Traumatic Brain Injury (TBI) patients often have an initial impairment of consciousness (DOC) that persists after acute care. However, according to a study in JAMA Neurology, most of these patients recover during the rehabilitation process.
A total of 17,470 patients with TBI from the National Database for Longitudinal Traumatic Brain Injury Model Systems were included in this cohort study. All patients had survived moderate or severe TBI and were discharged from acute hospitalization and entered an inpatient rehabilitation program between 1989 and 2019.
The patients were followed up to the end of the inpatient rehabilitation. Results included changes to the Glasgow Coma Scale (GCS) in ED, the Disability Rating Scale, Post Traumatic Amnesia, and the Functional Independence Measure.
The mean age of this population at the time of injury was 39 years. Approximately 57% (n = 7547) of the 13,458 patients for whom a GCS score was available in ED had an initial loss of consciousness. This initial loss of consciousness persisted in 12% (n = 2058) of the patients.
Individuals with persistent DOC were significantly younger (35 vs. 40 years; P <0.001), had more high-speed injuries (55% vs. 49%; P <0.001), had intraventricular bleeding (40% vs. 23%; P <) 0.001 ) and subcortical contusion (32% versus 18%; P <0.001) and had longer acute care (25 versus 15 days; P <0.001) compared to patients without persistent DOC.
A total of 1,674 (82%) comatose patients regained consciousness during inpatient rehabilitation. According to a multivariable analysis, factors associated with restoration of consciousness included the absence of intraventricular bleeding (adjusted odds ratio) [OR]0.678; 95% CI, 0.532-0.863; P = 0.002) and intracranial mass effect (adjusted OR 0.759; 95% CI 0.595-0.968; P = 0.03).
The functional improvement, defined in this study as the change in the total score of functional independence from admission to discharge, was +43 for patients with DOC versus +37 for patients without DOC (P = 0.002). Approximately 40% of patients with DOC became partially or completely independent. Factors associated with better functional outcome included younger age, male gender, and the absence of intraventricular hemorrhage, an intracranial mass effect, and subcortical contusion.
One possible limitation of this study was the inclusion of only those patients who were admitted to inpatient rehabilitation, which, in the opinion of the study researchers, could limit the generalizability of the results in patients with a poor prognosis, lack of insurance, or other factors.
The study researchers concluded that the recovery pathway identified in this study “may influence decisions about acute and rehabilitation treatment and that caution should be exercised when patients with TBI and DOC discontinue or withhold treatment.”
Disclosure: Several authors of the study have stated that they are part of the pharmaceutical industry. For a full list of the authors’ information, see the original reference.
Kowalski RG, Hammond FM, Weintraub AH et al. Restoration of consciousness and functional outcome in moderate and severe traumatic brain injuries. JAMA Neurol. Published online March 1, 2021. doi: 10.1001 / jamaneurol.2021.0084