Skip to main content Skip to main navigation menu Skip to site footer

Risk factors and novel prognostic score for predicting the 14-day mortality of severe traumatic brain injury patients

  • Nyoman Golden ,
  • Putu Eka Mardhika ,
  • Wayan Niryana ,
  • I Made Sukarya ,
  • I Putu Yuda Prabawa ,


Introduction: The mortality of severe traumatic brain injury (TBI) is contributed by the severity of the head injury, associated trauma, and complication during treatment. This study aimed to develop a prognostic scoring system of risk factors that contribute to the 14-day mortality of severe TBI.

Methods: This was a prospective cohort study including 105 severe TBI patients recruited consecutively from March to October 2016. Multivariate analysis with logistic regression was performed to determine the most contributing risk factors. The validation of prognostic factor was performed with ROC, sensitivity and specificity analysis.

Result: There were five significant risk factors of 14-day mortality, which were age > 60 years old (RR: 15.6, 95% CI: 1.88 – 129.95), hypoxia (RR: 17.78, 95% CI: 2.05 – 154.11), GCS 3 – 5 (RR: 34.71, 95% CI: 6.85 – 175.98), effacement of basal cistern (RR: 12.71, 95% CI: 2.61 – 61.95), and traumatic subarachnoid hemorrhage (tSAH) (RR:7.57, 95% CI: 1.19 – 48.36). The prognostic score ranged from 0 to 6 with the best cut-off point of 1. The best predictive AUC with ROC analysis was 0.817, 81.2% of sensitivity, and 75.0% of specificity.

Conclusion: The proposed prognostic score has shown good predictive ability.


