Original

Predictors of Mortality in Neurosurgical Patients After Traumatic Brain

Injury
Preditores de Mortalidade em Pacientes Neurocirúrgicos Após Trauma Cranioencefálico

Bruno Bastos Godoi1

Silvio Pereira Ramos Junior2
Pedro Henrique Scheidt Figueiredo3
Henrique Silveira Costa4
Samara Barroso de Figueiredo5
Lucas Mendes Melo5
Márcio Guilherme Leite Verssiane5
Pedro Lorentz Ribeiro Innecco5

ABSTRACT
Introduction: Traumatic brain injury (TBI) is considered a relevant worldwide cause of mortality and morbidity. Objective: To
evaluate independent factors at hospital admission and during hospitalization that predicts in-hospital mortality in patients with TBI
submitted to neurosurgery. Methods: Retrospective cohort analyzed data of patients that underwent neurosurgery due to the TBI.
Evaluated predictor factors were age, gender, Glasgow Coma Scale (GCS) at admission, sequels before and after neurosurgery, trauma
mechanism, and neurosurgical procedure. The survival analyses were verified. Positive and negative predictive values were calculated.
Results: A total of 312 patients were analyzed, majority male (81.4%) with mild TBI (55.8%), and mean age of 49.6 ± 23.5 years.
GCS at admission was an independent predictor of mortality (HR = 0.87; 95% CI: 0.81 to 0.93; p < 0.001). The GCS ≤ 13 was the
optimal cut-off value to predict survival with a significant difference between GCS groups (≤13 or >13; p<0.001). Patients with GCS
≤ 13 had a six times greater risk of mortality (HR 6.04; 95 CI 2.39 to 15.3; p<0.001). The positive and negative predictive values were
35.8% and 97%, respectively. Conclusions: The GCS in admission is an important predictor of in-hospital mortality in TBI patients
that need a neurosurgical procedure.
Keywords: Brain Injuries, Traumatic; Neurosurgery; Glasgow Coma Scale; Survival Analysis

RESUMO
Introdução: O traumatismo cranioencefálico (TCE) é considerado importante causa mundial de mortalidade e morbidade. Objetivo:
Avaliar de forma independente os fatores na admissão hospitalar e durante a internação que predizem mortalidade intra-hospitalar
em pacientes com TCE submetidos a neurocirurgia. Métodos: Coorte retrospectiva com análise de dados de pacientes submetidos à
neurocirurgia devido ao TCE. Os fatores preditores avaliados foram idade, sexo, Escala de Coma de Glasgow (ECG) na admissão,
sequelas antes e depois da neurocirurgia, mecanismo de trauma e procedimento neurocirúrgico. As análises de sobrevivência foram
verificadas. Valores preditivos positivos e negativos foram calculados. Resultados: Foram analisados 312 pacientes, a maioria do
sexo masculino (81,4%) com TCE leve (55,8%), e com média de idade de 49,6 ± 23,5 anos. A ECG na admissão foi um preditor
independente de mortalidade (HR = 0,87; IC 95%: 0,81 a 0,93; p <0,001). O GCS ≤ 13 foi o valor de corte ideal para prever a
sobrevivência com uma diferença significativa entre os grupos ECG (≤13 ou> 13; p <0,001). Pacientes com ECG ≤ 13 tiveram risco
seis vezes maior de mortalidade (HR 6,04; IC95 2,39 a 15,3; p <0,001). Os valores preditivos positivo e negativo foram 35,8% e
97%, respectivamente. Conclusões: A ECG na admissão é importante preditor de mortalidade hospitalar em pacientes com TCE que
necessitam de procedimento neurocirúrgico.

