Prognosis after Severe Brain Injury and Coma: Questions

Prognosis After Severe Brain Injury

By Attorney Gordon S. Johnson, Jr.

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Two days after a severe brain injury, no one knows the answer of how long the coma will last, how severe the permanent brain damage will be, the prognosis after severe brain injury.  Likewise, even two days before the severe brain injury survivor wakes up, the answer is still unknown. The question of prognosis after severe brain injury may not be available for day, weeks or even months.

Until emergence from the coma begins, there can be no accurate  prognosis after severe brain injury.  Likewise, because the coma continues today does not mean that it will not start to end tomorrow.  Yet, as the family waits for a prognosis after severe brain injury, there are some important time frames to keep in mind.  These are harsh realities in the next few paragraphs.  If you want to maintain blind hope, do not read on.  If you want to know more about what might be ahead, continue to read.  But either way, know that none of what we have learned about coma prognosis and prognosis after severe brain injury is fool proof.  Some people will emerge, yet never recover. Some people will remain comatose for long periods yet emerge closer to who they were, than seems scientifically possible.

A severe brain injury and the prognosis after severe brain injury often involves a coma that extends past two weeks.  In far fewer cases the coma makes it to a full month.  The majority of people who have survived a coma for less than one month have “satisfactory recoveries” and a good prognosis after brain injury.  More on what a satisfactory recovery is later. As a coma extends past a month, it indicates an increasing probability that the survivor will be profoundly disabled.  The coma that extends past two months involves almost a statistical certainty that normal adult functioning will never be regained.  Note the use of the word almost in that sentence. 25 years ago, when most of the coma data was collected[1], the word almost would not be included.  Since that time, coma treatment has improved and there have been anecdotal cases of injured persons emerging from coma’s longer than two months who have regained significant function and the prognosis after severe brain injury is encouraging.

We can hope for a time when some  realistic hope can be sustained past two months.  Yet here is the harsh reality: 25 years ago, the persistence of non-responsiveness or death could be predicted with nearly 75% accuracy based upon the analysis of only three things: pupillary response, age and the best motor score on the Glasgow Coma Scale.  That is still true today and will help with the question or prognosis after severe brain injury.

These three things stand as the first branches of what has been called the “Predictive Tree”, Choi, et. al.[2] More recent research which has factored in far more variables, including CT scan localization of lesions and a detailed analysis of blood pressure and oxygen saturation of cerebral blood flows, has largely only reinforced the significance of the three branches of the Predictive Tree.  A 1992 analysis of the Predictive Tree states what we all must remember: “The predictive accuracy is highest among patients who have a good recovery or die; it is lower for patients having intermediate outcomes.” [3] To make that statement more concrete as the waiting continues, there is a substantial basis for optimistism for those who emerge from a coma before a month.  There is no basis for optimism for those whose coma’s last more for than two months.  For those in between, we really just don’t know.

Yet there continues to be 20% of those who completely defy the odds of even the most modern of epidemiological research.   That doesn’t mean that there is a one in five odds of a miracle.  What it means is that we don’t have any way of differentiating 20% of the cases, on both the positive and negatives side.  If the family chooses to use that 20% error rate as basis to sustain the love, hope and energy necessary to get thru month two, then by all means do so.

NEXT: The Predictive Tree for Coma Emergence and Coma Recovery

[1] J Neurosurg. 1983 Aug ;59 (2):276-84 6345728 (P,S,G,E,B) Cited:71

The National Traumatic Coma Data Bank. Part 1: Design, purpose, goals, and results.
[My paper] L F Marshall, D P Becker, S A Bowers, C Cayard, H Eisenberg, C R Gross, R G Grossman, J A Jane, S C Kunitz, R Rimel, K Tabaddor, J Warren

J Neurosurg. 2003 Oct;99(4):666-73.
Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients.

J Neurosurg. 2009 Oct;111(4):672-82.
Brain tissue oxygen monitoring in traumatic brain injury and major trauma: outcome analysis of a brain tissue oxygen-directed therapy.

[2] J Neurosurg. 1991 Aug;75(2):251-5. Choi SC, Muizelaar JP, Barnes TY, Marmarou A, Brooks DM, Young HF. Prediction tree for severely head-injured patients.

[3] Choi SC, et. al.

by Attorney Gordon Johnson