.6%) experienced preoperative neurological and/or radiological deterioration. The mean age was 76.4 ± 6.6 years; 38 patients (65.5%) were male and 20 (34.5%) were female. Baseline characteristics, including age, sex, comorbidities (hypertension, diabetes, cardiac disease, prior stroke), and antithrombotic use, did not significantly differ between patients with and without deterioration (Table 1).
Subdural hemorrhage was the most common radiological finding (75.9%), followed by subarachnoid hemorrhage (39.7%) and intracerebral hemorrhage (24.1%). Subarachnoid hemorrhage was more prevalent in patients with deterioration than in patients without deterioration (50.0% vs. 25.0%), showing a trend toward significance (p = 0.064). The median Rotterdam CT score for the entire cohort was 3.0 (IQR, 2.0–4.0), and did not significantly differ between patients with and without deterioration (3.0 (IQR, 2.0–4.0) vs. 2.0 (IQR, 2.0–3.0); p = 0.176), indicating comparable baseline radiological severity.
High-energy trauma accounted for 13.8% with no significant intergroup difference between patients with and without deterioration (11.8% vs. 16.7%; p = 0.706). Similarly, the initial GCS scores were comparable between patients with and without deterioration (12.0 (IQR, 10.0–14.0) vs. 13.0 (IQR, 12.0–15.0); p = 0.220). Surgical procedures included craniectomy in 36.2% and craniotomy in 63.8% of cases, with no significant difference in surgical modality between patients with and without deterioration (p = 0.414).
Notably, in-hospital mortality was significantly higher among patients with preoperative deterioration (35.3%) than in those without (8.3%; p = 0.028). However, the proportion of patients with unfavorable functional outcomes at 6 months (GOS ≤ 3) was similar in both groups (67.6% vs. 62.5%; p = 0.777). The median interval between hospital arrival and the onset of deterioration (neurological and/or radiological) was 11.9 h (IQR, 5.1–38.0 h). The majority of preoperative deterioration cases (25 of 34, 73.5%) occurred within 24 h of admission, with more than half (18 of 34, 52.9%) developing within the first 12 h.

3.2. Clinical Outcomes According to Deterioration Type

Among the 34 patients with deterioration, 14 (41.2%) exhibited neurological deterioration, while 20 (58.8%) showed radiological deterioration. The outcomes in these subgroups were further analyzed (Table 2).
When stratified by deterioration type, patients with neurological deterioration showed a significantly increased in-hospital mortality rate compared to those without (57.1% vs. 13.6%; p = 0.002). Similarly, an unfavorable outcome at 6 months (GOS ≤ 3) was more frequent in patients with neurological deterioration than in those without (85.7% vs. 54.5%), although this difference did not reach statistical significance (p = 0.057). Radiological deterioration alone was not significantly associated with either in-hospital mortality (p = 0.751) or an unfavorable outcome at 6 months (p = 0.570).
The distribution of the GOS scores at 6 months revealed that none of the patients with neurological deterioration achieved a good recovery (GOS 5), with a higher proportion of mortality or severe disability cases (Figure 1).

3.3. Multivariable Analyses for Clinical Outcomes

In multivariable logistic regression for in-hospital mortality (Table 3; Figure 2), neurologic deterioration emerged as an independent predictor (adjusted OR, 47.9; 95% CI, 3.4–670.9; p = 0.004). Other variables, including age, sex, hypertension, antithrombotic use, Rotterdam CT score, high-energy trauma, initial GCS, and surgical procedure (craniectomy vs. craniotomy), were not independently associated with in-hospital mortality.
In multivariable logistic regression for unfavorable outcome at 6 months (Table 4; Figure 3), neurological deterioration (adjusted OR, 35.0; 95% CI, 2.0–601.7; p = 0.014) and lower preoperative GCS (adjusted OR, 0.5; 95% CI, 0.3–0.9; p = 0.013) were independently associated with worse outcomes. Radiological deterioration did not show significant predictive value for either outcome measure.

