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Recovery from severe TBI can be unpredictable, but proper care can aid recovery. Physicians should stay hopeful, avoiding pessimism and therapeutic nihilism.

Severe traumatic brain injury (TBI) is an increasingly common cause of disability and mortality globally.  According to the CDC, there were approximately 214,110 hospitalizations due to TBI in the US in 2020 and 69,473 TBI-related deaths in 2021.

Patients suffering from severe TBI face an unpredictable future with prolonged and incomplete recovery. Unfortunately, general guidelines to determine the likelihood of a good neurologic outcome don’t exist.  Based on personal or religious beliefs, advance directives, medical comorbidities, QOL, and other concerns, families face difficult decisions in care, particularly regarding the withdrawal of life support.

Patients With TBI Face Challenges

The Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) trial, published in the Journal of Neurotrauma, studied approximately 1,300 patients with severe, non-fatal TBI in 13 trauma centers across the US. Comparing the characteristics of patients who did and did not have withdrawal of life support, approximately 40% of patients with traumatic brain injury who were being taken off life support were estimated to survive with at least partial independence after 6 months.

Patients with TBI who are unable to follow commands have been assumed to be comatose or vegetative. Still, multiple studies in the last 20 years have documented that many patients unable to follow commands physically can understand and cognitively respond to voice and other stimuli.

Yelena Bodien, PhD, from Harvard, enrolled 353 adult patients with TBI from six multi-national centers from 2006 to 2023. Half of the group had a median age of 38 years and suffered from TBI. The rest mainly endured strokes or anoxic injury. The researchers found that 40% were diagnosed with a coma or vegetative state and 50% with a minimally conscious state. Of the 241 patients who did not follow commands, 25% generated cognitive responses on EEG or fMRI when asked to perform activities that necessitated concentration.

Among seriously injured patients with TBI, recovery may be unpredictable. Many of these patients may recover with appropriate treatment and rehabilitation. Intensivists and other physicians must maintain a hopeful attitude, free of self-fulfilling prophecy and therapeutic nihilism.