Incremental prognostic value of computed tomography scoring systems over Glasgow Coma Scale in traumatic brain injury: A comparative analysis of Marshall and Rotterdam scores

Abstract Introduction: Early prognostication in traumatic brain injury (TBI) is important for guiding acute management and risk stratification. While the Glasgow Coma Scale (GCS) is a standard bedside indicator, computed tomography (CT)-based scoring systems such as the Marshall CT classification and Rotterdam CT score may provide additional prognostic value. Materials and Methods: This hospital-based, observational, and analytical study included 180 patients with acute TBI. The clinical parameters, including GCS and pupillary response, were recorded at admission. CT images were evaluated using Marshall and Rotterdam scoring systems. The primary endpoint was in-hospital mortality and the secondary endpoint was discharge functional status assessed using the Glasgow Outcome Scale. Multivariable logistic regression and receiver operating characteristic analysis were performed to assess predictive performance and incremental value. Results: Among 180 patients, 52 (28.9%) died. GCS predicted mortality well (area under the curve [AUC] 0.812) and addition of Marshall or Rotterdam CT scores improved discrimination similarly (combined model AUCs 0.898 and 0.897). Decision curve analysis showed greater net benefit for the combined models than GCS alone across clinically relevant thresholds. For poor functional outcome, GCS showed moderate discrimination (AUC 0.755), with only modest incremental value from CT scores (ΔAUC 0.016–0.032). Conclusion: CT scoring systems significantly improve mortality prediction when combined with GCS but offer limited additional value for predicting functional outcomes. Marshall and Rotterdam scores demonstrate comparable performance.