4. Discussion

This study demonstrates that preoperative neurologic deterioration is an independent predictor of both in-hospital mortality and unfavorable functional outcome at 6 months in older patients undergoing surgery for moderate-to-mild TBI. In contrast, radiological deterioration without neurological decline was not significantly associated with worse outcomes. These findings suggest that dynamic neurological decline before surgery may serve as a clinically relevant marker of secondary injury progression in this population, even when the initial GCS is relatively preserved.
Previous studies have reported that early neurological decline is associated with poor prognosis in patients with severe TBI [26,27]; however, data focusing specifically on moderate-to-mild TBI in the older surgical population remains limited. Reynolds et al. (2003) highlighted that older patients undergoing anticoagulation therapy may experience rapid neurological deterioration—often within 6 h of injury—despite having an initially normal neurological status [28]. Additionally, a meta-analysis by Marincowitz et al. (2018) examined broader or more heterogeneous TBI populations, estimating an 11.7% risk of clinical deterioration in patients with mild TBI and CT abnormalities [29]. However, the study did not differentiate between types of deterioration and did not focus on older individuals. Our findings build upon and refine these earlier observations by categorizing deterioration based on the type and focusing specifically on a cohort of older individuals undergoing surgery for moderate-to-mild injury. We found that neurological deterioration occurred in 24.1% of patients and was associated with worse mortality and functional outcomes, highlighting the potential prognostic significance of neurological decline.
Lower preoperative GCS scores were independently associated with unfavorable functional outcome at 6 months, reaffirming the prognostic importance of baseline neurological status, as demonstrated in prior studies [30,31]. However, our findings indicate that dynamic neurological deterioration, rather than static GCS measurements alone, provides additional prognostic information. In addition, when comparing results by deterioration status, we found that the initial GCS was similar across deterioration groups, suggesting that the initial GCS was not predictive of deterioration. Although alternative instruments such as the Functional Status Examination or the Disability Rating Scale assess broader disability, these metrics are less suitable for frequent acute bedside monitoring; thus, the use of the GCS reflects our focus on early, dynamic neurological deterioration rather than long-term functional impairment.
Interestingly, isolated radiological progression was not associated with worse outcomes, despite being present in more than one-third of patients. Several pathophysiological and clinical factors may explain the limited prognostic value of radiological deterioration in older patients with TBI; however, these explanations should be regarded as hypothesis-generating rather than definitive. Radiological assessment primarily reflects structural changes, such as hematoma expansion or midline shift, and may not adequately capture dynamic physiologic processes directly related to the neurological outcome, including intracranial pressure dynamics, cerebral perfusion, and metabolic dysfunction. In older adults, age-related cerebral atrophy may further attenuate the association between radiological progression and clinical deterioration by permitting lesion expansion without a proportional increase in intracranial pressure or immediate neurological decline [32]. Consequently, radiological deterioration may represent compensated processes that remain clinically tolerated, whereas neurological deterioration more directly reflects failure of compensatory mechanisms. Prior studies also caution against over-reliance on imaging alone in older patients, especially those with preserved neurological function [16,33].
From a clinical standpoint, our findings emphasize the importance of early and repeated neurological assessments in older patients with TBI, particularly in the preoperative period. Neurological deterioration, even in the absence of radiographic progression, should prompt urgent neurosurgical evaluation, as this decline may represent a critical inflection point in the clinical course of the patient. Reliance on imaging alone may underestimate the extent of the evolving injury, especially in cases with dissociation between the radiological and clinical findings [34]. Conversely, radiological progression without neurological decline warrants more individualized interpretation, particularly in patients with significant reserve capacity from brain atrophy [35]. These results suggest a neurological-centered conceptual framework for older patients with TBI in which dynamic neurological deterioration guides surgical decision-making and subsequent treatment strategies, with radiological findings serving a supportive rather than primary prognostic role.
This study has several limitations. First, our retrospective single-center design may limit generalizability, although findings remained robust after multivariable adjustment. In addition, the relatively small cohort size (n = 58) and imbalance in participant numbers across subgroups may increase statistical uncertainty and the risk of type I error; therefore, the observed associations should be interpreted with caution rather than as definitive. Second, although the definition of deterioration was based on clinical criteria, variability in documentation practices may have introduced inconsistencies in the associated application. Furthermore, our operational definition of radiological deterioration primarily captures acute morphological changes in the brain and may not fully account for delayed secondary injury mechanisms, such as vasospasm. Third, hierarchical classification of patients with combined neurological and radiological deterioration into the neurological group may have attenuated the apparent prognostic effect of isolated radiological deterioration; therefore, the results should be interpreted conservatively.
A further conceptual limitation lies in the decision to restrict the study to patients undergoing surgery. This study aimed to identify prognostic factors among surgically managed older patients with moderate-to-mild TBI; consequently, patients with severe TBI (GCS < 9) or those managed non-surgically were excluded, which limits applicability across the full spectrum of TBI severity and management strategies. Moreover, patients who died within 72 h of admission were excluded to focus on perioperative prognostic factors, which may have introduced survivorship bias, particularly in the mortality analyses.
Despite these limitations, our findings provide preliminary insights that contribute to a more nuanced understanding of TBI in older adults, with a focus on moderate-to-mild injury severity. Specifically, we advocate for evaluating neurological status in addition to relying on radiological findings to guide clinical decision-making and prognostication in older patients undergoing surgical management for moderate-to-mild TBI. Nonetheless, future multicenter prospective studies are warranted to validate and extend these observations.

