It’s now day 14 of admission in the NCCU. The patient has not had any improvement in her mental status. You suspect that she’s in a state of unresponsive wakefulness. She’s been on pressure support ventilation with minimal support, but she clearly still can’t protect her airway. You discuss the idea of tracheostomy with the family further. They ask you if she has any realistic chance of neurologic recovery.
She clearly has sustained a severe injury, and her brain still hasn’t recovered to the point of regaining consciousness. With this being the case now two weeks out from the injury, it’s natural to conclude that she won’t ever regain consciousness.
However, fortunately, we know this to be false. In 2021, McCrea et al. reviewed the TRACK-TBI cohort and specifically looked at functional outcomes for patients in the first year after they sustained a moderate or severe TBI. Patients across multiple level 1 trauma centers were included, with a total of 484 patients. At 2 weeks from injury, there were 79 patients who were in a state of unresponsive wakefulness. At the 1 year mark, 17 patients died. Of the 62 survivors, 100% of them recovered consciousness by 1 year!
Now, you might say that recovering consciousness alone is a low bar. Well, of these survivors, all of whom regained consciousness, 65% were oriented or confused, 53% could completely or partially feed themselves, 32% were completely independent to mildly dependent, and 71% were employable. Considering that this cohort was the sickest of the sick, with the worst exams, these are astounding levels of improvement. Yes, severe TBI can be severe in resultant deficits and disabilities. However, there can also be great functional outcomes as well.
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