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Unexpected Recovery of Function After Severe Traumatic Brain Injury: The Limits of Early Neuroimaging-Based Outcome Prediction

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Abstract

Background

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.

Methods

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).

Results

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).

Conclusions

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.

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Acknowledgments

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.

Funding

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

None.

Author information

Authors and Affiliations

  1. Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA

    Brian L. Edlow & Leigh R. Hochberg

  2. Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA

    Brian L. Edlow & Ona Wu

  3. Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA

    Joseph T. Giacino & Ronald E. Hirschberg

  4. Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Joseph T. Giacino

  5. Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Ronald E. Hirschberg

  6. Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Jason Gerrard

  7. Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Ona Wu

  8. School of Engineering and Institute for Brain Science, Brown University, Providence, RI, USA

    Leigh R. Hochberg

  9. Center for Neurorestoration and Neurotechnology, Department of Veterans Affairs Medical Center, Providence, RI, USA

    Leigh R. Hochberg

Authors
  1. Brian L. Edlow
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  2. Joseph T. Giacino
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  3. Ronald E. Hirschberg
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  4. Jason Gerrard
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  5. Ona Wu
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  6. Leigh R. Hochberg
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Corresponding author

Correspondence to Brian L. Edlow.

Additional information

Brian L. Edlow and Joseph T. Giacino contributed equally to this article.

Ona Wu and Leigh R. Hochberg contributed equally to this article.

Electronic supplementary material

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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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Edlow, B.L., Giacino, J.T., Hirschberg, R.E. et al. Unexpected Recovery of Function After Severe Traumatic Brain Injury: The Limits of Early Neuroimaging-Based Outcome Prediction. Neurocrit Care 19, 364–375 (2013). https://doi.org/10.1007/s12028-013-9870-x

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