5. Conclusions

Neurological deterioration is a more important prognostic indicator in older patients undergoing surgery for moderate-to-mild TBI than radiological progression alone. These findings highlight the critical importance of vigilant and continuous neurological assessment in this high-risk population, even when initial GCS scores appear preserved.

Author Contributions

Conceptualization, S.H.L. and Y.-s.P.; Methodology, S.H.L.; Software, S.H.L.; Validation, J.T.L. and Y.-s.P.; Formal Analysis, S.H.L.; Investigation, J.T.L. and Y.-s.P.; Resources, J.T.L. and Y.-s.P.; Data Curation, S.H.L.; Writing—Original Draft Preparation, S.H.L.; Writing—Review and Editing, Y.-s.P.; Visualization, S.H.L.; Supervision, Y.-s.P.; Project Administration, Y.-s.P. All authors have read and agreed to the published version of the manuscript.

Funding

No funding was granted for this study.

Institutional Review Board Statement

This study was approved by the appropriate Institutional Review Board (IRB No. 2505-007-19573, approval date: 15 May 2025) and was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived due to the retrospective nature of the study.

Informed Consent Statement

This type of study does not require informed consent.

Data Availability Statement

The data presented in this study are available from the corresponding author upon request due to privacy concerns.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

TBItraumatic brain injury
GCSGlasgow Coma Scale
CTcomputed tomography
MRImagnetic resonance imaging
GOSGlasgow Outcome Scale
CIconfidence interval
ORodds ratio
SDstandard deviation