Palavras-chave: Lesões cerebrais traumáticas; Neurocirurgia; Escala de Coma de Glasgow; Análise de sobrevivência

Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane MGL, J Bras Neurocirur 32 (4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
 Original

1
MD, Faculty of Medicine, Federal University of Jequitinhonha’s Valley and Mucuri, Diamantina, Brazil
2
MD, PhD. Faculty of Medicine, Federal University of Jequitinhonha’s Valley and Mucuri, Diamantina, Brazil
3
PhD. Postgraduate Program in Rehabilitation and Functional Performance, Physical Therapy School, Federal University of Jequitinhonha’s Valley and Mucuri, Diamantina, Brazil
4
PhD. Postgraduate Program in Rehabilitation and Functional Performance, Physical Therapy School, Federal University of Jequitinhonha’s Valley and Mucuri, Diamantina, Brazil
5
Faculty of Medicine, Federal University of Jequitinhonha’s Valley and Mucuri, Diamantina, Brazil

Received Aug 13, 2020

Corrected Oct 13, 2021
Accepted Oct 15, 2021

The TBI severity index is determined by the Glasgow Coma

INTRODUCTION Scale (GCS), which is based on the analysis of 4 indicators: 1)
Eye response; 2) Verbal response; 3) Motor response and 4)
Pupilar Activity. These indicators are evaluated independently
Traumatic brain injury (TBI) is considered a relevant and the final score reflects the functional state of the brain.
worldwide cause of mortality and morbidity. TBI is The sum of the four GCS indicators ranges from 1 to 15
understood as any aggression of a traumatic order that results points. Scores from 3 to 8 indicate severe TBI; from 9 to 12,
in anatomical injury or functional compromise of the scalp, moderate; and 13 to 15, mild11–14. Severe TBI is associated with
skull, meninges, encephalon, or vessels1–3. The definitive lesson a mortality rate of 30% to 70%. The prognosis is marked by
that is established after the TBI is the result of the interaction severe neurological sequels and poor quality of life15.
between the so-called primary lesions (those occurring at
the time of trauma) and secondary changes that begin with Therefore, due to the important clinical meaning, the scarcity
the accident and last for days to weeks 3. It primarily affects of data in the scientific literature, and the growing need for
individuals economically active, specially males1,4,5, with specific epidemiological survival policies for neurotrauma in
negative personal impact and high expenditures for health low and middle-income countries, the present study aimed
systems. In teenagers and young adults, vehicle accidents are to evaluate the independent factors that predict mortality in-
the most common causes of TBI. Falls represent the second hospital of patients with TBI.
major cause and are more common in the pediatric and
geriatric ranges. In some places, gunshot injuries cause more
METHOD
TBI than car accidents 6,7.

The worldwide incidence of TBI is about 200 per 100 Study Design
thousand inhabitants, with a mortality of 20 per 100 thousand This study was a retrospective cohort study to establish the
inhabitants 4. In the United States, the estimated incidence is independent predictors of mortality in-hospital in TBI
538 per 100,000 inhabitants. When only mild and moderate patients undergoing neurosurgery intervention. The data
cases of TBI were considered (75% of the total), lead to a from 2010 to 2018 of TBI patients attended at a reference of
government expenditure of about 17 billion dollars a year 4. In neurosurgery center were recorded. The STROBE statement
Europe, the incidence is 235 per 100,000 individuals 5,8,9. was used as a guide to report this study and the study methods
and results are reported according to the REMARK checklist.
In countries of Latin America, including Brazil, studies are The study protocol was following the Declaration of Helsinki
scarce. Data from DATASUS from 2008 to 2012 indicate about and was approved by the Research Ethics Committee (protocol
125,500 hospital admissions per year associated with TBI in 82249418.9.0000.5108). The need for obtaining informed
the country, with an incidence of 65.7 hospital admissions consent was waived because of the retrospective nature of the
per 100,000 habitants per year, with 9,715 deaths, which study.
corresponds to a mortality rate of about 5.1 per 100 thousand
inhabitants per year (7.7% of the cases). Only data on in- Participants
hospital mortality from TBI are available in the DATASUS Patients with TBI who needed a neurosurgical procedure
database, so there is no inclusion of pre-admission mortality due to the trauma were included, independently the trauma
rates 1,10. mechanism, sex, age or GCS at the arrival, between January

Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane MGL, J Bras Neurocirur 32 (4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
 Original

2010 and December 2018. Patients without all data were The optimal cut-off considered was the value with the best
excluded. combination of sensitivity and specificity to predict death,
determined by the Youden index. The cut-off value was used
Preoperative and postoperative data in the Kaplan-Meier curve. Positive and negative predictive
Data were collected at the book of the surgery room, with values were calculated.
patient’s information about the clinical issue and procedure
to be performed. Date of TBI, age, gender, city of provenance,
surgery procedure applied, the total length of stay in-hospital
and at intensive unit care, and sequel after or post neurosurgical RESULTS
procedure were recorded. After that, the missing information
was collected from the medical records and the hospital
Among 353 selected patients, 41 were excluded due to the absence of data. Thus, the s
registry system. The investigators were blinded to the results. Among 353 selected patients, 41 were excluded due to the
absence
was composited of data.
of 312 Thus,
patients the 1),
(table sample was 312ofpatients
the majority (Tableand
young adults 1), males (8
Outcome measurement the majority of young adults and males (81.4%). The mean
The analyzed outcomes were GCS and respiratory rateThe onmean value
valueofofthe
theGCS
GCSononadmission
admissionwaswas14 ±14
4.3.± In theInsample,
4.3. 29.5% had seve
the sample,
admission, presence or absence of intracranial bleeding, (GCS ≤ 8),29.5%
14.7% had severe TBI
had moderate TBI(GCS
(GCS≤9-12)
8), 14.7% had moderate
and 55.8% TBI(GCS ≥ 13
had mild TBI
sequels after injury and after surgery, and need for implantation (GCS 9-12) and 55.8% had mild TBI (GCS ≥ 13). The majority
of the intracranial catheter. majority of of
trauma mechanisms
trauma were were
mechanisms not penetrating (96%, n=339),
not penetrating (96%, although
n=339), this fall fr
although this fall from own height was the second major
height was the second major trauma mechanism with 68 patients (19.3%). The minor t
Follow-up period trauma mechanism with 68 patients (19.3%). The minor
The follow-up was started immediately after the baseline mechanismtrauma
was gunshot wound with
mechanism was8 patients
gunshot (2.3%).
wound with 8 patients
assessment and all patients were followed up regularly. The (2.3%).
Table 1. Characteristics of the sample.
end-point was defined as in-hospital death, regardless of the Table 1. Characteristics of the sample.
cause.
N=312
Sex
Statistical Analyses Male 254 (81.4)
Data were analyzed with SPSS software, version 22.0 Female 58 (18.6)
(Chicago, Illinois, USA). The data distribution was verified
Age (years) 49.6 ± 23.5
by the Kolmogorov-Smirnov test. The descriptive analysis
was expressed as mean and standard deviation. Categorical TBI Severity
variables are presented as absolute numbers (percentage). Mild 174 (55.8)
Independent T-test, chi-square, and Mann-Whitney were Moderate 46 (14.7)
Severe 92 (29.5)
performed for data analysis, with significance levels at 0.05. Trauma mechanism
The predictors were verified with uni and multivariate Cox Car accident 37 (10.5)
regression analysis. In the Cox regression model, sequel after Bicycle accident 11 (3.1)
Fall from animals 18 (5.1)
surgery (yes vs no), sequel after injury (yes vs no), bleeding A falling object in the head 10 (2.8)
(yes vs no), intracranial hypertension (yes vs no), penetrating Motorcycle accident 50 (14.2)
injury (gunshot wound and white weapon injury) (yes vs no), Run over 17 (4.2)
and intracranial catheter implantation (yes vs no) were used Aggression 21 (5.9)
White weapon injury 6 (1.7)
as a categorical variable. Fall from height 36 (10.2)
Fall from own height 68 (19.3)
A receiver operating curve (ROC curve) was obtained to Gunshot wound 8 (2.3)
Undefined 71 (20.1)
determine the cut-off value of the independent predictors. Data represented as mean ± SD or n (%).

Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane
After the MGL, J Bras
follow-up period, 59 patients Neurocirur
(18.9%) died. 32 (4):average
The 357-366,survival
2021 time o
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
survivors was 8.8 ± 7.2 days. Inter-group differences are shown in Table 2. Non-survivo

lower GCS on admission compared to survivors.

 Original

After the follow-up period, 59 patients (18.9%) died. The Inter-group differences are shown in Table 2. Non-survivors
average survival time of non-survivors was 8.8 ± 7.2 days. had lower GCS on admission compared to survivors.

Table 2. Differences
Table 2. between
Differencessurvivors and non-survivors’
between survivors patients
and non-survivors’ patients.

Variable Survivors (n=253) Non-survivors (n=59) p-value

Age (years) 50.8 ± 23.4 44.4 ± 23.0 0.06

Gender (male) 204 (80.6%) 50 (84.8%) 0.465

Glasgow Coma Scale 12.1 ± 3.8 7.1 ± 3.9 <0.001

Length of stay (days) 9.8 ± 10.2 8.9 ± 6.7 0.538

Length of intensive care (days) 5.5 ± 9.3 8.2 ± 6.7 0.039

Data by mean ± SD or N (%).

The results of the Cox proportional hazards analysis of factors stratified into the low-GCS group (151 patients with GCS ≤
related to death are shown in Table 3. The univariate Cox 13) and high-GCS group (161 patients with GCS > 13).
analysis showed thatTheGCSresults
on admission, trauma
of the Cox mechanism,
proportional hazards analysis of factors related to death are shown in
sequel after injury, presence of intracranial hypertension, and Also, the sample was stratified among TBI classes (severe,
need for intracranialTable 3. The
catheter univariatewas
implantation Cox analysis showed
significantly that GCS
moderate, on admission,
and mild), following trauma mechanism,
the severity classification by
associated with death. In the multivariate analysis, GCS GCS. The results of the Kaplan-Meier curves for death-free
on admission andsequel trauma after injury, presence
mechanism remained of as
intracranial
an hypertension,
survival after the and need period
follow-up for intracranial
showed thatcatheter
the frequency
independent predictor of survival in patients with TBI. of death was higher in the low-GCS group (35.8% versus 3.1%;
implantation was significantly associated with death. In the multivariate analysis, GCS on
χ2 = 54.2; p <0.001) (Figure 2).
In Figure 1 is presented the results of the ROC analysis. The
admission and trauma mechanism remained as an independent predictor of survival in patients
area under the curve was 0.83 (95% CI 0.78 to 0.87). The The death-free survival after the follow-up period was also a
analysis showed that GCS on
with TBI. admission had a sensitivity of different severity of TBI, especially between mild-moderate to
91.5% and specificity of 61.7% when the clinical evaluation severe.
found a GCS ≤ 13. Based on this cut-off point, the groups were

Table 3. Uni and multivariate Cox analysis for death in patients with traumatic brain injury.

Univariate Multivariate

Variables HR (95% CI) p-value HR (95% CI) p-value

Age (years) 1.00 (0.99 – 1.01) 0.962 - -

Gender (male vs female) 1.24 (0.66 – 2.34) 0.500 - -

Glasgow Coma Scale (GCS) 0.87 (0.81 – 0.92) <0.001 0.87 (0.81 – 0.93) <0.001

Penetrating Injury (yes vs no) 2.71 (0.98 – 7.54) 0.056 3.83 (1.34 – 10.94) 0.012
TablePHS,
Godoi BB, Ramos Jr SP, Figueiredo 3. Uni
Costaand multivariate
HS, Figueiredo SB, MeloCox analysis
LM, Verssiane MGL,for death in patients withJ traumatic brain
Bras Neurocirur 32 injury.
(4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
RR on admission (irm) 1.01 (0.99 – 1.02) 0.370 - -
9

