Prognostic Significance of Preoperative Neurological Versus Radiological Deterioration in Older Patients with Moderate-to-Mild Traumatic Brain Injury

<b>Background</b>: The prognostic value of preoperative deterioration in older patients with moderate-to-mild traumatic brain injury (TBI) remains unclear. Therefore, this study aimed to evaluate the impact of preoperative neurological and radiological deterioration on clinical outcomes in this population undergoing surgery. <b>Methods</b>: We retrospectively reviewed patients aged ≥ 65 years with moderate-to-mild TBI (Glasgow Coma Scale (GCS) ≥ 9) who underwent surgery between 2013 and 2022. Patients were grouped based on preoperative deterioration, classified as neurological (≥2-point sustained GCS drop lasting more than 1 h) or radiological (new/aggravated imaging lesions). Study outcomes included in-hospital mortality and 6-month functional status. Multivariable logistic regression was performed to identify independent predictors of outcomes. <b>Results</b>: Among 58 patients, preoperative deterioration was observed in 34 (58.6%), including 14 (24.1%) with neurological and 20 (34.5%) with radiological deterioration. In-hospital mortality was significantly higher in patients with neurological deterioration than in those without (57.1% vs. 13.6%; <i>p</i> = 0.002). Radiological deterioration alone was not associated with increased mortality or unfavorable functional outcome at 6 months. Neurological deterioration was an independent predictor of in-hospital death (adjusted odds ratio (OR), 47.9; <i>p</i> = 0.004) and unfavorable 6-month outcome (adjusted OR, 35.0; <i>p</i> = 0.014), whereas radiological deterioration was not. A lower initial GCS was also associated with unfavorable outcomes (adjusted OR, 0.5; <i>p</i> = 0.013). <b>Conclusions</b>: Preoperative neurological deterioration is an independent predictor of in-hospital mortality and unfavorable functional outcome at 6 months in older patients undergoing surgery for moderate-to-mild TBI. These findings underscore clinical neurological decline-not radiologic progression-should guide prognostication and early intervention strategies.