Improving mortality prediction in older adults with traumatic brain injury: incorporating neurological and imaging scores into Geriatric Trauma Outcome ScoreOA

BACKGROUND: Predicting mortality in elderly traumatic brain injury(TBI) patients is challenging. The Geriatric Trauma Outcome Score(GTOS) may underestimate risk in moderate to severe cases. We hypothesized that integrating the Glasgow Coma Scale(GCS) and the Rotterdam CT Score(RCS) into GTOS would enhance mortality prediction.METHODS: This retrospective cohort study included trauma patients aged ≥65 years with head Abbreviated Injury Scale(AIS) ≥3 and admission GCS ≤12, treated at a tertiary trauma center between January 2016 and December 2024. Three models were assessed:(1) GTOS only;(2) GTOS+GCS;and(3) GTOS+RCS, with GTOS logit as an offset for recalibration. Discrimination and calibration were evaluated using the area under the receiver operating characteristic curve(AUC), Brier score, calibration intercept, and slope. Internal validation of the models were performed using 200 bootstrap samples. Net clinical benefit was compared using decision curve analysis(DCA).RESULTS: A total of 171 patients were included, of whom 111 survived and 60 did not. The GTOS model showed poor performance(AUC=0.538, 95%CI 0.442–0.664;Brier score 0.292) of prediction of 30-day mortality. Adding GCS improved model performance(AUC=0.721, 95%CI 0.652–0.793;Brier score 0.209). The GTOS+RCS model showed superior results(AUC=0.883, 95%CI 0.843–0.934;Brier score 0.134), with the greatest net benefit in DCA.CONCLUSION: Integrating RCS into GTOS enhances mortality prediction accuracy and clinical utility for elderly TBI patients. The combined model demonstrates superior discrimination, calibration, and decision analytic benefit, suggesting the need for prospective validation in clinical settings.