Evan Courville1, Syed Faraz Kazim1, John Vellek2, Omar Tarawneh2, Julia Stack2, Katie Roster2, Joanna Roy3, Meic Schmidt1, Christian Bowers1
  1. Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States
  2. Department of Neurosurgery, School of Medicine, New York Medical College, Valhalla, New York, United States,
  3. Department of Neurosurgery, Topiwala National Medical and B. Y. L. Nair Charitable Hospital, Mumbai, Maharashtra, India.

Correspondence Address:
Evan Courville, Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States.


Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Evan Courville1, Syed Faraz Kazim1, John Vellek2, Omar Tarawneh2, Julia Stack2, Katie Roster2, Joanna Roy3, Meic Schmidt1, Christian Bowers1. Machine learning algorithms for predicting outcomes of traumatic brain injury: A systematic review and meta-analysis. 28-Jul-2023;14:262

How to cite this URL: Evan Courville1, Syed Faraz Kazim1, John Vellek2, Omar Tarawneh2, Julia Stack2, Katie Roster2, Joanna Roy3, Meic Schmidt1, Christian Bowers1. Machine learning algorithms for predicting outcomes of traumatic brain injury: A systematic review and meta-analysis. 28-Jul-2023;14:262. Available from:

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Background: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The use of machine learning (ML) has emerged as a key advancement in TBI management. This study aimed to identify ML models with demonstrated effectiveness in predicting TBI outcomes.

Methods: We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. In total, 15 articles were identified using the search strategy. Patient demographics, clinical status, ML outcome variables, and predictive characteristics were extracted. A small meta-analysis of mortality prediction was performed, and a meta-analysis of diagnostic accuracy was conducted for ML algorithms used across multiple studies.

Results: ML algorithms including support vector machine (SVM), artificial neural networks (ANN), random forest, and Naïve Bayes were compared to logistic regression (LR). Thirteen studies found significant improvement in prognostic capability using ML versus LR. The accuracy of the above algorithms was consistently over 80% when predicting mortality and unfavorable outcome measured by Glasgow Outcome Scale. Receiver operating characteristic curves analyzing the sensitivity of ANN, SVM, decision tree, and LR demonstrated consistent findings across studies. Lower admission Glasgow Coma Scale (GCS), older age, elevated serum acid, and abnormal glucose were associated with increased adverse outcomes and had the most significant impact on ML algorithms.

Conclusion: ML algorithms were stronger than traditional regression models in predicting adverse outcomes. Admission GCS, age, and serum metabolites all have strong predictive power when used with ML and should be considered important components of TBI risk stratification.

Keywords: Artificial intelligence, Head injury, Machine learning, Mortality, Outcomes, Traumatic brain injury


Physicians are often presented with large quantities of complex data and limited processing time. This presents barriers to the real-time analysis and prediction of patient outcomes. In computer science, complex algorithms designed to learn from data and create generalizations are known as machine learning (ML). The marked proliferation of electronic medical record systems during recent years has presented unique opportunities for ML to improve patient care. Several ML learning techniques have been used in clinical practice to predict deleterious events and alert appropriate care teams. This has led to an increase in the number of early interventions, reduced mortality, and decreased lengths of hospital stay.[ 3 , 9 , 18 , 20 , 39 ]

Traumatic brain injury (TBI) remains one most prevalent causes of death and disability throughout the world.[ 10 , 19 , 38 ] Robust prediction of outcomes in these patients is critical for clinical decision-making, family counseling, and for the need-based allocation of quality of care. In recent years, TBI research has employed several ML models for the prediction of patient events and outcomes; however, there exists much variability in their results.[ 40 - 42 ] Conflicting data continues to be reported in the literature; for example, while one study reported that the ML-based predictive models were more powerful than classic multivariate analysis in head trauma patients, another reported ML algorithms performed no better than conventional for prognostication in TBI.[ 15 ] To the best of our knowledge, there exists no systematic review comparing various ML models used for predictions in TBI. The present systematic review and meta-analysis were conducted to summarize and analyze the available clinical literature regarding ML-based prediction of TBI outcomes. We conducted a small meta-analysis of available studies to estimate the predictive performance of ML-based algorithms for TBI outcomes.