References

  1. Ma, Z.; He, Z.; Li, Z.; Gong, R.; Hui, J.; Weng, W.; Wu, X.; Yang, C.; Jiang, J.; Xie, L.; et al. Traumatic brain injury in elderly population: A global systematic review and meta-analysis of in-hospital mortality and risk factors among 2.22 million individuals. Ageing Res. Rev. 2024, 99, 102376. [Google Scholar] [CrossRef]
  2. Thompson, H.J.; McCormick, W.C.; Kagan, S.H. Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. J. Am. Geriatr. Soc. 2006, 54, 1590–1595. [Google Scholar] [CrossRef]
  3. Laic, R.A.G.; Verhamme, P.; Vander Sloten, J.; Depreitere, B. Long-term outcomes after traumatic brain injury in elderly patients on antithrombotic therapy. Acta Neurochir. 2023, 165, 1297–1307. [Google Scholar] [CrossRef]
  4. Jung, I.H.; Yun, J.H.; Kim, S.J.; Chung, J.; Lee, S.K. Anticoagulation and Antiplatelet Agent Resumption Timing following Traumatic Brain Injury. Korean J. Neurotrauma 2023, 19, 298–306. [Google Scholar] [CrossRef] [PubMed]
  5. Haji, K.; Suehiro, E.; Kiyohira, M.; Fujiyama, Y.; Suzuki, M. Effect of Antithrombotic Drugs Reversal on Geriatric Traumatic Brain Injury. No Shinkei Geka. 2020, 48, 497–504. [Google Scholar] [CrossRef]
  6. Liu, C.; Xie, J.; Xiao, X.; Li, T.; Li, H.; Bai, X.; Li, Z.; Wang, W. Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma. Int. J. Med. Sci. 2021, 18, 1639–1647. [Google Scholar] [CrossRef]
  7. Retel Helmrich, I.R.A.; Lingsma, H.F.; Turgeon, A.F.; Yamal, J.M.; Steyerberg, E.W. Prognostic Research in Traumatic Brain Injury: Markers, Modeling, and Methodological Principles. J. Neurotrauma 2021, 38, 2502–2513. [Google Scholar] [CrossRef] [PubMed]
  8. Nasrallah, F.; Bellapart, J.; Walsham, J.; Jacobson, E.; To, X.V.; Manzanero, S.; Brown, N.; Meyer, J.; Stuart, J.; Evans, T.; et al. PREdiction and Diagnosis using Imaging and Clinical biomarkers Trial in Traumatic Brain Injury (PREDICT-TBI) study protocol: An observational, prospective, multicentre cohort study for the prediction of outcome in moderate-to-severe TBI. BMJ Open 2023, 13, e067740. [Google Scholar] [CrossRef] [PubMed]
  9. Hellstrøm, T.; Kaufmann, T.; Andelic, N.; Soberg, H.L.; Sigurdardottir, S.; Helseth, E.; Andreassen, O.A.; Westlye, L.T. Predicting Outcome 12 Months after Mild Traumatic Brain Injury in Patients Admitted to a Neurosurgery Service. Front. Neurol. 2017, 8, 125. [Google Scholar] [CrossRef]
  10. Gardner, R.C.; Dams-O’Connor, K.; Morrissey, M.R.; Manley, G.T. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J. Neurotrauma 2018, 35, 889–906. [Google Scholar] [CrossRef]
  11. Lenell, S.; Nyholm, L.; Lewén, A.; Enblad, P. Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care. Acta Neurochir. 2019, 161, 1243–1254. [Google Scholar] [CrossRef]
  12. LeBlanc, J.; de Guise, E.; Gosselin, N.; Feyz, M. Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury. Brain Inj. 2006, 20, 779–790. [Google Scholar] [CrossRef]
  13. Yamagami, K.; Kurogi, R.; Kurogi, A.; Nishimura, K.; Onozuka, D.; Ren, N.; Kada, A.; Nishimura, A.; Arimura, K.; Ido, K.; et al. The Influence of Age on the Outcomes of Traumatic Brain Injury: Findings from a Japanese Nationwide Survey (J-ASPECT Study-Traumatic Brain Injury). World Neurosurg. 2019, 130, e26–e46. [Google Scholar] [CrossRef] [PubMed]
  14. Garza, N.; Toussi, A.; Wilson, M.; Shahlaie, K.; Martin, R. The increasing age of TBI patients at a single level 1 trauma center and the discordance between GCS and CT Rotterdam scores in the elderly. Front. Neurol. 2020, 11, 112. [Google Scholar] [CrossRef]
  15. Scotti, P.; Séguin, C.; Lo, B.W.Y.; de Guise, E.; Troquet, J.M.; Marcoux, J. Antithrombotic agents and traumatic brain injury in the elderly population: Hemorrhage patterns and outcomes. J. Neurosurg. 2020, 133, 486–495. [Google Scholar] [CrossRef]