  1. Golden N, Niryana W, Mahadewa TGB, Maliawan S, Chandra A. Two different approaches in obtaining head computerized tomography scan in minor head injuries. J Neurol Res. 2013; 3: 114 – 12. DOI: 10.4021/jnr225w.
  2. Andriessen TM, et al. Epidemiology, severity classification, and outcome of moderate and severe traumatic brain injury: a prospective multicenter study. J Neurotrauma. 2011; 28(10): 2019 – 31. DOI: 10.1089/neu.2011.2034.
  3. Finfer SR, Cohen J. Severe traumatic brain injury. Resuscitation. 2001; 48(1): 77 – 90.
  4. Faul M, Xu L, Wald MW, Coronado VG. Traumatic brain injury in the United States: Emergency department visits, hospitalization and death 2002 – 2006. US Department of Health Centers for Disease and Prevention National Center for Injury Prevention and Control. (2010).
  5. Wahyuhadi J, Suryaningtyas W, Susilo RI. Pedoman Tatalaksana Cidera Otak (Guideline for Management of Traumatic Brain Injury). Tim Neurotrauma RSU dr. Soetomo FK Universitas Airlangga Surabaya. 2007
  6. Martins ET, et al. Mortality in severe traumatic brain injury: a multivariated analysis of 748 Brazilian patients from Flarianopolis City. J Trauma. 2009; 67(1): 85 – 90. DOI: 10.1097/TA.0b013e318187acee.
  7. Gerber LM, Chiu YL, Carney N, Harti R, Ghajar J. Marked reduction in mortality in patients with severe traumatic brain injury. J Neurosurg. 2013; 119(6): 1583 – 1590. DOI: 10.3171/2013.8.JNS13276.
  8. Jusuf WRA, Prasetyo E, Oley MC. Correlation between full outline responsiveness score and glasgow coma scale for severe head injury patients at Prof. dr. R. D. Kandou General Hospital, Manado-Indonesia. Bali Med J. 2012; 1(2): 71 – 73.
  9. Roberts I, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004; 364(9442): 1321 – 8. DOI: 10.1016/S0140-6736(04)17188-2.
  10. Perel P, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008; 336(7641): 425 – 429. DOI: 10.1136/bmj.39461.643438.25.
  11. Steyerberg EW, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristic. PLoS Med. 2008; 5(8): discussion e165. DOI: 10.1371/journal.pmed.0050165.
  12. Gomez PA, et al. Validation of a prognostic score for early mortality in severe head injury cases. J Neurosurg. 2014; 121(6): 1314 – 22. DOI: 10.3171/2014.7.JNS131874.
  13. Woratyla SP, Morgan AS, Mackay L, Bernstein B, Barba C. Factor associated with early onset pneumonia in the severely brain-injured patient. Conn Med. 1995; 59(11): 643 – 7.
  14. Perel P, Edwards P, Shakur H, Roberts I. Use of the Oxford Handicap Scale at hospital discharge to predict Glasgow Outcome Scale at 6 months in patients with traumatic brain injury. BMC Med Res Methodol. 2008; 8: 72. DOI: 10.1186/1471-2288-8-72.
  15. Tjahjadi M, Arifin MZ, Gill AS, Faried A. Early mortality predictor of severe traumatic brain injury: a single center study of prognostic variables based on admission characteristics. The Indian J Neurotrauma. 2013; 10(1): 3 – 8. DOI: 10.1016/j.ijnt.2013.04.007.
  16. Moppett IK. Traumatic brain injury: assessment, resuscitation, and early management. Br J Anaesth. 2007; 99(1): 18 – 31. DOI: 10.1093/bja/aem128.
  17. Murray GD, et al. The European Brain Injury Consortium Survey of head injuries. Acta Neurochir (Wien). 1999; 141(3): 223 – 236.
  18. Werner C, Engelhard K. Pathophysiology of traumatic brain injury. Br J Anaesth. 2007; 99(1): 4 – 9. DOI: 10.1093/bja/aem131.
  19. Wright DW, et al. Gender differences in neurological emergencies part II: a consensus summary and research agenda on traumatic brain injury. Acad Emerg Med. 2014; 21(12): 1414 – 20. DOI: 10.1111/acem.12532 (2014).
  20. Signorini DF, Andrews PJ, Jones PA, Wardlaw JM, Miller JD. Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry. 1999; 66(1): 20 – 25.
  21. Mosenthal AC, et al. Isolated traumatic brain injury: age is an independent predictor of mortality and early outcome. J Trauma. 2002; 52(5): 907 – 911.
  22. Hukkelhoven CW, et al. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg. 2003; 99(4): 666 – 673. DOI: 10.3171/jns.2003.99.4.0666.
  23. Maas AI, et al. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007; 24(2): 303 – 314. DOI: 10.1089/neu.2006.0033.
  24. Heiskanen O, Sipponen P. Prognosis of severe brain injury. Acta Neurol Scand. 1970; 46(3): 343 – 8. DOI: 10.1111/j.1600-0404.1970.tb05798.x
