A traumatic brain injury prognostic model to support in-hospital triage in a low-income country: a machine learning–based approach

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Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionate burden of this injury on low- and middle-income countries (LMICs). Limited access to diagnostic technologies and highly skilled providers combined with high patient volumes contributes to poor outcomes in LMICs. Prognostic modeling as a clinical decision support tool, in theory, could optimize the use of existing resources and support timely treatment decisions in LMICs. The objective of this study was to develop a machine learning–based prognostic model using data from Kilimanjaro Christian Medical Centre in Moshi, Tanzania.


This study is a secondary analysis of a TBI data registry including 3138 patients. The authors tested nine different machine learning techniques to identify the prognostic model with the greatest area under the receiver operating characteristic curve (AUC). Input data included demographics, vital signs, injury type, and treatment received. The outcome variable was the discharge score on the Glasgow Outcome Scale–Extended.


The AUC for the prognostic models varied from 66.2% (k-nearest neighbors) to 86.5% (Bayesian generalized linear model). An increasing Glasgow Coma Scale score, increasing pulse oximetry values, and undergoing TBI surgery were predictive of a good recovery, while injuries suffered from a motor vehicle crash and increasing age were predictive of a poor recovery.


The authors developed a TBI prognostic model with a substantial level of accuracy in a low-resource setting. Further research is needed to externally validate the model and test the algorithm as a clinical decision support tool.

ABBREVIATIONS AUC = area under the receiver operating characteristic curve; ED = emergency department; GCS = Glasgow Coma Scale; GOSE = Glasgow Outcome Scale–Extended; HIC = high-income country; ICU = intensive care unit; KCMC = Kilimanjaro Christian Medical Centre; LMICs = low- and middle-income countries; ML = machine learning; MOI = mechanism of injury; PERRLA = pupils equal, round, and reactive to light and accommodation; TBI = traumatic brain injury.

Article Information

Correspondence Cyrus Elahi: Duke University, Durham, NC. cyrusweal@gmail.com.

INCLUDE WHEN CITING Published online May 10, 2019; DOI: 10.3171/2019.2.JNS182098.

Disclosures Dr. Staton acknowledges salary support funding from the Fogarty International Center (K01, TW010000-01A1), Mr. Rocha acknowledges scholarship support funding from the CAPES foundation (88881.131508/2016-01), and Dr. Haglund acknowledges support from NuVasive and LifeNet for non–study-related clinical or research effort.

© AANS, except where prohibited by US copyright law.



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    Comparison of ML models applied to predict TBI outcome. Each line represents the receiver operating characteristic (ROC) curve for a different ML technique. The Bayesian generalized linear model (Bay. Gen. Lin. Mod) was the top performing technique. Grad. boost. machine = gradient boosting machine; Bay. Add. Reg. Tr. = Bayesian additive regression trees. Figure is available in color online only.

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    Bar chart for the extracted beta coefficients (Coeff) from the top performing prognostic model, the Bayesian generalized linear model. Orange lines represent variables associated with a poor recovery, whereas blue lines represent variables associated with a good recovery. BP = blood pressure; intercept = value in regression model, included for the sake of transparency. Figure is available in color online only.

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    The web-based application (A) and the mobile-based application (B). Figure is available in color online only





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