Outcome After Brain Damage

Outcome after brain damage has major social and financial implications for both patients and their families. In a welfare state, society may carry most, if not all of the financial burden, particularly with more severe disability. The greater the disability, the greater the support required. Conditions causing brain damage do not respect age; survivors may need long-term care.

A variety of methods have been devised to categorise outcome. Such classifications provide end-points for audit and research, and a means of assessing therapeutic intervention. They permit predictions based on clinical and investigative findings early in the course of the disease. Most outcome scales have been developed with a particular disease in mind (e.g. Bartel/Rankin - stroke, Karnofsky - tumour). In 1975 Jennett and Bond developed the Glasgow Outcome Scale (GOS) for the assessment of head injured patients, and this is now widely applied in the assessment of patients with other causes of brain damage.

The Glasgow Outcome Scale Five categories exist -

1. Death

2. Persistent Vegetative State - see below.

3. Severe Disability - dependent for some support in every 24 hour period.

4. Moderate Disability - independent but disabled. May or may not be capable of return to work.

5. Good recovery - good, but not necessarily complete recovery, e.g. cranial nerve deficit. Could (although may not) return to work.

The Vegetative State

Severe bilateral hemisphere damage may result in a state in which the patient has no awareness of themselves or of their environment. Although periods of eye opening and closure may occur suggesting sleep/wake cycles, along with spontaneous movements of the face, trunk and limbs, the patient does not communicate or interact with others in any way.

The vegetative state becomes 'permanent' when irreversibility can be established with a high degree of certainty, i.e. > 6 months after non-traumatic coma and >12 months after traumatic coma. At one month after trauma, about '/3 of patients in the vegetative state will show some improvement over the subsequent year. After non-traumatic coma, outcome is much worse; only about 7% show some improvement and have severe disability.

Outcome Prediction

Outcome from non-traumatic coma depends on a variety of factors including the patient's age, the duration and depth of the coma, and the cause of the damage provided this is not drug induced.

Poor outcome Favourable outcome

Cause Infective metabolic 65% 35%

Hypoxic - ischaemic 90% 10%

Cerebrovascular 95% 5%

Duration >6 hours 85% 15%

Depth Absent pupillary response at 24 hours 100% 0%

Speaking, eye movements and reactive pupils at 2 hours 0% 100%

210 Outcome from traumatic coma see page 85.

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