Unexpected Recovery of Function After Severe Traumatic Brain Injury: The Limits of Early Neuroimaging-Based Outcome Prediction
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Prognostication in the early stage of traumatic coma is a common challenge in the neuro-intensive care unit. We report the unexpected recovery of functional milestones (i.e., consciousness, communication, and community reintegration) in a 19-year-old man who sustained a severe traumatic brain injury. The early magnetic resonance imaging (MRI) findings, at the time, suggested a poor prognosis.
During the first year of the patient’s recovery, MRI with diffusion tensor imaging and T2*-weighted imaging was performed on day 8 (coma), day 44 (minimally conscious state), day 198 (post-traumatic confusional state), and day 366 (community reintegration). Mean apparent diffusion coefficient (ADC) and fractional anisotropy values in the corpus callosum, cerebral hemispheric white matter, and thalamus were compared with clinical assessments using the Disability Rating Scale (DRS).
Extensive diffusion restriction in the corpus callosum and bihemispheric white matter was observed on day 8, with ADC values in a range typically associated with neurotoxic injury (230–400 × 10−6 mm2/s). T2*-weighted MRI revealed widespread hemorrhagic axonal injury in the cerebral hemispheres, corpus callosum, and brainstem. Despite the presence of severe axonal injury on early MRI, the patient regained the ability to communicate and perform activities of daily living independently at 1 year post-injury (DRS = 8).
MRI data should be interpreted with caution when prognosticating for patients in traumatic coma. Recovery of consciousness and community reintegration are possible even when extensive traumatic axonal injury is demonstrated by early MRI.
KeywordsTraumatic brain injury Coma Magnetic resonance imaging Traumatic axonal injury Diffusion-weighted imaging Apparent diffusion coefficient Diffusion tensor imaging
We are grateful to the patient and his family for participating in this study and for sharing their photos and videos. All photos and videos are shown with consent. We thank Kristin Parlman and Anne McGrail for their assistance with functional outcome assessments. We also thank the nurses and the physical, occupational, and speech/language therapy teams at Massachusetts General Hospital, Spaulding Rehabilitation Hospital, and Crotched Mountain Rehabilitation Center. We thank Kathryn R. Tringale and Brittany Sorice for assistance with video capture and editing. We are grateful to Dr. Hannah C. Kinney for consultation regarding neuroanatomic localization of the regions of interest used in this study.
This study was supported in part by grants from the National Institutes of Health (R25NS065743 and P41EB015896), the National Institute on Disability and Rehabilitation Research (H133A120085), and the Center for Integration of Medicine and Innovative Technology (Boston, MA). The views in this article represent those of the authors alone, and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.
Conflict of interest
The first 2 years of the patient’s recovery are documented longitudinally in pictures and videos that were shared by the patient and his family with their consent. All clinicians who appear in the video also provided consent. An interview with the patient was performed on day 783, at which time he reflected on the major milestones in his recovery. (MOV 54104 kb)
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