  16. Coffeng, S.M.; Foks, K.A.; van den Brand, C.L.; Jellema, K.; Dippel, D.W.J.; Jacobs, B.; van der Naalt, J. Evaluation of Clinical Characteristics and CT Decision Rules in Elderly Patients with Minor Head Injury: A Prospective Multicenter Cohort Study. J. Clin. Med. 2023, 12, 982. [Google Scholar] [CrossRef]
  17. Guan, J.; Hawryluk, G.W. Targeting Secondary Hematoma Expansion in Spontaneous Intracerebral Hemorrhage—State of the Art. Front. Neurol. 2016, 7, 187. [Google Scholar] [CrossRef]
  18. Lord, A.S.; Gilmore, E.; Choi, H.A.; Mayer, S.A. Time course and predictors of neurological deterioration after intracerebral hemorrhage. Stroke 2015, 46, 647–652. [Google Scholar] [CrossRef]
  19. Ziai, W.C.; Badihian, S.; Ullman, N.; Thompson, C.B.; Hildreth, M.; Piran, P.; Montano, N.; Vespa, P.; Martin, N.; Zuccarello, M.; et al. Hemorrhage Expansion Rates Before and After Minimally Invasive Surgery for Intracerebral Hemorrhage: Post Hoc Analysis of MISTIE II/III. Stroke Vasc. Interv. Neurol. 2024, 4, e001165. [Google Scholar] [CrossRef]
  20. Podell, J.; Yang, S.; Miller, S.; Felix, R.; Tripathi, H.; Parikh, G.; Miller, C.; Chen, H.; Kuo, Y.M.; Lin, C.Y.; et al. Rapid prediction of secondary neurologic decline after traumatic brain injury: A data analytic approach. Sci. Rep. 2023, 13, 403. [Google Scholar] [CrossRef] [PubMed]
  21. Alcock, S.; Batoo, D.; Ande, S.R.; Grierson, R.; Essig, M.; Martin, D.; Trivedi, A.; Sinha, N.; Leeies, M.; Zeiler, F.A.; et al. Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): Protocol for a prospective cohort study. BMJ Open 2021, 11, e047305. [Google Scholar] [CrossRef]
  22. Orimo, H.; Ito, H.; Suzuki, T.; Araki, A.; Hosoi, T.; Sawabe, M. Reviewing the definition of “elderly”. Geriatr. Gerontol. Int. 2006, 6, 149–158. [Google Scholar] [CrossRef]
  23. Teasdale, G.; Jennett, B. Assessment of coma and impaired consciousness: A practical scale. Lancet 1974, 2, 81–84. [Google Scholar] [CrossRef]
  24. Kwakkel, G.; Kollen, B.; Lindeman, E. Understanding the pattern of functional recovery after stroke: Facts and theories. Restor. Neurol. Neurosci. 2004, 22, 281–299. [Google Scholar] [CrossRef]
  25. Koroukian, S.M.; Warner, D.F.; Owusu, C.; Given, C.W. Multimorbidity redefined: Prospective health outcomes and the cumulative effect of co-occurring conditions. Prev. Chronic Dis. 2015, 12, E55. [Google Scholar] [CrossRef] [PubMed]
  26. McCredie, V.A.; Chavarría, J.; Baker, A.J. How do we identify the crashing traumatic brain injury patient—The intensivist’s view. Curr. Opin. Crit. Care 2021, 27, 320–327. [Google Scholar] [CrossRef] [PubMed]
  27. Wang, S.; Wang, R.; Han, C.; Hu, H.; Sun, H. Development and validation of a nomogram for predicting early neurological deterioration in patients with moderate traumatic brain injury: A retrospective analysis. Front. Neurol. 2025, 16, 1512125. [Google Scholar] [CrossRef]
  28. Reynolds, F.D.; Dietz, P.A.; Higgins, D.; Whitaker, T.S. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J. Trauma. 2003, 54, 492–496. [Google Scholar] [CrossRef]
  29. Marincowitz, C.; Lecky, F.E.; Townend, W.; Borakati, A.; Fabbri, A.; Sheldon, T.A. The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis. J. Neurotrauma 2018, 35, 703–718. [Google Scholar] [CrossRef]
  30. Marmarou, A.; Lu, J.; Butcher, I.; McHugh, G.S.; Murray, G.D.; Steyerberg, E.W.; Mushkudiani, N.A.; Choi, S.; Maas, A.I. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: An IMPACT analysis. J. Neurotrauma 2007, 24, 270–280. [Google Scholar] [CrossRef] [PubMed]
  31. Husson, E.C.; Ribbers, G.M.; Willemse-van Son, A.H.; Verhagen, A.P.; Stam, H.J. Prognosis of six-month functioning after moderate to severe traumatic brain injury: A systematic review of prospective cohort studies. J. Rehabil. Med. 2010, 42, 425–436. [Google Scholar] [CrossRef] [PubMed]