Sequel after injury 2.18 (1.07 – 4.43) 0.031 - -

 Univariate Multivariate

Variables Original
HR (95% CI) p-value HR (95% CI) p-value

Age (years) 1.00 (0.99 – 1.01) 0.962 - -

Table 3. Uni and multivariate Cox analysis for death in patients with traumatic brain injury.
Gender (male vs female) 1.24 (0.66 – 2.34) 0.500 - -
Univariate Multivariate
Glasgow Coma Scale (GCS) 0.87 (0.81 – 0.92) <0.001 0.87 (0.81 – 0.93) <0.001
Variables HR (95% CI) p-value HR (95% CI) p-value
Penetrating Injury (yes vs no) 2.71 (0.98 – 7.54) 0.056 3.83 (1.34 – 10.94) 0.012
Age (years) 1.00 (0.99 – 1.01) 0.962 - -
RR on admission (irm) 1.01 (0.99 – 1.02) 0.370 - -
Gender (male vs female) 1.24 (0.66 – 2.34) 0.500 - -
Sequel after injury 2.18 (1.07 – 4.43) 0.031 - -
Glasgow Coma Scale (GCS) 0.87 (0.81 – 0.92) <0.001 0.87 (0.81 – 0.93) <0.001
(yes vs no)
Penetrating Injury (yes vs no) 2.71 (0.98 – 7.54) 0.056 3.83 (1.34 – 10.94) 0.012
Sequel after surgery 0.63 (0.10 – 3.95) 0.618 - -
RR
(yeson
vsadmission
no) (irm) 1.01 (0.99 – 1.02) 0.370 - -

Sequel
Bleedingafter
(yesinjury
vs no) 2.18
1.01 (1.07
Figure – 4.43)
1. Sensitivity
(0.51 1.98) and0.031 - of Glasgow Coma Scale
specificity
0.979 - on admission to predict death in
patients with traumatic brain injury.
(yes vs no) hypertension
Intracranial 2.19 (1.29 – 3.71) 0.004 - -
Sequel
(yes vs after
no) surgery 0.63 (0.10 – 3.95) 0.618 - -

(yes vs no) catheter

Intracranial 2.19 (1.26 – 3.78) 0.004 - -
Bleeding (yes(yes
implantation vs no)
vs no) 1.01 (0.51 – 1.98) 0.979 - -

Intracranial hypertension
HR=hazard 2.19 (1.29
ratio; 95% CI=95% 0.004 RR:- respiratory rate.
– 3.71) interval.
confidence -
Figure 1. Sensitivity and specificity of Glasgow Coma Scale on admission to predict death in
(yes vs
patients with traumatic no)injury.
brain

Intracranial catheter 2.19 (1.26 – 3.78) 0.004 - -

In figure 1 are presents the results of the ROC analysis. The area under the curve was 0.83
implantation (yes vs no)
(95% CI 0.78 to 0.87). The analysis showed that GCS on admission had a sensitivity of 91.5%
HR=hazard ratio; 95% CI=95% confidence interval.
Variable AUC (95%CI)RR: respiratory rate. Specificity
Sensitivity Cut-off
and specificity of 61.7% when the clinical evaluation finds a GCS ≤ 13. Based on this cut-off
GCS 0.83 (0.78 – 0.87) 91.5% 61.7% ≤ 13
point, the groups were stratified into the low-GCS group (151 patients with GCS ≤ 13) and
GCS: Glasgow Coma Scale; AUC: area under curve.
In figure 1group
high-GCS are presents the results
(161 patients of the> ROC
with GCS 13). analysis. The area under the curve was 0.83

(95% CI 0.78 to 0.87). The analysis showed

Also, the sample that GCS onamong
was stratified admission had a(severe,
TBI classes sensitivity of 91.5%
moderate, and mild), following the

and specificity of 61.7% whenseverity

the clinical evaluation
classification finds
by GCS. Thearesults
GCS of≤ the
13.Kaplan-Meier
Based on this cut-off
curves for10death-free survival