The present systematic review and meta-analysis were performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[ 28 , 32 ] Figure 1 shows the PRISMA flow diagram for the study.

Figure 1:

Flow diagram of literature selection process per PRISMA guidelines in the present systematic review and meta-analysis. n: Number of articles; PRISMA: Preferred reporting items for systematic reviews and meta-analyses.


Literature search strategy

We conducted a literature search of studies reporting on ML-based prediction of TBI outcomes published until March 31, 2021. We searched the following three electronic bibliographic databases: PubMed, EMBASE, and Cochrane Library. We used the following MeSH (Medical Subject Heading) terms in combination with Boolean Operators OR and AND: “machine learning” OR “artificial intelligence” OR “neural network” OR “naive Bayes” OR “Bayesian learning” OR “random forest” OR “deep learning” OR “machine intelligence” OR “boosting” OR “nature language processing” OR “decision tree” AND “traumatic brain injury” OR “head injury.” An additional search involving the following terms was also performed: “machine learning” OR “artificial intelligence” OR “neural network” OR “naive Bayes” OR “Bayesian learning” OR “random forest” OR “deep learning” OR “machine intelligence” OR “boosting” OR “nature language processing” OR “decision tree” AND “traumatic brain injury” OR “head injury” OR AND “outcome” OR “mortality” OR “morbidity.”

Inclusion and exclusion criteria

We included peer-reviewed prospective and retrospective cohort studies published in the English language utilizing ML algorithms to predict outcomes of TBI in human patients. Single case reports, editorials, reviews, and conference/meeting abstracts were excluded from the study. Furthermore, TBI studies that used ML for a purpose other than predicting outcomes were also excluded. We also reviewed the reference lists of the selected articles for any additional articles related to the topic.

Data extraction

Three independent investigators (JV., OHT., and JS.) reviewed the full text of the included articles and extracted the data on a data collection form. Any disagreement between the three authors was resolved by discussion. The following data were extracted from each study: study design, TBI population characteristics, ML and comparative regression models used, ML input variables, outcome variables, study results, and predictive performance of various models used in the study.

Risk of bias assessment

We employed the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) in the Review Manager (RevMan) software version 5.4 to assess the quality of extracted studies [ Figure 2 ]. The following four domains are included in the QUADAS-2: (1) patient selection; (2) index test; (3) reference standard; and (4) flow and timing.[ 46 ] We assessed each domain with regard to the risk of bias, and the first three also for concerns regarding applicability. We used the signaling questions to assess the risk of bias and applicability concerns. For each domain, we analyzed the risk of bias and concerns about applicability (the latter not applying to the domain of flow and timing) and rated each domain as low (+), high (−), or unclear (?) (could not be assessed due to missing information) risk. Studies rated as “low” on all domains regarding bias or applicability concerns were identified as having an overall low risk of bias or low concerns regarding applicability.[ 46 ] Contrarily, studies judged as having a high risk of bias in one or more domains were identified as having an overall high risk of bias or high concerns regarding applicability.[ 46 ]

Figure 2:

The risk of bias assessment.


Quality assessment

The quality of the included studies was evaluated using the QUADAS-2 tool in RevMan version 5.4.1 software. Each study was assessed using 12 signaling questions (three from each domain) and three questions regarding study applicability (one each from the first three domains) [ Figure 1 ]. The rating for each question was yes, no, or unclear. “No” indicates a small risk of bias, whereas “yes” indicates a high risk of bias for the specific question. “Unclear” indicates that the risk of bias could not be assessed due to missing information. We assessed agreement between both evaluators using three (yes, no, or unclear) and two (yes or combined unclear/no) response levels. The agreement was calculated for each question, for each domain, and for the overall assessment. Studies that were judged as “low” on all domains regarding bias or applicability were rated as having an overall low risk of bias or low concern regarding applicability. Studies that were judged as having a high risk of bias in one or more domains were rated as having an overall high risk of bias or high concern regarding applicability.