  32. Depreitere, B.; Becker, C.; Ganau, M.; Gardner, R.C.; Younsi, A.; Lagares, A.; Marklund, N.; Metaxa, V.; Muehlschlegel, S.; Newcombe, V.F.J.; et al. Unique considerations in the assessment and management of traumatic brain injury in older adults. Lancet Neurol. 2025, 24, 152–165. [Google Scholar] [CrossRef] [PubMed]
  33. Karibe, H.; Hayashi, T.; Narisawa, A.; Kameyama, M.; Nakagawa, A.; Tominaga, T. Clinical Characteristics and Outcome in Elderly Patients with Traumatic Brain Injury: For Establishment of Management Strategy. Neurol. Med. Chir. 2017, 57, 418–425. [Google Scholar] [CrossRef] [PubMed]
  34. Wu, X.; Kirov, I.I.; Gonen, O.; Ge, Y.; Grossman, R.I.; Lui, Y.W. MR Imaging Applications in Mild Traumatic Brain Injury: An Imaging Update. Radiology 2016, 279, 693–707. [Google Scholar] [CrossRef]
  35. Ross, M.; Pang, P.S.; Raslan, A.M.; Selden, N.R.; Cetas, J.S. External retrospective validation of Brain Injury Guidelines criteria and modified guidelines for improved care value in the management of patients with low-risk neurotrauma. J. Neurosurg. 2020, 133, 1880–1885. [Google Scholar] [CrossRef]
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Figure 1. Distribution of 6-month Glasgow Outcome Scale (GOS) by type of preoperative deterioration. Stacked horizontal bar chart of the distribution of 6-month GOS categories according to preoperative deterioration type. Functional outcomes are displayed as proportions within each group.
Figure 1. Distribution of 6-month Glasgow Outcome Scale (GOS) by type of preoperative deterioration. Stacked horizontal bar chart of the distribution of 6-month GOS categories according to preoperative deterioration type. Functional outcomes are displayed as proportions within each group.
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Figure 2. Forest plot of predictors for in-hospital mortality. Adjusted ORs with 95% CIs from multivariable logistic regression are shown. ORs are plotted on a logarithmic scale; a two-tailed p < 0.05 was considered statistically significant.
Figure 2. Forest plot of predictors for in-hospital mortality. Adjusted ORs with 95% CIs from multivariable logistic regression are shown. ORs are plotted on a logarithmic scale; a two-tailed p < 0.05 was considered statistically significant.
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Figure 3. Forest plot of predictors for unfavorable functional outcome (GOS ≤ 3) at 6 months. Adjusted ORs with 95% CIs from multivariable logistic regression are shown. ORs are plotted on a logarithmic scale; a two-tailed p < 0.05 was considered statistically significant.
Figure 3. Forest plot of predictors for unfavorable functional outcome (GOS ≤ 3) at 6 months. Adjusted ORs with 95% CIs from multivariable logistic regression are shown. ORs are plotted on a logarithmic scale; a two-tailed p < 0.05 was considered statistically significant.
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Table 1. Baseline characteristics of patients with and without preoperative deterioration.
Table 1. Baseline characteristics of patients with and without preoperative deterioration.
VariableTotal (n = 58)No Deterioration (n = 24)Deterioration (n = 34)p-Value
Age76.4 ± 6.676.1 ± 6.876.7 ± 6.50.750
Male sex38 (65.5)17 (70.8)21 (61.8)0.579
Hypertension34 (58.6)13 (54.2)21 (61.8)0.598
Diabetes mellitus16 (27.6)6 (25.0)10 (29.4)0.773
Cardiac disease7 (12.1)1 (4.2)6 (17.6)0.221
Prior stroke8 (13.8)1 (4.2)7 (20.6)0.123
Antithrombotic use17 (29.3)6 (25.0)11 (32.4)0.575
Initial radiological findings    
 Subdural hemorrhage44 (75.9)21 (87.5)23 (67.6)0.121
 Intracerebral hemorrhage14 (24.1)6 (25.0)8 (23.5)1.000
 Subarachnoid hemorrhage23 (39.7)6 (25.0)17 (50.0)0.064
 Rotterdam CT score3.0 (2.0–4.0)3.0 (2.0–4.0)2.0 (2.0–3.0)0.176
High-energy trauma8 (13.8)4 (16.7)4 (11.8)0.706
