Research Reports - Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury

J Neurosurg. 2017 Sep 22:1-7. doi: 10.3171/2017.3.JNS162720. [Epub ahead of
print]

Vedantam A(1), Robertson CS(1), Gopinath SP(1).

OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor
prognosis is responsible for the majority of in-house deaths in severe traumatic
brain injury (TBI). With increased focus on the decision and timing of withdrawal
of care in patients with severe TBI, data on early neurological recovery in
patients with a favorable outcome is needed to guide physicians and families.
METHODS The authors reviewed prospectively collected data obtained in 1241
patients with head injury who were treated between 1986 and 2012. Patients with
severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who
had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating
moderate disability or good recovery) at 6 months were selected. Baseline
demographic, clinical, and imaging data were analyzed. The time from injury to
the first record of following commands (mGCS score of 6) after injury was
recorded. The temporal profile of GOS scores from discharge to 6 months after the
injury was also assessed. RESULTS The authors studied 218 patients (183 male and
35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were
able to follow commands (mGCS score of 6) within the 1st week after injury
(71.4%), with the highest percentage of patients in this group recovering on Day
1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the
injury was seen in 14.8% of patients, who experienced significantly longer
durations of intracranial pressure monitoring (p = 0.001) and neuromuscular
blockade (p < 0.001). In comparison with patients with moderate disability,
patients with good recovery had a higher initial GCS score (p = 0.01), lower
incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p <
0.001) and total hospital stay (p < 0.001). There was considerable improvement in
GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of
patients with a favorable outcome after severe TBI may begin to follow commands
beyond 2 weeks after the injury. These data caution against early withdrawal of
life-sustaining treatment in patients with severe TBI. 

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