The domain “Patient Selection” addresses the following question: “Could the selection of patients or study participants have introduced bias?” The constitution of the study population is centrally important to a high-quality study. We distinguished three populations, study, source, and target. The study population is the population that was reported on in an article, sampled from a larger source population. Only two studies (Gravesteijn et al. 2020 and Raj et al. 2019) reported an unclear risk of bias while others answered a low risk of bias and only one study answered a high risk (Rizoli et al. 2016).[ 15 , 34 , 37 ]

The domain “Index Text” addresses the question: “Could the conduct or interpretation of the index test have introduced bias?” The index test results are one central component of a 2 × 2 table that is evaluated in diagnostic studies. The index test is the assay under investigation in the study, and a study may evaluate one or more index tests in the same population or among population subsets. Among the studies cohort in our systematic review and meta-analysis using ML and comparative regression models in the prediction of TBI, only one study qualified as high risk (Rizoli et al. 2016), four studies (Amorim et al. 2019, Rau et al. 2017, Kayhanian et al. 2019, and Raj et al. 2019) remained unclear risk while others reported a low risk of bias.[ 4 , 21 , 36 , 37 ]

The domain “Reference standard” addresses the question: “Could the reference standard, its conduct, or its interpretation have introduced bias?” Among all pooled studies, Gravesteijn et al. 2020, Shi et al. 2013, and Bonds et al. 2015 answered a high risk, Zelnick et al. 2014, Rau et al. 2018, Raj et al. 2019, and Feng et al. 2019 reported unclear risk while others pooled studies reported low risk.[ 7 , 14 , 15 , 34 , 36 , 43 , 49 ]

The domain “Flow and Timing” addresses the question: “Could the study flow and timing have introduced bias?” The methods and results sections should provide a clear description of clinical referral algorithms (i.e., patients who did/did not receive the index tests or reference standard, respectively) and of any patients excluded from the analyses. Three studies in our analysis (Zelnick et al. 2014, Gravesteijn et al. 2020, and Rizoli et al. 2016) reported a considerable risk of bias while one study (Kayhanian et al. 2019) answered unclear risk of bias, all others reported a low risk of bias. Figure 2 summarizes the overall risk of bias in our systematic review/meta-analysis studies.[ 15 , 21 , 37 , 49 ]

Statistical analysis

We recorded data from the included studies in a Microsoft Excel datasheet (Microsoft Corp., Redmond, Washington, USA). For the pooled mortality rate, we employed a random-effects meta-analysis model in R statistical software version 4.02 (R Foundation for Statistical Computing, Vienna, Austria). We measured the heterogeneity between the included studies employing the Higgins I2 statistic. We used a random-effects model due to the high statistical heterogeneity (defined as I2 > 25%) among studies included in the meta-analysis. Forest plots were generated using the function “metaforest” in R statistical software.[ 49 ] A meta-analysis of diagnostic accuracy with hierarchical modeling was carried out for each of the ML models across the selected studies where the true positive (TP), false positive (FP), true negative (TN), and false negative (FN) values were reported. The sensitivity and specificity with corresponding 95% confidence intervals (95% CIs) were calculated from the TP, FP, FN, and TN rates extracted through a 2 × 2 table from each included study. The “metandi” module in STATA Version 14.1 (StataCorp., 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP) was used for meta-analysis of diagnostic accuracy.[ 22 , 23 ]


The initial literature search identified 9180 articles. After removing duplicates (n = 4663) and screening the titles and abstracts (n = 4517), we excluded a total of 9063 studies. After the screening of full-text articles based on our selection criteria (n = 117), we included a total of 15 studies in the qualitative systematic review and quantitative meta-analysis. However, the actual number of included studies for the small meta-analysis varied depending on how many studies documented the data for a particular algorithm using a similar methodology. Figure 1 shows the flow diagram of the literature selection process per PRISMA guidelines. Figure 2 shows the risk of bias assessment in included studies. Tables 1 and 2 present a review of the major relevant findings of the included 15 studies.

Table 1:

Summary of included study findings.


Table 2:

Summary of included study findings.


