Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury

Abstract

IMPORTANCE Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness.OBJECTIVE To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma. DESIGN, SETTING, AND PARTICIPANTSThis cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation. EXPOSURES Traumatic brain injury.MAIN OUTCOMES AND MEASURES Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings. RESULTSThe 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database.CONCLUSIONS AND RELEVANCE This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inf...

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action

“…Yet later research has explored the extent of influence insurance has on discharge location and has found that despite similar insurance, minority patients were found to be discharged more frequently to home without care than to SNF or acute-care facility post-hospitalization. Similarly, these studies found that white patients with lower vulnerable group membership (VGM) were discharged quicker to SNF or acute-rehab facility, which has been shown to provide higher rates of functional recovery than home care, than patients of color with higher VGM scores (31)(32)(33).…”

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

“…4 San Gerardo Hospital, ASST-Monza, Monza, Italy. 5 Department of Physiopathology and Transplantation, Milan University, Milan, Italy. 6 Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.…”

“…However, intracranial surgery and extracranial surgery were less often performed in the early WLSM group compared to the later WLSM group (34 and 12% versus 58 and 22%, respectively). The maximum TIL score during ICU stay was lower in the early WLSM group compared to the later WLSM group (median [IQR] 5[1][2][3][4][5][6][7][8][9][10][11] versus10 [6.50-15]). Decisions to withdraw LSM were made in consultation with a relative in 17% of the early WLSM group and in 15% in the later WLSM group (Table…”

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action

“…Yet later research has explored the extent of influence insurance has on discharge location and has found that despite similar insurance, minority patients were found to be discharged more frequently to home without care than to SNF or acute-care facility post-hospitalization. Similarly, these studies found that white patients with lower vulnerable group membership (VGM) were discharged quicker to SNF or acute-rehab facility, which has been shown to provide higher rates of functional recovery than home care, than patients of color with higher VGM scores (31-33) .…”