Performance of GFAP and UCH-L1 compared to S100B in detecting intracranial injury: influence of age, hemolysis, neurodegenerative diseases, and extracranial fractures in a prospective cohort of over 1,000 patients

Antoine Puravet; Vincent Sapin; Jean-Baptiste Bouillon-Minois; Bruno Pereira; Julie Durif; Benjamin Bouthors; Farès Moustafa; Jeannot Schmidt; Damien Bouvier; Charlotte Oris

doi:10.1515/cclm-2025-1129

Article

Performance of GFAP and UCH-L1 compared to S100B in detecting intracranial injury: influence of age, hemolysis, neurodegenerative diseases, and extracranial fractures in a prospective cohort of over 1,000 patients

Antoine Puravet , Vincent Sapin , Jean-Baptiste Bouillon-Minois , Bruno Pereira , Julie Durif , Benjamin Bouthors , Farès Moustafa , Jeannot Schmidt , Damien Bouvier and Charlotte Oris

Published/Copyright: October 9, 2025

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From the journal Clinical Chemistry and Laboratory Medicine (CCLM)

Abstract

Objectives

To compare the diagnostic performances of GFAP and UCH-L1 with S100B in detecting intracranial injury, while investigating the impact of confounding factors.

Methods

In a large prospective cohort of 1,010 patients with mild traumatic brain injury, we first evaluated the clinical performances of S100B and the GFAP/UCH-L1 combination. To explore the impact of pre-analytical interferences on GFAP and UCH-L1 levels, HIL indices (hemolysis, icterus, lipemia) were measured using the Atellica^® analyzer, and spiking experiments were performed with increasing concentrations of hemolysate, bilirubin, and Intralipid^®. We then assessed the influence of four confounders on biomarker specificity: age over 80 years, hemolysis, neurodegenerative diseases, and extracranial fractures. Finally, we evaluated the ability of the biomarkers to predict clinical outcomes at one month.

Results

S100B and the GFAP/UCH-L1 combination showed sensitivities of 96 and 100 %, and specificities of 25 and 27 %, respectively. False positives were significantly associated with age >80 and extracranial fractures for S100B; with age >80 and neurodegenerative diseases for GFAP; and with age >80, hemolysis, and extracranial fractures for UCH-L1. UCH-L1 levels were markedly increased by hemolysis, starting at 400 mg/L of hemoglobin. Age was the only confounding factor to significantly affect specificity. Using age-adjusted thresholds in patients over 80 increased specificity to 30 % for S100B and 33 % for GFAP/UCH-L1. Overall, the biomarkers exhibited limited predictive value and performed poorly for one-month clinical outcomes.

Conclusions

S100B and the GFAP/UCH-L1 combination demonstrated very high sensitivities, close to 100 %, with specificities of approximately 30 % for the diagnosis of intracranial lesions. Age-adjusted thresholds improve specificity in older patients, supporting their clinical implementation. This study also provides the first evidence that hemolysis significantly elevates UCH-L1 concentrations from 400 mg/L of hemoglobin.

Keywords: confounding factors; glial fibrillary acidic protein (GFAP); hemolysis; mild traumatic brain injury (mTBI); S100B; ubiquitin carboxy-terminal hydrolase L1 (UCH-L1)

Corresponding author: Dr. Charlotte Oris, PhaemD, PhD, Service de Biochimie et Génétique Moléculaire, Centre de Biologie, CHU Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France, E-mail: coris@chu-clermontferrand.fr

Acknowledgments

The authors would like to thank the technicians in the Department of Biochemistry and Molecular Genetics at Clermont-Ferrand University Hospital for their help with the biomarker assays.

Research ethics: This study received approval from the Ile-de-France Ethics Committee for the Protection of Persons, in accordance with French regulations on research involving human participants (Reference 52-2019).
Informed consent: Patients were informed of their right to express disagreement regarding the use of their clinical information for research purposes.
Author contributions: AP, CO and DB analyzed and interpreted the data. AP wrote the initial version of the manuscript. DB, VS, JB, JS, FM and CO designed the study and assisted with interpretation of the data and writing of the manuscript. AP, BB and JD carried out assays. AP and BP provided statistical advice for the study design and analyzed the data. All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Use of Large Language Models, AI and Machine Learning Tools: None declared.
Conflict of interest: The authors state no conflict of interest.
Research funding: None declared.
Data availability: The raw data can be obtained on request from the corresponding author.

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Received: 2025-08-28

Accepted: 2025-09-30

Published Online: 2025-10-09

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https://doi.org/10.1515/cclm-2025-1129

Keywords for this article

confounding factors; glial fibrillary acidic protein (GFAP); hemolysis; mild traumatic brain injury (mTBI); S100B; ubiquitin carboxy-terminal hydrolase L1 (UCH-L1)