Prognostic factors for mortality and unfavorable outcomes

Although there was significant heterogeneity in the selected input variables used for the prediction of mortality and unfavorable outcomes, critical clinicopathological and imaging findings were identified from our review: abnormal serum glucose,[ 21 , 27 , 34 ] lactic acidosis,[ 21 ] older age and lower GCS at admission,[ 4 , 27 , 35 ] higher Marshall scores and decreased pupillary activity,[ 37 ] and high surgeon caseload and overall hospital workload.[ 43 ]

Diagnostic accuracy: Meta-analysis for ML algorithms

A small meta-analysis was conducted for studies using mortality as a primary outcome. Figure 3a illustrates the mortality data extracted from each study in which mortality was predicted using ML. A total of 32,721 patients were identified from nine studies, with an overall pooled mortality rate of 23%. Mortality rates within the individual studies ranged from 6%[ 16 ] to 54%,[ 15 ] with the majority falling in the range of 10–30%. A forest-funnel plot depicting mortality data is shown in Figure 3b , demonstrating a high degree of variability in the reported mortality; however, these values are in agreement with previously reported data.[ 24 , 48 ] Meta-analysis of diagnostic accuracy was conducted for recurring ML algorithms using receiver operating characteristic (ROC) curves. Figure 4 illustrates the findings for artificial neural networks (ANN), support vector machines (SVM), decision trees (DT), and logistic regression (LR), respectively. Meta-analysis of diagnostic accuracy demonstrated that ANN results were consistent across studies and that its predictions were more accurate than traditional CT scanning models.[ 16 ]

Figure 3:

The forest (a) and funnels (b) plots of mortality data extracted from studies in which mortality was predicted using machine learning.


Figure 4:

(a-d) Meta-analysis of diagnostic accuracy with hierarchical modeling for machine learning models across the selected studies. ANN: Artificial neural network, SVM: Support vector machine, DT: Decision tree, LR: Logistic regression.


In-hospital mortality

ANN and SVM have both been used to assess in-hospital mortality in a study containing 1620 patients.[ 1 ] The goal was to compare the performance of ML models to traditional inhospital mortality measures that use multivariate regression. ML prediction variables included GCS, radiologic findings, arrival method, and time of day of presentation, among others. ANN and SVM predicted in-hospital mortality with an accuracy of>91%; however, SVM outperformed ANN with an accuracy of 95.6% and an area under curve (AUC) of 96%. SVM also outperformed traditional multivariate LR.[ 1 ] An additional study assessed the efficacy of various ML models versus LR in predicting mortality in TBI using a retrospective chart review.[ 14 ] The ML predictive variables included vital signs and GCS at admission and discharge. Linear, cubic, and quadratic SVM models all demonstrated an accuracy of 94%, whereas LR had an accuracy of 88%. Linear and quadratic SVM both showed an AUC of 0.93 with cubic SVM demonstrating an AUC of 0.94, in comparison to LRs value of 0.83.[ 14 ] All SVM ML models demonstrated a sensitivity of 0.98 or higher, the highest among the five studies in the meta-analysis for ML predicting mortality.[ 14 ] ANN was also used to predict in-hospital mortality using retrospective hospital data and patient comorbidities.[ 43 ] When comparing ANN to comparative regression model LR, ANN had a higher accuracy (95.23% vs. 82.44%), AUC (0.8961 vs. 0.7739), sensitivity (67.56% vs. 54.83%), specificity (95.23% vs. 92.67%), and positive (83.24% vs. 74.81%) and negative (89.35% vs. 87.64%) predictive values over LR. The study also included the Charlson comorbidity index, hospital volume, and surgeon volume as ML predictive variables.[ 43 ]

14-day mortality after TBI

An additional study used models to predict in-hospital and 14-day mortality. The models assessed mortality in 517 TBI patients in a low-middle-income country (LMIC).[ 4 ] Comparing regularized least squares and linear regression to 9 ML models, the models consistently demonstrated an AUC above 0.80. Naïve Bayes (NB) had the highest predictive performance model for 14-day mortality prediction with an AUC of 0.906. In-hospital mortality prediction was best predicted by random forest (RF) with an AUC value of 0.838.[ 4 ] In a separate study, NB was again used for mortality prediction with an accuracy of >90% in the training set.[ 36 ] ANN had the highest AUC (0.968) with a prediction sensitivity of 80.59%. In the test set, ANN remained the highest predictor of mortality followed by the additional three models used in the study: SVR, NB, and DT.[ 36 ]