  25. Doyle KP, Simon RP, Stenzel-Poore MP. Mechanisms of ischemic brain damage. Neuropharmacology. 2008; 55(3): 310 – 318. DOI: 10.1016/j.neuropharm.2008.01.005.
  26. Yajima D, et al. The relationship between cell membrane damage and lipid peroxidation under the condition of hypoxia-reoxygenation: analysis of the mechanism using antioxidants and electron transport inhibitors. Cell Biochem Funct. 2009; 27(6): 338 – 343. DOI: 10.1002/cbf.1578.
  27. Chesnut RM, et al. Early indicators of prognosis in severe traumatic brain injury. J Neurotrauma. 2000; 17: 557 – 627.
  28. Chi JH, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: a prospective multicenter study. J Trauma. 2006; 61(5): 1134 – 1141. DOI: 10.1097/01.ta.0000196644.64653.d8.
  29. Brain Trauma Foundation Guidelines for The Management of Severe Traumatic Brain Injury. 2007; Mary Ann Liebert: New York.
  30. Hsiang JN, Yeung T, Yu AL, Poon WS. High-risk mild head injury. J Neurosurg. 1997; 87(2): 234 – 8 .DOI: 10.3171/jns.1997.87.2.0234.
  31. Oertel M, et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg. 2002; 96(1): 109 – 116. DOI: 10.3171/jns.2002.96.1.0109.
  32. Mizraji R, et al. Brain death epidemiology in Uruguay and utilization of the Glasgow coma score in acute brain injured patients as a predictor of brain death. Transplant Proc. 2009; 41(8): 3489 – 91. DOI: 10.1016/j.transproceed.2009.09.008.
  33. Petroni G, et al. Early prognosis of severe traumatic brain injury in urban argentinian trauma center. J Trauma. 2010; 68(3): 564 – 570. DOI: 10.1097/TA.0b013e3181ce1eed.
  34. Ting HW, Chen MS, Hsieh YC, Chan CL. Good mortality prediction by Glasgow Coma Scale for neurosurgical patients. J Chin Med Assoc. 2010; 73(3): 139 – 143. DOI: 10.1016/S1726-4901(10)70028-9.
  35. Saini NS, Rampal V, Dewan Y, Grewal SS. Factors predicting outcome in patients with severe head injury: multivariate analysis. The Indian J Neurotrauma. 2012; 9(1), 45 – 48; 10.1016/j.ijnt.2012.04.009 (2012).
  36. Liu HM, Tu YK, Su CT. Changes of brainstem and perimesenchepalic cistern: dynamic predictor of outcome in severe head injury. J Trauma. 1995; 38(3): 330 – 333.
  37. Harders A, Kakarieka A, Braakman R. Traumatic subarachnoid hemorrhage and its treatment with nimodipine. German tSAH Study Group. J Neurosurg. 1996; 85(1): 82 – 89. DOI: 10.3171/jns.1996.85.1.0082.
  38. Zurynski YA, Dorsch NW. A review of cerebral vasospasm. Part IV. Post-traumatic vasospasm. J Clin Neurosci. 1998; 5(2): 146 – 154.
  39. Aminmansour B, Ghorbani A, Sharifi D, Shemshaki H, Ahmadi A. Cerebral vasospasm following traumatic subarachnoid hemorrhage. J Res Med Sci. 2009; 14(6): 343 – 348.
  40. Splitz WU, Splitz DJ. Splitz and Fisher’s Medicolegal Investigation of Death. Charles C Thomas Publisher; 2006.
  41. Kakarieka A, Braakman R, Schakel EH. Clinical significance of finding of subarachnoid blood on CT scan after head injury. Acta Neurochir (Wien). 1994; 129(1-2): 1 – 5.
  42. Wong GK, et al. Long-term cognitive dysfunction in patients with traumatic subarachnoid hemorrhage: prevalence and risk factors. Acta Neurochir (Wien). 2012; 154(1): 105 – 111; discussion 111. DOI: 10.1007/s00701-011-1198-8.
  43. Eisenberg HM, et al. Initial CT finding in 753 patients with severe head injury: A report from the NIH Traumatic Coma Data Bank. J Neurosurg. 1990; 73(5): 688 – 698. DOI: 10.3171/jns.1990.73.5.0688.
  44. Maas AI. et al. Prognostic value of computerized tomography scan characteristics in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007; 24(2): 303 – 314. DOI: 10.1089/neu.2006.0033.
  45. Lin TK, Tsai HC, Hsieh TC. The impact of traumatic subarachnoid hemorrhage on outcome: a study with grouping of traumatic subarachnoid hemorrhage and transcranial doppler sonography. J Trauma Acute Care Surg. 2012; 73(1): 131 – 136. DOI: 10.1097/TA.0b013e31824aff74.
  46. Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocritical Care. 2005; 2(2): 110 – 118. DOI: 10.1385/NCC:2:2:110 (2005).

How to Cite

Golden, N., Mardhika, P. E., Niryana, W., Sukarya, I. M., & Prabawa, I. P. Y. (2020). Risk factors and novel prognostic score for predicting the 14-day mortality of severe traumatic brain injury patients. Intisari Sains Medis, 11(3), 1020–1028.




Search Panel