Abstract
In this study, we sought to assess the predictors of outcome in patients with disorders of consciousness (DOC) after severe traumatic brain injury (TBI) during neurorehabilitation stay. In total, 96 patients with DOC (vegetative state, minimally conscious state, or emergence from minimally conscious state) were enrolled (69 males; mean age 43.6 ± 20.8 years) and the improvement of the degree of disability, as assessed by the Disability Rating Scale, was considered the main outcome measure. To define the best predictor, a series of demographical and clinical factors were modeled using a twofold approach: (1) logistic regression to evaluate a possible causal effect among variables; and (2) machine learning algorithms (ML), to define the best predictive model. Univariate analysis demonstrated that disability in DOC patients statistically decreased at the discharge with respect to admission. Genitourinary was the most frequent medical complication (MC) emerging during the neurorehabilitation period. The logistic model revealed that the total amount of MCs is a risk factor for lack of functional improvement. ML discloses that the most important prognostic factors are the respiratory and hepatic complications together with the presence of the upper gastrointestinal comorbidities. Our study provides new evidence on the most adverse short-term factors predicting a functional recovery in DOC patients after severe TBI. The occurrence of medical complications during neurorehabilitation stay should be considered to avoid poor outcomes.
Highlights
Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide
From an initial cohort of 145 traumatic brain injury (TBI) patients, we enrolled only those who fulfilled the following inclusion criteria: (1) severe TBI with Glasgow Coma Scale (GCS) score ≤8, identified based on medical records relative to the acute phase of the intensive care unit (ICU) period; (2) clinical diagnosis at intensive rehabilitation unit (IRU) admission of vegetative state (VS), minimally consciousness state (MCS), or emersion according to standard diagnostic criteria (Giacino et al, 2002); (3) age ≥18 years; and (4) first admission to neurorehabilitation unit
For the clinical domain, we considered cause of TBI, the presence of associated fractures or other trauma, days in intensive care, GCS values at admission/discharge in ICU, Extended Glasgow Outcome Scale (GOSE) values at ICU discharge, Coma Recovery Scale–revised (CRS-r) at admission to IRU, tracheostomy, respiration, feeding pathway, and medical complication (MC) measured by Cumulative Illness Rating Scale (CIRS) upon admission to IRU and during the follow-up period
Summary
Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. Recovery from TBI is a complex process and severe brain injuries commonly result in a wide range of disorders of consciousness (DOC). This condition is characterized by high heterogeneity in clinical phenotypes and, mainly, in prognostic models (Langlois et al, 2006; Menon et al, 2010; Lasry et al, 2017) that contributed to disappointing results in several clinical trials (Menon, 2009). The presence of one or more MCs is associated with increased hospitalization time, worsened functional outcome, and increased mortality (Fu et al, 2015; Chan et al, 2017) These disorders are directly related to paroxysmal sympathetic hyperactivity (Lucca et al, 2019) or epileptic seizures (Pascarella et al, 2016). The presence of diabetes, ischemic heart disease, renal failure, and chronic obstructive pulmonary disease (Hansen et al, 2008) has been commonly reported as risk factors for older TBI patients (Stocchetti et al, 2017)
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