30-day mortality after TBI

Two custom models were developed to predict the 30-day mortality of TBI patients using commonplace neurointensive care unit measurements as predictive variables.[ 34 ] ML model variables include a combination of intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) all measured in 5 min medians over 5 days. The second model included ICP, CPP, and MAP and GCS. Model 1 (ICP-CPP-MAP) had an AUC that increased from 67% to 81% from day 1 to day 5. False positives and false negatives also influenced mortality prediction. There were 18 false positives potentially caused by decompressive craniectomy, two additional false positives, and nine false negatives on mortality prediction. The second model (ICP-CPP-MAP-GCS) had an AUC that increased from 72% to 84% from day 1 to day 5, with 1 false positive and 4 false negatives on mortality prediction.[ 34 ] Another study performed a secondary analysis of a multi-center, randomized, placebo-controlled clinical trial of TBI patients to evaluate patterns of missing outcome data, and changes in functional status between hospital discharge and 6 months follow-up.[ 49 ] Three novel prognostic models were developed to predict long-term functional outcome from covariates available at hospital discharge. The ML predictive variables included the Glasgow outcome scale extended (eGOS) and the disability rating scale (DRS). An adverse outcome was defined as eGOS less than or equal to four. In both models, discharge DRS was used. ML model results included missing data for poor outcomes for 15% of enrolled patients. The model performance was excellent (C-statistic between 0.88 and 0.91) for all three prognostic models and calibration was adequate for two models (P = 0.22 and 0.85). A two-variable predictive model was compared to more in-depth programs to predict mortality in adult moderate-severe TBI patients in a retrospective database study.[ 35 ] Notably, 64% of 6-month mortality occurred during hospital stay.[ 35 ] Data were split for development and validation. ML models used to predict mortality were Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA), and SOFA Adjusted. The reference model, LR, scored an AUC of 0.75 in development. During validation, SAPS II and APACHE II scored higher than LR, whereas SOFA scored AUC of 0.68. The AUC of the SAPS II was 0.80 (95% CI 0.77–0.83).[ 35 ]

Unfavorable outcomes at 6 months

DT was used as the ML model to predict unfavorable outcomes at 6 months post-TBI.[ 37 ] The comparative model was ROC curves. ML predictive variables included various vital signs, pupil reactivity, AIS severity, initial CT scan, and Marshall score (scale of 1–6). When considering eGOS 6 months post-injury, an acceptable outcome was labeled as an eGOS score of greater than four indicating moderate or no disability. A poor outcome indicated a severe disability or death, a score of four or less. The proposed model had a specificity of 62.5%, which was higher than the core model (47.7%) and extended model (44.3%).[ 37 ] The proposed model had the highest positive predictive value of 74.0% and the extended model had a negative predictive value of 80.4%. The sensitivity was also higher in the extended model (92.7%) when compared to the proposed model (72.3%) and core model (83.8%).[ 37 ] ML and LR were used to assess mortality as an unfavorable outcome using the GOS score of <4.[ 15 ] ML predictive values include vital signs, GCS, pupillary response, and CT Classification. Prediction of mortality was measured using internal-external cross-validation, with all regressions and ML models scoring 0.81 except RF, which scored 0.79. The cross-validation of unfavorable outcomes included all regression models scoring 0.81 and all ML models scoring 0.80 except RF, which scored 0.79.[ 15 ] Various ML models were used to predict unfavorable outcomes and mortality in an additional study.[ 27 ] Unfavorable outcomes were defined as a GOS score of 1–3 (death = 1, persistent vegetative state = 2, and severe disability = 3). The RF ML model was the most effective at predicting poor outcomes (100% sensitivity, 72.3% specificity, 91.7% accuracy, and 0.895 AUC). Ridge regression (RR) was most effective at predicting mortality (88.4% sensitivity, 88.2% specificity, 88.6% accuracy, and 0.875 AUC).[ 27 ]

