Disclosures: Kowalski reports receiving grants from the National Institute on Disability, Independent Living, and Rehabilitation Research during the conduct of the study. Please see the study for all other authors’ relevant financial disclosures. Kim reports receiving grants from the American Academy of Neurology, the NIH and Swebilius Foundation. Sheth reports receiving grants from the American Heart Association, Bard, Biogen, Hyperfine, the NIH and Novartis; other support from Alva Equity and Zoll DSMB Chair; and personal fees from NControl outside the submitted work.
March 16, 2021
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Caution ‘warranted’ in treatment decisions for co-morbid TBI, disorder of consciousness

Disclosures: Kowalski reports receiving grants from the National Institute on Disability, Independent Living, and Rehabilitation Research during the conduct of the study. Please see the study for all other authors’ relevant financial disclosures. Kim reports receiving grants from the American Academy of Neurology, the NIH and Swebilius Foundation. Sheth reports receiving grants from the American Heart Association, Bard, Biogen, Hyperfine, the NIH and Novartis; other support from Alva Equity and Zoll DSMB Chair; and personal fees from NControl outside the submitted work.
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Most individuals who became comatose after moderate or severe traumatic brain injury regained consciousness, including those who regained consciousness during rehabilitation, according to findings from a cohort study.

The researchers, who published the findings in JAMA Neurology, noted that these findings suggest the use of caution in deciding whether to withdraw or withhold treatment among patients with traumatic brain injury (TBI) and a disorder of consciousness.

Robert G. Kowalski

“Historically, the prognosis for recovery among patients who have prolonged unconsciousness or disorders of consciousness like this has been perceived to be poor, with little hope for a return to independence,” Robert G. Kowalski, MBBCh, MS, clinical instructor in the department of neurology at the University of Colorado School of Medicine, told Healio Neurology. “For this reason, in a significant proportion of cases, decisions are made to withdraw or withhold life-sustaining therapies, and the patients die. This in turn contributes to perceived poor prognosis in severe TBI — a so-called ‘self-fulfilling prophecy.’ We sought to evaluate progress during the early acute care and inpatient rehabilitation treatment phases for these patients, including the more severely injured and those who lost consciousness, when their care was continued.”

Specifically, Kowalski and colleagues aimed to quantify the loss of consciousness, factors linked to recovery and return to functional independence among a sample of individuals with moderate or severe brain trauma between Jan. 4, 1989, and June 19, 2019. They analyzed data from 17,470 individuals with TBI included in the prospective, multiyear, longitudinal Traumatic Brain Injury Model Systems National Database. Median participant age at injury was 39 years and 74% of participants were men. Participants had survived moderate or severe TBI and had been discharged from acute hospitalization and admitted to inpatient rehabilitation at one of 23 inpatient rehabilitation centers. The study follow-up period went through completion of inpatient rehabilitation.

The Glasgow Coma Scale in the ED, Disability Rating Scale, posttraumatic amnesia and Functional Independence Measure served as outcome measures. Demographic characteristics, injury cause and brain computed tomography findings comprised patient-related data.

Among patients with TBI, 7,547 (57%) had initial loss of consciousness, which continued through rehabilitation among 2,058 (12%) of these individuals. Factors associated with increased risk for persisting disorder of consciousness included younger age; more high-velocity injuries; having had intracranial mass effect, intraventricular hemorrhage and subcortical contusion; and having had longer acute care vs. patients without disorder of consciousness. A total of 1,674 (82%) of comatose patients regained consciousness during inpatient rehabilitation. Multivariable analysis demonstrated that factors linked to consciousness recovery included absence of intraventricular hemorrhage (adjusted OR [aOR] = 0.678; 95% CI, 0.532-0.863) and intracranial mass effect (aOR = 0.759; 95% CI, 0.595-0.968).

Functional improvement — defined as the change in total functional independence score from admission to discharge — increased by 43 points for patients with a disorder of consciousness and 37 points for those without a disorder of consciousness (P = .002), according to the study results. A total of 803 (40%) of 2,013 patients with disorder of consciousness became partially or fully independent. Factors linked to better functional outcome included younger age, male sex and absence of intraventricular hemorrhage, intracranial mass effect and subcortical contusion. The researchers noted consistent findings across the database’s 3 decades.

The findings have clinical relevance for patients who have experienced a TBI, as well as their families and acute care physicians, according to Kowalski.

“Treating physicians want and need evidence of prognosis upon which to make these decisions and to provide guidance in treatment decisions with families. Family members also want this information. The same is true for clinicians who provide rehabilitation care if this is chosen,” he said. “The results of our study, we think, show that caution is warranted in decision making to withdraw or withhold care in patients with these serious brain injuries. Even when loss of consciousness occurs after the brain injury, a meaningful recovery is possible.”

The results also provide strategies that could help guide treatment decisions, Kowalski continued.

“Our study found that absence of specific signs of neuroanatomic injury on brain imaging (typically brain CT in the acute phase of treatment), including blood in the ventricles of the brain and pronounced midline shift and compression of cerebral structures within the skull, portends better prospects for recovery of consciousness and functional ability for these patients. These findings may provide imaging guidance upon which decisions can be made, using tools readily available to most TBI treating teams,” he said. “We think the results support the value of pursuing inpatient rehabilitation after initial hospital care for these patients, both in terms of recovery of consciousness and to aid a return to independence in daily life.”

In a related editorial, Jennifer A. Kim, MD, PhD, and Kevin N. Sheth, MD, both of the division of neurocritical care in the department of neurology at Yale School of Medicine, highlighted “a few important questions” that the findings from Kowalski and colleagues raise, including the factors associated with late withdrawal of life-sustaining therapies and with the criteria used to evaluate eligibility for acute rehabilitation.

“Defining both good and poor prognostic risk factors is critical to portending recovery,” they wrote. “Future work must refine biomarker identification and use in patients with [disruption of consciousness] to improve physician prognostication and avoid self-fulfilling prophecy.”