Preoperative initial GCS13.0 (11.0–14.8)12.0 (10.0–14.0)13.0 (12.0–15.0)0.220
Surgical procedure   0.414
 Craniectomy21 (36.2)7 (29.2)14 (41.2) 
 Craniotomy37 (63.8)17 (70.8)20 (58.8) 
In-hospital death14 (24.1)2 (8.3)12 (35.3)0.028
Unfavorable GOS at 6 months38 (65.5)15 (62.5)23 (67.6)0.777
Time interval to deterioration, h  11.9 (5.1–38.0) 
 Deterioration ≤ 24 h  25 (73.5) 
 Deterioration ≤ 12 h  18 (52.9) 
Data are presented as the mean ± standard deviation, median (IQR), or proportion (%). Continuous variables were compared using Student’s t-test or the Mann–Whitney U test, and categorical variables using the chi-square test or Fisher’s exact test, as appropriate; a two-tailed p < 0.05 was considered statistically significant. GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale.
Table 2. Association between deterioration type and clinical outcomes.
Table 2. Association between deterioration type and clinical outcomes.
OutcomeNeurological Deteriorationp-ValueRadiological Deteriorationp-Value
No (n = 44)Yes (n = 14)No (n = 38)Yes (n = 20)
In-hospital death6 (13.6)8 (57.1)0.00210 (26.3)4 (20.0)0.751
Unfavorable GOS24 (54.5)12 (85.7)0.05725 (65.8)11 (55.0)0.570
Among patients with preoperative deterioration, outcomes were compared according to deterioration type (neurological vs. radiological). Outcomes are presented as proportions (%) and were compared using the chi-square test or Fisher’s exact test, as appropriate; a two-tailed p-value < 0.05 was considered statistically significant. GOS, Glasgow Outcome Scale.
Table 3. Multivariable logistic regression for in-hospital mortality.
Table 3. Multivariable logistic regression for in-hospital mortality.
OutcomeVariableβAdjusted OR (95% CI)p-Value
In-hospital deathAge0.041.0 (0.9–1.2)0.623
 Male sex0.241.3 (0.2–8.8)0.806
 Hypertension−2.290.1 (0.0–1.2)0.072
 Antithrombotic use−0.140.9 (0.1–5.5)0.884
 Rotterdam CT score0.121.1 (0.5–2.8)0.797
 High-energy trauma1.785.9 (0.8–45.0)0.084
 Preoperative initial GCS−0.200.8 (0.5–1.4)0.434
 Craniectomy2.229.2 (0.7–115.0)0.084
 Neurological deterioration3.8747.9 (3.4–670.9)0.004
 Radiological deterioration1.193.3 (0.4–27.1)0.269
A two-tailed p < 0.05 was considered statistically significant. GCS, Glasgow Coma Scale; OR, odds ratio; CI, confidence interval.
Table 4. Multivariable logistic regression for unfavorable outcome.
Table 4. Multivariable logistic regression for unfavorable outcome.
OutcomeVariableβAdjusted OR (95% CI)p-Value
Unfavorable GOSAge0.101.1 (1.0–1.3)0.092
 Male sex1.755.8 (0.9–36.3)0.061
 Hypertension−0.700.5 (0.1–2.6)0.406
 Antithrombotic use0.802.2 (0.4–12.7)0.367
 Rotterdam CT score0.201.2 (0.6–2.5)0.591
 High-energy trauma−0.360.7 (0.1–4.9)0.721
 Preoperative initial GCS−0.620.5 (0.3–0.9)0.013
 Craniectomy0.902.4 (0.4–13.6)0.305
 Neurological deterioration3.5635.0 (2.0–601.7)0.014
 Radiological deterioration0.101.1 (0.2–5.3)0.901
A two-tailed p < 0.05 was considered statistically significant. GCS, Glasgow Coma Scale; GOS, Glasgow Outcome Scale; OR, odds ratio; CI, confidence interval.
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Lee, S.H.; Lee, J.T.; Park, Y.-s. Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury. Life 2026, 16, 28. https://doi.org/10.3390/life16010028

AMA Style

Lee SH, Lee JT, Park Y-s. Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury. Life. 2026; 16(1):28. https://doi.org/10.3390/life16010028

Chicago/Turabian Style

Lee, Shin Heon, Jong Tae Lee, and Yong-sook Park. 2026. "Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury" Life 16, no. 1: 28. https://doi.org/10.3390/life16010028

APA Style

Lee, S. H., Lee, J. T., & Park, Y.-s. (2026). Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury. Life, 16(1), 28. https://doi.org/10.3390/life16010028

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