Prediction of outcomes in the pediatric population

ANN was compared to traditional head computed tomography (CT) analysis (i.e., Marshall CT, Helsinki CT, and Rotterdam CT) and GCS to predict adverse outcomes and mortality in pediatric TBI patients.[ 16 ] ML predictive variables included GCS, serum glucose, serum hemoglobin, pupillary response, and admission head CT results: subdural hematoma, intracranial hemorrhage, intraventricular hemorrhage, cistern integrity, and midline shift. The AUC using ANN was 0.9462 when predicting mortality and adverse outcomes, defined as a 6-month GOS ≤3.[ 35 ] The CT results ranged from an AUC of 0.781–0.838. The GCS had an AUC of 0.920.[ 16 ] An additional study used serum metabolic markers to program an ML algorithm to predict unfavorable GOS in pediatric TBI patients with both SVM and LR.[ 21 ] Both models were programmed as both a focused (only used pH, lactate, and glucose) and an inclusive algorithm using serum metabolic markers for prediction. AUC was not calculated for SVM. When predicting favorable outcomes, SVM scored a specificity of 0.99 and sensitivity of 0.80 using the focused model. The inclusive model for SVM had higher specificity with a value of 1 and the sensitivity was lower with a value of 0.63. LR predicted favorable outcomes using the focused model with an AUC of 0.83, specificity of 0.99, and sensitivity of 0.75.[ 21 ] The LR inclusive model scored higher across AUC, specificity, and sensitivity.

Prediction of secondary insults: ICP, hypotensive events, and shock index (SI)

Two studies used vital signs as outcome variables for ML. Bayesian Artificial Neural Network (BANN) was used to assess blood pressure values to develop a predictive model for hypotensive events in TBI patients in the neuro-intensive care unit.[ 45 ] Hypotensive events were described as an SBP ≤90 mmHg and MAP ≤70 mmHg sustained for at least 5 min. A hypotensive event ceases when blood pressure returns to a level above threshold/baseline for at least 5 min. [ 45 ] Vital signs were also used for the prediction of secondary insult following severe TBI.[ 7 ] Using the Nearest Neighbor Regression (NNR), ML model predictive variables such as SI and ICP were assessed.[ 7 ] Both studies assessed HR, SBP, and MAP. AUC values for BANN were as follows: test set 0.74, false-positive correction 0.68, without false-positive correction 0.63. Finally, the target sensitivity of >30% and specificity of >90% were achieved.[ 45 ] Using NNR, the other study found good agreement in predicting actual ICP with a bias of 0.02 (±2 standard deviation [SD] = 4 mm Hg) for the subsequent 5 min and −0.02 (±2 SD = 10 mm Hg) for the subsequent 2 h. The patient’s vital signs were continuously collected on 132 adult patients over a minimum of 3 h/patient (5,466 h total; 65,600 data points).[ 7 ] However, ANN was the most effective model for the prediction of hypotensive events in critical care patients.[ 45 ]


In the present systematic review and meta-analysis, we evaluate the predictive power of various ML algorithms for unfavorable outcomes and mortality in patients with TBI. Several studies have demonstrated the utility of ML in medicine; however, most TBI studies were focused on diagnosis and classification.[ 17 , 30 , 44 , 48 ] The 15 studies included in this review sought to expand the use of ML in TBI patients with a focus on mortality and unfavorable outcome prediction. ML algorithms encountering in this review including SVM, ANN, RF, NNR, and NB.

TBI remains one of the leading causes of death and disability throughout the world.[ 10 , 19 , 38 ] It is estimated that as many as 50 million people experience TBI each year.[ 10 , 13 , 19 , 25 ] TBI is a trimodal class of injury, affecting young children (falls), adults (motor vehicle accidents), and the elderly (falls) at high rates compared to other injuries.[ 13 , 24 , 31 , 47 ] TBI can result in multiple deficits, ranging from motor to sensory, and often affects cognition and memory.[ 33 , 47 ] Causes of brain damage can also include hemorrhagic infarct, cerebral edema, and crush injuries to the brain and brainstem.[ 31 , 47 ] Clinical practice has also shown that immediate treatment is dependent on clear and accurate neuroimaging, and ML algorithms have been designed to diagnose and classify TBI using radiological findings.[ 8 , 44 ] Depending on the severity of the injury, deficits from TBI can be permanent, or require intensive care and extensive rehabilitation.[ 24 , 29 , 31 , 47 ] However, neurointensive care and rehabilitation are expensive, time-consuming, and require significant effort from both the patient and their caregivers. In addition, TBI mortality is high, reaching up to 30–40% in severe TBI, and lifelong deficits are reported in approximately 60% of patients who recover.[ 5 , 6 , 11 , 13 , 24 - 26 , 29 , 47 ]

