Summary: One in four patients who were in a vegetative state after severe head trauma regained orientation — able to recall their identity, location, and the date — within 12 months of injury.
Source: UCSF
New findings strengthen the case that decisions to withdraw life-sustaining treatment for people with moderate-to-severe traumatic brain injury (TBI) should not be made in the first days after injury.
A July 6, 2021 study published in JAMA Neurology and led by researchers at UC San Francisco, the Medical College of Wisconsin, and Spaulding Rehabilitation Hospital tracked 484 adults with moderate-to-severe TBI. The study found that among patients who were in a vegetative state soon after injury, roughly 25% regained orientation — awareness of who they were, where they were, and what the date was — within 12 months.
“Early withdrawal of life-sustaining treatment based on an optimistic early prediction of a poor outcome accounts for many deaths after severe TBI,” said senior author Geoffrey Manley, MD, PhD, professor and vice chair of neurological surgery at UCSF and chief of neurosurgery at Zuckerberg San Francisco General Hospital. In the study, 64 of the 92 deaths occurred within two weeks of injury, underscoring how often early decisions influence outcomes.
“TBI can cause profound, long-lasting disability, and in some cases the prognosis is clear early on,” Manley added. “However, our results show that a meaningful portion of patients experience substantial recovery between two weeks and one year, with many regaining independence during that period.”
Participants were enrolled through the TRACK-TBI (Transforming Research and Clinical Knowledge in Traumatic Brain Injury) research initiative, led by Manley. All were age 17 or older and had presented to level 1 trauma centers within 24 hours of injury. Their initial clinical findings qualified them as having either moderate or severe TBI.
Falls, assaults, and motor vehicle or motorcycle crashes were the most common causes of injury in both the moderate and severe TBI groups. The study population skewed young and male: the median age was mid-to-late 30s, with about 78–80% male participants in both severity groups.
Researchers assessed recovery using the Glasgow Outcome Scale Extended (GOSE), which ranges from 1 (death) to 8 (upper good recovery and return to normal life), and the Disability Rating Scale (DRS), which evaluates impairment and functional disability.
By 12 months, a meaningful minority of severe TBI patients had little or no disability
At two weeks post-injury, most patients still showed moderate-to-severe disability: 93% of those with severe TBI and 79% of those with moderate TBI had DRS scores indicating substantial impairment. Nearly 80% across both groups scored 2–3 on the GOSE, reflecting the need for assistance with basic daily activities.
By one year after injury, outcomes had improved substantially. About half of the severe TBI group and three-quarters of the moderate TBI group achieved GOSE scores of 4 or higher, indicating they could be independent at home for at least eight hours a day. According to the DRS, 19% of patients with severe TBI reported no disability at 12 months, and another 14% had only mild disability.
The most striking results involved patients who were in a vegetative state at two weeks — a condition defined by wakefulness without signs of awareness. Of the 62 surviving patients who had been vegetative early on, all had regained consciousness by 12 months, and 14 of the 56 with complete data (about 25%) had regained orientation. Nearly every survivor in this group recovered at least basic communication abilities.
“These individuals ultimately met criteria for a favorable outcome,” said co-first author Joseph Giacino, PhD, of Spaulding Rehabilitation Hospital, Massachusetts General Hospital, and Harvard Medical School. “GOSE scores of 4 or higher meant they could be at home unsupervised for parts of the day, able to manage basic needs such as eating and toileting.”
This study builds on earlier research showing that many patients with severe early impairments can achieve meaningful functional recovery months to years later. It echoes the American Academy of Neurology’s 2018 guidance advising clinicians to avoid definitive negative prognoses during the first 28 days after injury.
“While a large proportion of patients will die or have persistent disability, our findings add to growing evidence that severe early impairment does not always predict uniformly poor long-term outcomes,” said Manley, who is also affiliated with the UCSF Weill Institute for Neurosciences. “Even a vegetative state can evolve; recovery potential remains dynamic throughout the first year.”
Co-first author Michael McCrea, PhD, of the Medical College of Wisconsin is also listed among the study leaders. A complete list of authors and TRACK-TBI investigators appears in the published article.
Funding: The research was supported by grants from the U.S. National Institutes of Health, the National Institute of Neurologic Disorders and Stroke, the U.S. Department of Defense, and the TBI Endpoints Development (TED) Initiative.
About this TBI research news
Source: UCSF
Contact: Press Office – UCSF
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Original Research: Closed access. “Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study” by Geoffrey Manley et al. JAMA Neurology
Abstract
Functional Outcomes Over the First Year After Moderate to Severe Traumatic Brain Injury in the Prospective, Longitudinal TRACK-TBI Study
Importance
Moderate to severe traumatic brain injury (msTBI) is a leading cause of death and disability globally. Few studies have prospectively tracked outcomes from the acute phase through chronic recovery after msTBI.
Objective
To prospectively measure outcomes across major domains of life function at 2 weeks and at 3, 6, and 12 months after msTBI.
Design, Setting, and Participants
This cohort study, part of the TRACK-TBI program, enrolled patients at 18 U.S. level 1 trauma centers from February 2014 through August 2018 and followed participants for 12 months. The analysis included 484 patients with moderate to severe TBI (Glasgow Coma Scale scores 3–12) drawn from the larger TRACK-TBI cohort. Data analysis ran from October 2019 to April 2021.
Exposures
Moderate or severe traumatic brain injury.
Main Outcomes and Measures
Global functional status was measured with the Glasgow Outcome Scale–Extended (GOSE) and Disability Rating Scale (DRS) at 2 weeks and 3, 6, and 12 months postinjury. GOSE scores were dichotomized into favorable (4–8) versus unfavorable (1–3). Neurocognitive testing and patient-reported outcomes were also analyzed at 12 months.
Results
Of the 484 eligible patients, 362 had severe TBI (median age ~35.5 years; 78% men) and 122 had moderate TBI (median age ~38 years; 80% men). At two weeks, favorable GOSE outcomes were present in 12.4% of severe and 41% of moderate cases. By 12 months, favorable outcomes were observed in 52.4% of severe and 75% of moderate TBI patients. Approximately 19% of severe and 32% of moderate TBI patients reported no disability on the DRS at 12 months. Among those in a vegetative state at two weeks, 78% regained consciousness and 25% regained orientation by one year.
Conclusions and Relevance
Patients with moderate-to-severe TBI often make substantial functional gains, including recovery of independence, between 2 weeks and 12 months after injury. Severe early impairment does not always predict poor long-term outcome. Clinicians should be cautious about early, definitive prognoses that could lead to withdrawal of life-sustaining treatment in the first two weeks after injury.