Time course and diagnostic utility of NfL, tau, GFAP, and UCH-L1 in subacute and chronic TBI

Neurology. 2020 Aug 11;95(6):e623-e636. doi: 10.1212/WNL.0000000000009985. Epub 2020 Jul 8.


Objective: To determine whether neurofilament light (NfL), glial fibrillary acidic protein (GFAP), tau, and ubiquitin C-terminal hydrolase-L1 (UCH-L1) measured in serum relate to traumatic brain injury (TBI) diagnosis, injury severity, brain volume, and diffusion tensor imaging (DTI) measures of traumatic axonal injury (TAI) in patients with TBI.

Methods: Patients with TBI (n = 162) and controls (n = 68) were prospectively enrolled between 2011 and 2019. Patients with TBI also underwent serum, functional outcome, and imaging assessments at 30 (n = 30), 90 (n = 48), and 180 (n = 59) days, and 1 (n = 84), 2 (n = 57), 3 (n = 46), 4 (n = 38), and 5 (n = 29) years after injury.

Results: At enrollment, patients with TBI had increased serum NfL compared to controls (p < 0.0001). Serum NfL decreased over the course of 5 years but remained significantly elevated compared to controls. Serum NfL at 30 days distinguished patients with mild, moderate, and severe TBI from controls with an area under the receiver-operating characteristic curve (AUROC) of 0.84, 0.92, and 0.92, respectively. At enrollment, serum GFAP was elevated in patients with TBI compared to controls (p < 0.001). GFAP showed a biphasic release in serum, with levels decreasing during the first 6 months of injury but increasing over the subsequent study visits. The highest AUROC for GFAP was measured at 30 days, distinguishing patients with moderate and severe TBI from controls (both 0.89). Serum tau and UCH-L1 showed weak associations with TBI severity and neuroimaging measures. Longitudinally, serum NfL was the only biomarker that was associated with the likely rate of MRI brain atrophy and DTI measures of progression of TAI.

Conclusions: Serum NfL shows greater diagnostic and prognostic utility than GFAP, tau, and UCH-L1 for subacute and chronic TBI.

Classification of evidence: This study provides Class III evidence that serum NfL distinguishes patients with mild TBI from healthy controls.

Publication types

  • Research Support, N.I.H., Intramural
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adult
  • Area Under Curve
  • Atrophy
  • Biomarkers / blood
  • Brain / pathology
  • Brain Injuries, Traumatic / blood*
  • Brain Injuries, Traumatic / cerebrospinal fluid
  • Brain Injuries, Traumatic / diagnostic imaging
  • Brain Injuries, Traumatic / epidemiology
  • Chronic Disease
  • Diffuse Axonal Injury / blood
  • Diffuse Axonal Injury / cerebrospinal fluid
  • Diffuse Axonal Injury / diagnostic imaging
  • Diffuse Axonal Injury / epidemiology
  • Diffusion Tensor Imaging
  • Female
  • Glial Fibrillary Acidic Protein / blood*
  • Humans
  • Male
  • Middle Aged
  • Neurofilament Proteins / blood*
  • Organ Size
  • Prospective Studies
  • ROC Curve
  • Recovery of Function
  • Ubiquitin Thiolesterase / blood*
  • United States / epidemiology
  • tau Proteins / blood*


  • Biomarkers
  • GFAP protein, human
  • Glial Fibrillary Acidic Protein
  • MAPT protein, human
  • Neurofilament Proteins
  • UCHL1 protein, human
  • neurofilament protein L
  • tau Proteins
  • Ubiquitin Thiolesterase