ML algorithms including RF, RR, and NB were all identified as effective prediction models for the unfavorable outcome or in-hospital mortality in TBI patients.[ 4 , 12 ] SVM was identified in multiple studies as more effective than LR in predicting mortality and unfavorable outcome using GOS.[ 2 , 14 , 21 ] Interestingly, using the NNR model, ICP fluctuations were more effectively predicted compared to traditional LR models.[ 7 ] ANN outperformed LR and other ML models in the prediction of mortality in moderate and severe TBI patients. [ 36 , 43 ] A large-scale database study identified no difference in the predictive power of both SVM and ANN; however, the authors did hypothesize that the predictive power identified in other studies may be population-dependent.[ 15 ]

The use of scoring algorithms SAPS II, APACHE II, and SOFA was found to have increased predictive power of inhospital mortality over LR, but no significant difference with overall 6-month mortality.[ 35 ] These results indicate that the benefit of ML in the prediction of outcomes may be limited to short-term complications such as in-hospital mortality and major complications. However, this information is still valuable when making clinical decisions surrounding how to treat these patients. In addition, these models outperformed the predictive power of the IMPACT II TBI database. However, these models found little influence from the input of MAP values. Furthermore, the inclusion of GCS improved the accuracy.[ 34 ] The C-statistic of models for prediction of eGOS at 6 months after discharge improved with the addition of new input variables. Discharge eGOS was used as a baseline, and with the addition of hospital length of stay as well as age, predictive power improved.[ 29 ] These findings lend further support to the importance of age and admission GCS in TBI prognosis.

The heterogeneity of input variables between ML models and studies limits the potential for cross-comparison. Those studies that had compatible methodologies were included in a small meta-analysis in an attempt to draw a quantitative conclusion regarding which model best predicts mortality. However, with the heterogeneity of input variables, inconsistency of outcome measurement, and variable criteria for TBI classification, this cannot be generalized to all TBI mortality predictions. A further prospective study with an increased sample size is necessary to definitively state, in which ML model is objectively most effective at mortality prediction. Furthermore, future studies should seek to standardize the necessary input variables for the operation of ML models. There is great inconsistency among the presented studies in the selection of input variables, with some studies only utilizing a few simple serum studies. While convenient for the provider, this limited input data may fail to capture a complete picture of the patient’s current condition. On the other hand, multiple studies employ a myriad of input variables including information that may not be easily accessible in an emergent situation, such as detailed radiological findings and hospital staffing statistics. [ 21 , 24 , 26 , 27 ] While many of these variables are employed for training the model, in practice, this level of detail is not feasible in emergent cases where these models could be most beneficial, such as emergency room triage. Based on the common variables between the analyzed studies and their individual analysis of which variables were most impactful, we would recommend studying the efficacy of models when programmed with patient age, admission GCS, serum lactate, and serum glucose.[ 18 - 22 ] While multiple studies within the review employed blood pressure measurements for programming, these were not found to be significant prognostic factors when programming the ML models to predict adverse events.[ 19 ]


TBI continues to be one of the leading causes of death and disability worldwide. This study reiterates the clinical utility of ML as an adjunct in patients with TBI. The use of ML to predict outcomes following TBI is entering clinical practice at an increasing rate and the present study reinforces the utility of these models. Using these models, simple admission data can be used to accurately predict the prognosis for individual patients. This can ultimately enhance the clinical decision-making process in terms of whether surgical intervention, medical management, or palliative care is most appropriate. There was a lack of consistency among the investigated studies with the selection of input variables used for predictive models; as a result, some models simply had more data to utilize for prediction, making inter-study comparisons more difficult. Further, research should utilize the core prediction variables identified in this review and apply these markers across a wide range of models and in multiple clinical settings. Given that the described models have demonstrated a robust ability to predict outcomes, there exists a significant degree of untapped potential in implementing ML to aid in neurosurgical decision-making. It is conceivable that these tools can be further expanded to guide and optimize patient treatment and perhaps alert neuro-care providers of patients at high risk of early neurological deterioration. Despite the increased use and predictive power of ML, it remains to be seen whether clinicians will routinely incorporate these models to guide clinical care following TBI.

Declaration of patient consent

Patient’s consent not required as there are no patients in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.


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