Patients with traumatic brain injury (TBI) often experience an initial disorder of consciousness (DOC) that persists after acute care, but most of these patients recover consciousness during the rehabilitation process, according to a study in JAMA Neurology.
A total of 17,470 patients with TBI from the longitudinal Traumatic Brain Injury Model Systems National Database were included in this cohort study. All patients had survived a moderate or severe TBI and were discharged from acute hospitalization and admitted to an inpatient rehabilitation program between 1989 and 2019.
Patients were followed through completion of inpatient rehabilitation. Outcomes included changes on the Glasgow Coma Scale (GCS) in the ED, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure.
The median age of this population at time of injury was 39 years. Approximately 57% (n=7547) of the 13,458 patients who had a GCS score available in the ED had an initial loss of consciousness. This initial loss of consciousness persisted to rehabilitation in 12% (n=2058) of patients.
Individuals with persisting DOC were significantly younger (35 vs 40 years; P <.001), had more high-velocity injuries (55% vs 49%; P <.001), had intraventricular hemorrhage (40% vs 23%; P <.001) and subcortical contusion (32% vs 18%; P <.001), and had longer acute care (25 vs 15 days; P <.001) compared with patients without persisting DOC.
A total of 1674 (82%) patients who were comatose were able to recover consciousness during inpatient rehabilitation. According to a multivariable analysis, factors associated with recovery of consciousness included the 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).
The functional improvement, which was defined in this study as the change in total functional independence score from admission to discharge, was +43 for patients with DOC vs +37 for patients without DOC (P =.002). Approximately 40% of patients with DOC became partially or fully independent. Factors associated with better functional outcome included younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion.
A potential limitation of this study was the inclusion of only those patients who were admitted to inpatient rehabilitation, which the study researchers suggest may limit generalizability of the findings across patients with poor prognosis, lack of insurance, or other factors.
The study researchers concluded that the recovery trajectory identified in this study “may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Kowalski RG, Hammond FM, Weintraub AH, et al. Recovery of consciousness and functional outcome in moderate and severe traumatic brain injury. JAMA Neurol. Published online March 1, 2021. doi:10.1001/jamaneurol.2021.0084