Figure 1. Sensitivity and specificity of Glasgowafter

ComatheScale on admission
follow-up to predictthat
periodgroup
showed death
theinfrequency
patients with traumatic brain injury.
point, the groups were stratified into the low-GCS (151 patients withofGCSdeath≤was
13)higher
and in the low-GCS
Variable AUC (95%CI) Sensitivity Specificity Cut-off
group (35.8% versus 3.1%; χ2 = 54.2; p <0.001) (figure 2).
Godoi BB, Ramos
GCSJr SP,high-GCS
Figueiredo
0.83 (0.78 group
PHS, (161
Costa HS,
– 0.87) patients
Figueiredo
91.5% with
SB, Melo LM,GCS
61.7% > 13).
Verssiane MGL,
≤ 13 J Bras Neurocirur 32 (4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
The death-free survival after the follow-up period was also a different severity of TBI,
GCS: Glasgow Coma Scale; AUC: area under curve.
especially between mild-moderate to severe.
10
 Original

(GCS)
Figure on admission
2. Kaplan-Meier inofpatients
analysis event-freewith
survivaltraumatic
according tobrain injuryComa
the Glasgow ScaleB:
(TBI); and sample stratified by
trauma mechanism.
A. sample stratified by cut-off point (≤ 13) of Glasgow Coma Scale (GCS) on admission in patients with traumatic brain injury (TBI);
B. sample
severity stratifiC:
of TBI; ed by severitystratified
sample of TBI; C. sample
by traumastratified by trauma mechanism
mechanism (penetrating
(penetrating vs not).
vs not).

The results of the Cox proportional hazards analysis showed severity classification patients with moderate and severe TBI
that patients with GCS ≤ 13 had a risk of mortality 6.04-fold had a risk of mortality 2.67-fold and 3.82-fold higher than
The results
higher than patients of the
with GCS > Cox proportional
13 (Table 4). By thehazards
TBI analysis showed
those with mild TBI.that patients with GCS ≤ 13 had

a risk of mortality 6.04-fold higher than patients with GCS > 13 (table 4). By the TBI severity

Godoi BB, Ramos Jrclassification patients

SP, Figueiredo PHS, Costa with SB,
HS, Figueiredo moderate and MGL,
Melo LM, Verssiane severe TBI had a risk ofJ Bras Neurocirur
mortality 32 (4): 357-366,
2.67-fold and 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury

3.82-fold higher than those with mild TBI.

 Original

Table 4. Univariate Cox analysis for death prediction by Glasgow Coma Scale on admission.

Variables Univariate PPV NPV

HR (95% CI) p-value

Glasgow Coma Scale (≤13) 6.04 (2.39 – 15.3) <0.001 35.8% 97.0%

Traumatic brain injury classes

Mild ---- ----- 5.2% 63.8%

Moderate 2.67 (1.10 – 6.51) 0.031 24.1% 82.0%

Severe 3.82 (1.81 – 8.05) <0.001 42.4% 90.9%

HR = hazard ratio; 95% CI =95% confidence interval. PPV: Positive predictive value;
NVP: Negative predictive value.

