Admission Glasgow Coma Scale, Pupillary Reactivity, and Age as Independent Predictors of Survival and Functional Dependency After Emergent Surgery for Traumatic Brain Injury

Abstract

Background. Early prognosis after moderate-to-severe traumatic brain injury (TBI) that needs emergent surgery is important but easily confounded. The Glasgow Coma Scale (GCS) is the usual starting point. Used alone, it can mislead.

Objective. To estimate the independent association of admission GCS with outcome after adjustment for pupillary light reactivity, age, and Marshall computed tomography (CT) class.

Methods. This retrospective cohort study included 150 consecutive patients with moderate-to-severe TBI (admission GCS 3–12) who had emergent surgery and postoperative intensive care from July to December 2024. The outcomes were in-hospital mortality (14 deaths) and unfavorable functional outcome (death or discharge to a skilled nursing or palliative facility). We used receiver operating characteristic (ROC) analysis and multivariable logistic regression (Firth-penalized for mortality).

Results. A GCS cut-off of ≤ 5.5 gave a crude odds ratio for mortality of 104.87 (95% CI 12.80–859.40), which was unstable because one death occurred above the cut-off. Admission GCS remained independently associated with mortality (adjusted odds ratio [aOR] 2.78 per point decrease, 95% CI 1.99–3.89, p < 0.001) and with unfavorable functional outcome (aOR 3.11, 95% CI 2.34–4.14, p < 0.001). Bilaterally non-reactive pupils were independently associated with mortality (aOR 5.12, 95% CI 1.81–14.50, p = 0.002). Age was independently associated with unfavorable functional outcome (aOR 1.07 per year, 95% CI 1.04–1.10, p < 0.001).

Conclusion. Admission GCS is independently associated with outcome after surgery for TBI, and it is best read together with pupillary response and age. These findings need validation in larger cohorts.