Research Reports - Unexpected recovery of function after severe traumatic brain injury: the limits of early neuroimaging-based outcome prediction

Neurocrit Care. 2013 Dec;19(3):364-75

Edlow BL, Giacino JT, Hirschberg RE, Gerrard J, Wu O, Hochberg LR

BACKGROUND: Prognostication in the early stage of traumatic coma is a common
challenge in the neuro-intensive care unit. We report the unexpected recovery of
functional milestones (i.e., consciousness, communication, and community
reintegration) in a 19-year-old man who sustained a severe traumatic brain
injury. The early magnetic resonance imaging (MRI) findings, at the time,
suggested a poor prognosis.
METHODS: During the first year of the patient's recovery, MRI with diffusion
tensor imaging and T2*-weighted imaging was performed on day 8 (coma), day 44
(minimally conscious state), day 198 (post-traumatic confusional state), and day
366 (community reintegration). Mean apparent diffusion coefficient (ADC) and
fractional anisotropy values in the corpus callosum, cerebral hemispheric white
matter, and thalamus were compared with clinical assessments using the Disability
Rating Scale (DRS).
RESULTS: Extensive diffusion restriction in the corpus callosum and bihemispheric
white matter was observed on day 8, with ADC values in a range typically
associated with neurotoxic injury (230-400 × 10(-6 )mm(2)/s). T2*-weighted MRI
revealed widespread hemorrhagic axonal injury in the cerebral hemispheres, corpus
callosum, and brainstem. Despite the presence of severe axonal injury on early
MRI, the patient regained the ability to communicate and perform activities of
daily living independently at 1 year post-injury (DRS = 8).
CONCLUSIONS: MRI data should be interpreted with caution when prognosticating for
patients in traumatic coma. Recovery of consciousness and community reintegration
are possible even when extensive traumatic axonal injury is demonstrated by early

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