Discussion
and other kinds of trauma18. Despite that, in middle and low-
DISCUSSION income countries,
Our study aimed to verify the independent predictors the atsetting
of mortality is still in
admission thepatients
same, mainly by car
accidents 1,10,25. Meanwhile, our results show that the major
with Trauma Brain Injury. Thus, we found that patients trauma with GCS under
mechanism, or equal to those
desconsidering 13 have a
undefined, is the
Our study aimed to verify the independent predictors of fall from own height, this can be explained due to the growing
mortality
mortality at admission rate sixfold
in patients with higher
TraumathanBrainthose with GCS major than 13. Moreover, a GCS≤13 has a
Injury. elderly population and epidemiological transition. Although
Thus, we found that patients with GCS under or equal to candeath
accidents figured as
sensitivity of 91.5% and specificity of 61.7% for prediction. So,fourth
thesecause of TBI
results (10.5%).
bring a
13 have a mortality rate sixfold higher than those with GCS
major than 13. Moreover,
view thata the
GCS≤13
GCS has a sensitivity
cutoff in 13 hasofa 91.5%
stronger mortality predictor thanTBI
As aforementioned, the ordinary division in neurological/
is a multifactorial
and specificity of 61.7% for death prediction. So, these results neurosurgical issue and the outcome, besides some
bring a view that mild,
the GCSmoderate,
cut-off inand
13 hassevere TBI. mortality
a stronger Differently from othercharacteristics,
patients’ study [5,16–24], we included
is involved whether only
the trauma was
predictor than the ordinary division in mild, moderate, and penetrating or not penetrating. Those with not penetrating
patients who passed through a neurological surgery.
severe TBI. Differently from other study 5,16–24, we included TBI had better outcomes27–29. Our results also showed that
only patients whoTBI underwent a neurological
is a worldwide causesurgery. penetratingwhich
of mortality and morbidity, injurycan
wasbring
correlated
high withcostsa major
to themortality rate
in univariate analysis (HR 2.71, 95% CI 0.98-7.54, p-value
TBI is a worldwide government with the and
cause of mortality rehabilitation of the survivors
morbidity, which 0.056) [2]. It is important
and multivariate to know
analysis that95%
(HR 3.83, TBICI 1.34-10.94,
can bring high costs to the government system with the p-value 0.012).
rehabilitation ofremains one of2. the
the survivors It isleading causes
important to of
knowmortality in many countries, although many social
that TBI remains one of the leading causes of mortality in Some studies take into consideration the following patients´
practices to prevent and, consequently, reduce this high rate. Seen this, in high-income
many countries, although many social practices to prevent characteristics to predict the survival in-hospital: age, gender,
and, consequently, reduce this high rate. Seen this, in high-
countries the scenario of patients´ characteristics trauma mechanism,
is changing GCS at Currently,
[9,12,25,26]. admission,TBI pupillary
is response,
income countries the scenario of patients´ characteristics is cerebral damage, presence of extracranial injury, hypoxia,
faced by an
changing9,12,25,26. Currently, TBIincreasing
is facing anrateincreasing
of falls inrate
elderly
of peoples and a decreasing
hypotension, rate from. car
and CT15,16,19,22,23,30,31 accidents
Therefore prognosis after a
falls in elderly peoples and a decreasing rate from car accidents TBI is probably multifactorial.
and other kinds of trauma [18]. Despite that, in middle and low-income countries, the setting

still the same, starred by car accidents [1,10,25]. Meanwhile, our results show that the major
Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane MGL, J Bras Neurocirur 32 (4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury 13

