PITTSBURGH- A new study led by University of Pittsburgh School of Medicine clinical scientists and UPMC neurosurgeons challenges assumptions about early withdrawal of care in patients with severe traumatic brain injury, or TBI. The research, published today in the journal Neurosurgery, the official publication of the Congress of Neurological Surgeons, suggests that more than 1 in 3 critically ill patients with TBI could have achieved partial independence if their life-sustaining care had not been withdrawn.
"This research calls into question the long-held belief that odds of meaningful recovery are poor in most severe TBI cases," said lead author Shawn R. Eagle, Ph.D., research assistant professor in the Department of Neurological Surgery at Pitt. "Our data show that meaningful recovery is not only possible but occurs at a rate higher than many clinicians and families might expect. Even among patients with the most severe injuries, optimism for recovery is warranted, and decisions to withdraw care should be made with caution and compassion."
Severe TBI affects an estimated 80,000 to 90,000 people annually in the United States, according to the Centers for Disease Control and Prevention (CDC). Severe TBI is typically defined as a Glasgow Coma Scale (GCS) score of 8 or less out of 15; the GCS measures a patient's level of consciousness based on eye, verbal and motor responses following injury.
Predicting patient outcomes after severe TBI remains a major challenge, and the leading cause of death in this patient population is care withdrawal. Current models, such as the IMPACT calculator, which incorporates GCS score, age, pupillary response, CT findings and lab values to estimate the likelihood of survival and functional outcome, were developed for guiding the design of clinical trials, not care decisions for individual patients.
"Our findings underscore the need for ongoing research and for a more holistic approach to prognostication in neurotrauma," said Dr. Eagle.
The research team analyzed data from more than 500 patients with severe TBI and compared outcomes between patients whose life-sustaining therapies were withdrawn and those who continued to receive care.
The results were striking: Recovery was observed across all injury types, including those with the most severe prognoses.
More than one-third of patients who were fully dependent on life-supporting care at three months achieved meaningful independence by 24 months, defined as being able to spend eight or more hours a day independently.
Nearly one in four survivors regained partial independence between six and 24 months post-injury, and more than one in 10 improved between 12 and 24 months.
"Families deserve time, transparency and care plans that evolve with the patient's status," said senior author David Okonkwo, M.D., Ph.D., neurosurgeon and director of neurotrauma at UPMC, as well as professor of neurological surgery and clinical director of the Brain Trauma Research Program at Pitt. "Decisions about withdrawing life-sustaining therapy should be individualized and made cautiously, resisting therapeutic nihilism when meaningful recovery remains possible."
These findings build on earlier research from the TRACK-TBI Network, of which Pitt is a member, that first demonstrated a substantial proportion of patients with severe TBI could achieve partial independence after injury, even when the initial prognosis was poor. The latest research not only confirms these results but extends them, showing that meaningful recovery continues to occur up to two years post-injury.
The study's authors emphasize that decisions about continuing or withdrawing care are deeply personal and complex, involving medical, psychological and social considerations. As leaders in neurotrauma science and patient-centered care, the research team advocates for the development and validation of more nuanced prognostic tools that incorporate not only clinical and imaging data but also social and psychological factors.
Explore the full study, related research and expert insights at:
Co-authors include Ava M. Puccio, Ph.D. and Regan Shanahan, both of Pitt; John K. Yue, M.D., of the University of California, San Francisco; and Jaeyong Shim of Carnegie Mellon University.
