Prediction of death by neurologic criteria in patients with non-traumatic acute brain injury: a systematic review and meta-analysis.

BACKGROUND

Robust predictors of death by neurologic criteria (DNC) after non-traumatic acute brain injury remain insufficiently defined. We therefore aimed to systematically synthesize the available evidence on prediction of DNC in non-traumatic brain injury.

METHODS

We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines. MEDLINE, Embase, Scopus, the Cochrane Library and Web of Science were searched to August 31, 2026. Eligible studies included randomized controlled trials, observational studies, case series and registry data. Studies were included in the quantitative synthesis when sufficient comparable data for the same prognostic factor were available from at least two studies. Pooled effect estimates were calculated using random-effects models. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. The certainty of evidence was assessed using the GRADE approach.

RESULTS

The database search identified 2,091 records. Eighteen studies comprising reported study cohorts of 9,070 participants were included. Quantitative synthesis included four studies (n=1,738), comprising two post-cardiac arrest and two stroke cohorts. In stroke populations, CT markers of severe intracranial mass effect were associated with a more than threefold increased odds of DNC (pooled OR 3.14, 95%CI 1.98-4.96; p<0.0001; I2=0%), while in post-cardiac arrest cohorts lower gray-white matter ratio values were associated with progression to DNC (pooled mean difference -0.15, 95%CI -0.22 to -0.07; p<0.001; I2=72%).

CONCLUSIONS

Evidence on predictors of DNC after non-traumatic acute brain injury remains limited and methodologically heterogeneous, with only a small number of studies providing robust analyses. Across these studies, CT-based markers - particularly indicators of diffuse cerebral edema or intracranial mass effect - show the most reproducible associations with progression to DNC.