Fu et al. (2017)18 demonstrated a growing rate of TBI in elderly
people due to falls, increasing an average of 5% mortality
in-hospital of these patients. Besides that, they have found
in univariate logistic regression that higher age, male sex,
higher comorbidity level, greater injury level, and falls were
associated with a higher odds of in-hospital mortality. But, in
multivariate analysis, falls were associated with reducing of
the odds of mortality compared to other trauma mechanisms
(OR 0.84, 95% CI 0.74-0.96, p = 0.01318.
Baum et al. (2016)24 showed that in-hospital mortality
predictor is more associated with the severity of brain injury
instead of extracranial injury. Although this, El-Menyar
et al. (2017)17 showed greater mortality in patients with
polytrauma than those with single brain trauma. In our
sample, information that could predict the severity of the
injury, as presence or absence of intracranial hemorrhage,
intracranial hypertension, implantation of an intracranial
catheter, sequel after and post neurosurgery, and respiratory
rate on admission were recorded. At univariate analysis, any
factors related to severity injury were related to mortality.
But, in multivariate analysis, only GCS was an independent
predictor for mortality in-hospital after TBI (p < 0.001).
Therefore, our results demonstrate that, independently from
the patient’s characteristics or neurosurgical procedures, the
GCS at admission is the predictor of in-hospital mortality.
Two large databases5,32, widely validated, have built models
to predict the prognosis of patients after a TBI including
multiple individual characteristics: the International Mission
on Prognosis and Analysis of Clinical Trials (IMPACT) and
the Corticoid Randomisation After Significant Head Injury
(CRASH). Based mainly on these two databases, some other
studies have found a set of patients’ characteristics that could
predict prognosis and, consequently, mortality after TBI,
including the GCS score 6,16,19,20,22,24.
Since 1974, GCS is an instrument used in pre-hospital and
emergency department assessment to achieve neurological
patients’ response and integrity13. This scale is worldwide
used, mainly in patients after TBI, to predict prognosis by the
severity of the trauma (mild, moderate, or severe) 14. Many
Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane MGL,
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury
Original
studies take into consideration that the lower the GCS the
lower are the chances to survive and higher is the morbidity
and years of lifelong lost 7,12,20,33. Despite that GCS is a strong
predictor, especially when lower than 14, as shown in CRASH
trial5, it is important to investigate other characteristics to
strengthen the prediction of mortality in-hospital and late
mortality.
Hawryluk and Manley (2015)33 and McNet (2007)31 showed
that GCS (total value or just motor response) at admission
linked to age and pupillary activity is a strong predictor
,instead of each one independently. Although these results,
also found by other authors, we did not reach this combination
to predict the survival rate in patients after TBI. In our results,
in multivariate analysis, GCS was the only independent
predictor of mortality after TBI. Teasdale et al. (2014) 13 showed
that early mortality rate increases in indirect proportionality
to the GCS, that is the smaller the GCS higher the mortality.
Corroborating with these findings, our data demonstrated an
inverse relationship between the risk of death and GCS values.
Each one-point increase in GCS was associated with a 13%
reduction in the risk of death. Also, an increased risk was
attributed to “moderate” and “severe” severity classes.
Differently from other studies, we found that a GCS under
13 is a stronger predictor of mortality in hospitals. The
risk of death increased 6.08 times when the GCS was ≤ 13.
Notably, the GCS value ≤ 13 showed a PPV lower than the
severe TBI classification (approximately 36%), suggesting the
multifactorial nature of death in patients with TBI. However, a
high negative predictive value was observed (97%). This data
is clinically relevant because suggests a probability of death of
only 3% for patients with GCS values above the cut-off point.
Moreover, suggest that the clinical manifestation at arrival
was the main mortality in-hospital predictor, independently
from the other factors such as age, gender, intracranial
hypertension, and presence of bleeding.
Some limitations can be noted in our study. This was a
retrospective sample of a single-center at high complexity in
neurosurgery, and thus has a smaller sample size compared to
multicenter analyses. Complications during the hospital stay,
J Bras Neurocirur 32 (4): 357-366, 2021

causes of death, trauma mechanism, pupillary activity were
not analyzed due to data collection from physical medical
records and very old, which makes it difficult to detect some
important data for traumatic brain injury (such as pupillary
response) because of poor or illegible records. This did not
allow us to make a discriminative analysis based on the cause
of death. Lastly, the patients included in this study were only
those who just underwent a neurosurgical procedure, so
these results cannot be extrapolated to patients with clinical
treatment. However, our results strengthen the importance
of clinical evaluation at arrival in patients with TBI and also
predict the prognosis of these patients with GCS ≤13.
CONCLUSION
In conclusion, the pre-hospital and emergency department
assessment of neurosurgical patients with TBI is quite
important to predict the prognosis and possible chances of
mortality in the hospital. Our results showed that GCS is a
strong and independent predictor of mortality in hospitals.
Furthermore, the medical and nursing assistance should be
attentive to those patients with GCS under or equal to 13,
which is associated with a significant increase in mortality.
Acknowledgments
We would like to acknowledge the billing team of Santa Casa
de Caridade in Diamantina, Minas Gerais, who helped us with
the data collection.
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Godoi BB, Ramos Jr SP, Figueiredo PHS, Costa HS, Figueiredo SB, Melo LM, Verssiane MGL, J Bras Neurocirur 32 (4): 357-366, 2021
Innecco PLR - Predictors of Mortality in Neurosurgical Patients after Traumatic Brain Injury