International prospective study on long-term clinical evolution of patients with severe brain injury and disorders of consciousness

OBJECTIVEData on long-term functional recovery (LFR) following severe brain injury are essential for counseling of surrogates and for appropriate timing of outcome assessment in clinical trials. Delayed functional recovery (DFR) beyond 3–6 months is well documented following severe traumatic brain injury (sTBI), but there are limited data on DFR following severe cerebrovascular brain injury. The objective of this study was to assess LFR and DFR in patients with sTBI and severe stroke dependent on tracheostomy and tube feeding at the time of discharge from the intensive care unit (ICU).METHODSThe authors identified patients entered into their tracheostomy database 2008–2013 with sTBI and severe stroke, encompassing SAH, intracerebral hemorrhage (ICH), and acute ischemic stroke (AIS). Eligibility criteria included disease-specific indicators of severity, Glasgow Coma Scale score < 9 at time of tracheostomy, and need for tracheostomy and tube feeding at ICU discharge. Assessment was at 1–3 months, 6–12 months, 12–24 months, and 24–36 months after initial injury for presence of tracheostomy, ability to walk, and ability to perform basic activities of daily living (B-ADLs). Long-term functional recovery (LFR) was defined as recovery of the ability to walk or perform B-ADLs by the 24- to 36-month follow-up. Delayed functional recovery (DFR) was defined as progression in functional milestones between any 2 time points beyond the 1- to 3-month follow-up.RESULTSA total of 129 patients met the eligibility criteria. Functional outcomes were available for 129 (100%), 97 (75%), 83 (64%), and 80 (62%) patients, respectively, from assessments at 1–3, 6–12, 12–24 and 24–36 months; 33 (26%) died by 24–36 months. Fifty-nine (46%) regained the ability to walk and 48 (37%) performed B-ADLs at some point during their recovery. Among survivors who had not achieved the respective milestone at 1–3 months, 29/58 (50%) were able to walk and 28/74 (38%) performed B-ADLs at 6–12 months. Among survivors who had not achieved the respective milestone at 6–12 months, 5/16 (31%) were able to walk and 13/30 (43%) performed B-ADLs at 12–24 months. There was no significant difference in rates of LFR or DFR between patients with sTBI and those with severe stroke.CONCLUSIONSAmong patients with severe brain injury requiring tracheostomy and tube feeding at ICU discharge, 46% regained the ability to walk and 37% performed B-ADLs 2–3 years after injury. DFR beyond 1–3 and 6–12 months was seen in over 30% of survivors, with no significant difference between sTBI and severe stroke.

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Towards a state of play: A case study exploring insight-oriented musical experiences with a woman with severe brain injury

British Journal of Music Therapy ◽

10.1177/1359457519841906 ◽

2019 ◽

Vol 33 (1) ◽

pp. 39-50

Author(s):

Maybelle Swaney

Keyword(s):

Brain Injury ◽

Emotional Health ◽

Haemorrhagic Stroke ◽

Musical Experience ◽

Severe Brain Injury ◽

Self Identity ◽

Therapeutic Outcomes ◽

Reflective Processing

This article presents an improvisational approach to insight-oriented therapy in music therapy with a woman with severe cognitive impairments following haemorrhagic stroke. Analysis of five clinical excerpts across 40 sessions demonstrates how a prepared improvised musical experience can facilitate meaningful self-exploration in dialogue, leading to a renewed self-identity in life after brain injury. The therapist’s reflective processing is integral to the therapeutic outcomes; these are examined alongside the casework material. This article suggests that insight-oriented musical experiences may be one way of supporting the emotional health of individuals living with the enduring consequences of severe brain injury in slow-stream rehabilitation or long-term neurological care.

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Disorders of Consciousness and Neuro-Palliative Care

10.1093/oxfordhb/9780199974412.013.15 ◽

2015 ◽

Author(s):

Joseph J. Fins ◽

Maria Masters

Keyword(s):

Palliative Care ◽

Brain Injury ◽

Minimally Conscious State ◽

Conscious State ◽

Disorders Of Consciousness ◽

Right To Die ◽

Severe Brain Injury ◽

Brain States ◽

The Right ◽

Minimally Conscious

This chapter explains how neuro-palliative care can be provided to patients with severe brain injury. Before arguing that the right to die must be preserved and that the right to care for patients who are minimally conscious must be supported, it defines and reviews brain states that constitute disorders of consciousness along with their differential biology. It then gives an overview of palliative care for patients with severe brain injury and the challenges involved in diagnosing the minimally conscious state. It proceeds by discussing advances in technology, particularly neuroimaging, that may help meet the needs of such patients. It also considers the neuroethics of diagnosis and concludes by suggesting ways to integrate the needs of individuals suffering from disorders of consciousness in both the local and national palliative care infrastructure.

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Long-Term Outcome from Severe Brain Injury

Neurorehabilitation and Neural Repair ◽

10.1177/154596839601000406 ◽

1996 ◽

Vol 10 (4) ◽

pp. 259-265

Author(s):

P. J. Wisdom ◽

H. Jones ◽

J. R. Couch ◽

R. L. Bayles

Keyword(s):

Brain Injury ◽

Severe Brain Injury ◽

Term Outcome ◽

Long Term Outcome

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Quality of evidence of rehabilitation interventions in long-term care for people with severe disorders of consciousness after brain injury: A systematic review

Journal of Rehabilitation Medicine ◽

10.2340/16501977-1983 ◽

2015 ◽

Vol 47 (7) ◽

pp. 577-585 ◽

Cited By ~ 9

Author(s):

H Klingshirn ◽

E Grill ◽

A Bender ◽

R Strobl ◽

R Mittrach ◽

...

Keyword(s):

Systematic Review ◽

Brain Injury ◽

Long Term Care ◽

Disorders Of Consciousness ◽

Term Care ◽

Quality Of Evidence

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Resting-State Electroencephalography for Prognosis in Disorders of Consciousness Following Traumatic Brain Injury

Frontiers in Neurology ◽

10.3389/fneur.2020.586945 ◽

2020 ◽

Vol 11 ◽

Author(s):

Ruth Pauli ◽

Alice O'Donnell ◽

Damian Cruse

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Resting State ◽

Disorders Of Consciousness ◽

Alpha Power ◽

Disorder Of Consciousness ◽

Term Care ◽

Prognostic Utility ◽

Eeg Recordings

Although the majority of patients recover consciousness after a traumatic brain injury (TBI), a minority develop a prolonged disorder of consciousness, which may never fully resolve. For these patients, accurate prognostication is essential to treatment decisions and long-term care planning. In this review, we evaluate the use of resting-state electroencephalography (EEG) as a prognostic measure in disorders of consciousness following TBI. We highlight that routine clinical EEG recordings have prognostic utility in the short to medium term. In particular, measures of alpha power and variability are indicative of relatively better functional outcomes within the first year post-TBI. This is hypothesized to reflect intact thalamocortical loops, and thus the potential for recovery of consciousness even in the apparent absence of current consciousness. However, there is a lack of research into the use of resting-state EEG for predicting longer-term recovery following TBI. We conclude that, given the potential for patients to demonstrate improvements in consciousness and functional capacity even years after TBI, a research focus on EEG-augmented prognostication in very long-term disorders of consciousness is now required.

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