Department of Neurology, Ludwig-Maximilians-University, Munich, Germany.
J Neurotrauma. 2013 Sep 1;30(17):1476-83. doi: 10.1089/neu.2012.2735. Epub 2013 Jul 26.
Outcome prediction of traumatic brain injury (TBI) patients with severe disorders of consciousness (DOC) at the end of their time in an intensive care setting is important for clinical decision making and counseling of relatives, and constitutes a major challenge. Even the question of what constitutes an improved outcome is controversially discussed. We have conducted a retrospective cohort study for the rehabilitation dynamics and outcome of TBI patients with DOC. Out of 188 patients, 37.2% emerged from a minimally conscious state (MCS) and 16.5% achieved at least partial functional independence after a mean observation period of 107 days (range 1-399 days). This reflects that emergence from MCS is much easier to achieve than functional independence. Logistic regression analysis identified age and level of consciousness upon admission to neurorehabilitation as independent prognostic factors for both outcomes. The group who reached at least partial functional independence started to improve significantly more than the corresponding outcome group by post-injury week 7, and the average time to reach this functional status was 18 weeks. In contrast, the group who emerged from MCS started to improve after 6 weeks. The longest delay between brain injury and the beginning of functional improvement (measured by biweekly Functional Independence Measure [FIM] scores) still compatible with reaching at least partial functional independence was 18 weeks. In conclusion, despite a strong negative selection, a substantial proportion of severe TBI patients with DOC achieve functional improvements or at least emerge from MCS within the inpatient rehabilitation phase. In order to avoid self-fulfilling prophecies in decision making, it is important to be aware of the fact that the beginning of clinical improvement may take several months after brain injury. In this study, separation of both of the functional outcome groups started by 7 weeks post-injury.
颅脑创伤（TBI）患者在重症监护结束时严重意识障碍（DOC）的预后预测对于临床决策和家属咨询非常重要，这构成了一个主要的挑战。即使是什么构成了改善的结果也存在争议。我们对 TBI 伴 DOC 患者的康复动态和结果进行了回顾性队列研究。在 188 例患者中，37.2%从最小意识状态（MCS）中恢复，16.5%在平均观察期 107 天（范围 1-399 天）后至少部分实现了功能独立性。这表明从 MCS 中恢复比实现功能独立性容易得多。逻辑回归分析确定了神经康复入院时的年龄和意识水平是这两个结果的独立预后因素。达到至少部分功能独立性的组在损伤后第 7 周开始显著改善，达到这一功能状态的平均时间为 18 周。相比之下，从 MCS 中恢复的组在 6 周后开始改善。从脑损伤到功能改善开始的最长延迟（通过每周两次的功能性独立测量[FIM]评分测量）仍然与达到至少部分功能独立性兼容为 18 周。总之，尽管存在强烈的负选择，但相当一部分严重 TBI 伴 DOC 的患者在住院康复阶段仍能实现功能改善或至少从 MCS 中恢复。为了避免自我实现的预言，重要的是要意识到临床改善的开始可能需要在脑损伤后几个月。在这项研究中，两组功能结果的分离在损伤后 7 周开始。
