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Original Investigation
March 1, 2021

Recovery of Consciousness and Functional Outcome in Moderate and Severe Traumatic Brain Injury

Author Affiliations
  • 1Department of Neurology, University of Colorado School of Medicine, Aurora
  • 2Research Department, Craig Hospital, Englewood, Colorado
  • 3Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis
  • 4CNS Medical Group, Englewood, Colorado
  • 5Mental Health and Behavioral Sciences, James A. Haley Veterans Hospital, Tampa, Florida
  • 6Sleep Medicine Division, Department of Internal Medicine, University of South Florida, Tampa
  • 7Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital and Harvard Medical School, Boston
  • 8Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania
JAMA Neurol. Published online March 1, 2021. doi:10.1001/jamaneurol.2021.0084
Key Points

Question  What are the trajectory of and factors associated with recovery of consciousness in patients with a disorder of consciousness (DOC) after traumatic brain injury (TBI)?

Findings  In this cohort study of 17 470 patients with TBI, 57% of patients experienced initial loss of consciousness, which persisted after acute care treatment in 12% of patients. However, 98% of these patients recovered consciousness by the end of subsequent inpatient rehabilitation, and their trajectory of functional improvement mirrored that of patients with TBI who did not lose consciousness.

Meaning  Results of this study indicated that most individuals who became comatose after moderate or severe TBI recovered consciousness in the short term and almost half of them regained functional independence, suggesting that caution is warranted in early decisions to withdraw or withhold treatment in patients with TBI and a DOC.


Importance  Traumatic brain injury (TBI) leads to 2.9 million visits to US emergency departments annually and frequently involves a disorder of consciousness (DOC). Early treatment, including withdrawal of life-sustaining therapies and rehabilitation, is often predicated on the assumed worse outcome of disrupted consciousness.

Objective  To quantify the loss of consciousness, factors associated with recovery, and return to functional independence in a 31-year sample of patients with moderate or severe brain trauma.

Design, Setting, and Participants  This cohort study analyzed patients with TBI who were enrolled in the Traumatic Brain Injury Model Systems National Database, a prospective, multiyear, longitudinal database. Patients were survivors of moderate or severe TBI who were discharged from acute hospitalization and admitted to inpatient rehabilitation from January 4, 1989, to June 19, 2019, at 1 of 23 inpatient rehabilitation centers that participated in the Traumatic Brain Injury Model Systems program. Follow-up for the study was through completion of inpatient rehabilitation.

Exposures  Traumatic brain injury.

Main Outcomes and Measures  Outcome measures were Glasgow Coma Scale in the emergency department, Disability Rating Scale, posttraumatic amnesia, and Functional Independence Measure. Patient-related data included demographic characteristics, injury cause, and brain computed tomography findings.

Results  The 17 470 patients with TBI analyzed in this study had a median (interquartile range [IQR]) age at injury of 39 (25-56) years and included 12 854 male individuals (74%). Of these patients, 7547 (57%) experienced initial loss of consciousness, which persisted to rehabilitation in 2058 patients (12%). Those with persisting DOC were younger; had more high-velocity injuries; had intracranial mass effect, intraventricular hemorrhage, and subcortical contusion; and had longer acute care than patients without DOC. Eighty-two percent (n = 1674) of comatose patients recovered consciousness during inpatient rehabilitation. In a multivariable analysis, the factors associated with consciousness recovery were absence of intraventricular hemorrhage (adjusted odds ratio [OR], 0.678; 95% CI, 0.532-0.863; P = .002) and intracranial mass effect (adjusted OR, 0.759; 95% CI, 0.595-0.968; P = .03). Functional improvement (change in total functional independence score from admission to discharge) was +43 for patients with DOC and +37 for those without DOC (P = .002), and 803 of 2013 patients with DOC (40%) became partially or fully independent. Younger age, male sex, and absence of intraventricular hemorrhage, intracranial mass effect, and subcortical contusion were associated with better functional outcome. Findings were consistent across the 3 decades of the database.

Conclusions and Relevance  This study found that DOC occurred initially in most patients with TBI and persisted in some patients after rehabilitation, but most patients with persisting DOC recovered consciousness during rehabilitation. This recovery trajectory may inform acute and rehabilitation treatment decisions and suggests caution is warranted in consideration of withdrawing or withholding care in patients with TBI and DOC.

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