Patients with Diffuse Axonal Injury Can Recover to a Favorable Long-Term Functional and Quality of Life Outcome

Abstract

Functional outcome and quality of life are difficult to predict in patients with diffuse axonal injury (DAI) after traumatic brain injury (TBI). The primary aim of this cross-sectional cohort study was to assess the long-term functional outcome in patients with DAI and to identify prognostic factors. Second, health-related quality of life (HRQL) at long-term follow-up was assessed. Patients ≥16 years of age with TBI and DAI (admitted 2008-2014) were included. Clinical and imaging data were collected. The primary outcome parameter was the Glasgow Outcome Scale Extended (GOSE) at long-term follow-up. Second, the HRQL was assessed with the Quality Of Life after Brain Injury (QOLIBRI) questionnaire. DAI was diagnosed in 185 patients. Long-term functional outcome was obtained in 134 patients (72%), median follow-up was 54 months (range 14-100); and 51% had a favorable outcome (GOSE 6-8). Independent prognostic factors were age, pupillary reaction, Hb, DAI grading, and return of consciousness ≤7 days. Sixty-two percent had a good HRQL, after a median follow-up of 57 months (range 14-100) with age as an independent prognostic factor. More than half of patients with DAI had a favorable functional outcome and a good HRQL at long-term follow-up. Also in patients with a DAI grade 3, a favorable outcome was seen. HRQL is a clinically relevant outcome measure because it reflects perceived outcome by patients. Independent prognostic variables for functional outcome were factors obtained in the acute phase after injury, whereas age was an independent prognostic factor for HRQL.

Quality of life up to 10 years after traumatic brain injury: a cross-sectional analysis

“…Furthermore, the first year following TBI revealed unfavorable HRQoL with an increased risk of psychiatric sequelae, suggesting that early neuropsychiatric treatment is crucial to support patient's adaption and resilience. The presented results are in line with the QOLIBRI validation study having analyzed 795 TBI patients ( Supplementary Table S3) as well as with a Dutch study, which reported good HRQoL in 62% of patients having experienced diffuse axonal injury (DAI) [21,38]. However, there are still controversial findings in the literature regarding age and sex differences that need further attention-most probably explainable due to the heterogeneity of TBI cohorts.…”

“…Van Eijck and colleagues analyzed 86 chronic TBI patients aged 16-87 years on average up to 57 months (range 14-100 months post-TBI) after DAI due to a TBI with younger patients reporting less good HRQoL. This age-related finding which contrasts our current results, might be explained by the cognitive impairment after DAI [21]. Nevertheless, the QOLIBRI validation cohort included 795 chronic TBI patients-aged 17 to 68 years-3 months and up to 18 years after TBI, thus highly comparable with our QOLIBRI cohort, with only very weak correlations (r ≤ 0.11) for age effects, education, time since injury, and severity of injury (GCS) with HRQoL [30].…”

“…On average, our cohort was 20 years older than the cohort used to validate the QOLIBRI questionnaire, but this age difference did not change HRQoL and supports our finding that age is not a contributor to HRQoL in cTBI patients [38]. In contrast, the Dutch study found younger age as an independent predictor of lower HRQoL after DAI, while others report older age as an independent risk factor for a decreased HRQoL or likewise no age effects [21,40,41]. In detail, Scholten et al analyzed HRQoL using the SF-36 instrument at 6 and 12 months after predominantly mild and after moderate to severe TBI with a mean age of 44 years (range 27-57) compared to 53 (range 18-85) years at survey in our QOLIBRI cohort [40].…”

“…Seventh, the initial GCS was not documented in 38% of cases in our cohort-a well-known finding in previous studies [25,37]. Finally, the results' generalizability might be limited due to the following issues: i) the age span of 18-to 85-year-olds, ii) the German population, iii) the heterogeneity of TBI in our cohort, and iv) treatment regimens including neurorehabilitation [21,22]. Nevertheless, age does not seem to be relevant for longterm outcome regarding HRQoL as the presented results are comparable to the large QOLIBRI validation study, that included 20 years younger patients on average [38].…”

“…Previous TBI outcome studies have primarily assessed patients' physical status using the extended Glasgow Outcome Scale within 6 months after TBI, as about 85% of recovery occurs within this time frame [20]. But, today it is well-known that patients recover beyond 6 months after their head impact and outcome is not only related to patient's mental and physical status, but also to their self-assessed health-related quality of life (HRQoL) [21][22][23][24][25]. Furthermore, approximately one third of chronic TBI (cTBI) patients present with ongoing functional and/or cognitive decline, suggesting a progressive pathophysiology, when evaluated up to 10 years after their head impact [26,27].…”