Clinicians should refrain from making early negative prognostic generalisations about poor functional outcomes following moderate and severe TBI, results from a US study suggest.

A large proportion of patients with moderate to severe traumatic brain injury (msTBI) show major improvement in life functioning, with many regaining independence between two weeks and 12 months post injury, according to TRACT-TBI study.

The finding from 484 patients with msTBI  has prompted the US investigators to recommend that clinicians be ‘particularly cautions about making early definitive prognostic statements suggesting poor outcomes and withdrawal of life-sustaining treatment in patients with msTBI.’

At 2 weeks post-injury, 94% of the severe TBI group and 79% of the moderate TBI group had moderate to severe disability or worse (DRS scores ≥4) and approximately 80% required assistance in basic aspects of everyday function (GOSE scores 1-3).

By 12 months, however, half of the severe TBI group and three-quarters of the moderate TBI group were able to function independently at home for at least 8 hours per day (GOSE scores ≥4).

Among the severe TBI group, 19% went on to report no disability (DRS score 0) and another 14% had only mild disability (DRS scores 1-3) at 12 months postinjury.

Perhaps most compelling, among participants who were in a vegetative state at 2 weeks and survived, all recovered consciousness and more than 25% regained orientation by 12 months.

Meanwhile the percentage of participants with severe TBI and a favourable outcome nearly quadrupled from 12% at 2 weeks to 45% at 3 months, compared with an increase from 41% to 70% in the moderate TBI group.

Ongoing efforts by TRACK-TBI investigators are underway to identify clinical variables that improve prognostic accuracy in patients with msTBI but in the meantime the group suggests ‘early prognostic counselling and decision-making about withdrawal of life-sustaining care should acknowledge the limitations of prognostic certainty’.

Holy grail for predicting TBI outcomes

Commenting on the study Professor Melinda Fitzgerald, Professor of Neurotrauma at Curtin University and the Perron Institute for Neurological and Translational Science, said the findings were an important addition to the literature.

“It has been a bit of a holy grail in terms of being able to predict outcomes in traumatic brain injury and there’s been a number of large scale initiatives that have looked to address this because it’s become apparent that we really don’t have a good idea when someone enters into an ED whether or not they will recover,”she told the limbic.

“TRACT-TBI says that at two weeks someone being in a vegetative state is not an indication that they’re going to stay that way – they may well recover quite substantially. It tell us that we can’t really predict outcomes at two weeks.”

Though certain elements do have some prognostic predictive value – potential imaging findings, blood biomarkers, a range of functional elements around the persons injury,  how quickly they receive care and how quickly clinical signs can be normalised for instance – Professor Fitzgerald says more data is required.

“What we really need to do, and where the gap in the field remains, is in putting all these elements together in a predictive model so that we can effectively predict outcome for moderate to severe traumatic brain injury rather than having hints at what might indicate a better outcome.”

It’s an area that Professor Fitzgerald is already at forefront of. Securing almost $500,000 in Federal Government funding to help improve care for people with traumatic brain injury (TBI), the neurotrauma expert will lead an Australian and and international research team that will design a system to confidentially gather data on treatment and outcomes of TBI across the country.

The information collected through the two-year research program will be shared and used to help personalise care for people with TBI and determine which treatments and care pathways work best for specific symptoms and individuals.

“The information will encompass all demographics and span the diversity of presentations of people with moderate to severe traumatic brain injury, including people with multiple injuries or other conditions, which is also a first for this type of research,” she said,

The study is published in JAMA Neurology