What Is the Potential of Severe TBI Recovery While on Life Support?

A significant percentage of patients with severe traumatic brain injury (TBI) may recover at least partial independence if life support is not quickly withdrawn, according to study results published in Journal of Neurotrauma.

Limited information is available on the potential outcomes of patients with TBI who died after withdrawal of life-sustaining treatment (WLST), which affects prognostic modeling and clinical counseling.

Using data from the TRACK-TBI trial (ClinicalTrials.gov Identifier: NCT02119182), researchers aimed to determine the potential for survival and recovery of independence in patients with severe TBI who died after receiving WLST.

Eligible participants had TBI, presented to the hospital within 24 hours of injury, and were referred for a cranial computed tomography (CT) scan after injury. All participants were followed-up with at the intensive care unit (ICU), and any deaths were recorded. Those who received WLST were propensity score-matched with those in whom this treatment was not withdrawn, who, in turn, were categorized into 3 tiers based on disability level (tier 1=0%-11%; tier 2=11%-27%; and tier 3=27%-70%).

The primary endpoints were Glasgow Outcome Scale-Extended (GOSE) scores, ranging from 1 (death) to 8 (full recovery), and Disability Rating Scale (DRS) outcomes.

A total of 1392 patients with TBI (75% men; mean age, 43.5) were admitted to the ICU. Of these, 90 (6.5%; 80% men; mean age, 59.2) received WLST; 33 (37%) received WLST within 72 hours of injury. Black patients vs Asian or Hispanic patients were less likely to receive WLST (P <.002). Among patients in whom life-sustaining treatment was not withdrawn, fewer than 4% died in the ICU (median time to death, 6.1 days). Overall, WLST resulted in 68% of total deaths.

Patients with vs without WLST were found to have more severe injuries (Glasgow Coma Scale [GCS] motor scores of 1/no movement and lower “best” GCS scores on day 0 of hospitalization).

Based on 6-month data, 44% (95% CI, 31.5%-58.8%; P <.001) of patients in whom life-sustaining treatment was not withdrawn survived. In addition, the percentage of these patients who survived and had GOSE scores of 4 or greater was 42.4% (95% CI, 22.9%-63.4%; P =.183). Among participants who survived, more than 30% who had scores of 4 or greater recovered at least partial independence.

Study limitations included the smaller sample size in terms of initial cohort who received WLST and matching these patients with those without WLST; lack of information on several WLST variables that could have improved interpretation of the results; and the fact that existing preexisting conditions could have predicted WLST.

The researchers concluded, “Future TBI trials should consider the potential for recovery in patients who die after WLST when developing analytic strategies to account for WLST as a study outcome.”