The families of my patients admitted to the Neurosurgical ICU often ask me how much brain damage the patient can survive. The short answer is – a lot. A more specific answer – well, it depends, of course.

In reality, most people are able to physically survive massive brain damage. With current technology, we are able to keep “alive” even the patients declared brain dead. What really matters, though, is not physical survival, but the extent of the neurological recovery.

The neurological recovery is more like a spectrum of possibilities. The best outcome would be a complete recovery with a return to the baseline functional capacity. The worst case scenario is for the patient to remain in a comatose state. It is not always possible to reliably predict the extent of the recovery for any given patient. When asked about the prognosis, I often give the family a range of likely possibilities. The most likely outcome in many cases is somewhere in the middle of this spectrum.

Also, when talking about recovery, it is important to look at things from the patient’s perspective. A good recovery in many cases would be for the patient to be responsive and able to communicate, yet not being able to care for him/herself. In most cases this means an admission to a Nursing Home with 24/7 care. This “favorable” outcome is considered unacceptable by many patients. If the patient was fully functional and independent before the admission, being dependent on somebody else’s help with the activities of daily living is a huge compromise to their quality of life. I often hear from the families that their loved one would never want to be in a Nursing Home.

Once we start talking about placing a tracheostomy tube or a feeding tube, the discussion gets even more complicated. The presence of some kind of tube to keep the patient alive is often considered “life support”. Once it becomes clear that the patient would need a tracheostomy tube to breath or a feeding tube to receive nutrition, it often changes the tone of the discussion. Being unable to eat naturally, for example, and, thus, require a feeding tube is a major set back in the quality of life for many patients.

Physicians look at multiple factors while trying to predict the likely neurological outcome for any given patient. I often tell the families of my patients that everybody is different and such is the outcome. The mechanism and the extent of the brain injury are the most important factors to consider. Head injured trauma patients have a relatively good prognosis, depending on the severity of the injury, of course. The patients surviving an anoxic brain injury (brain injury due to a lack of blood flow and oxygen supply to the brain) after a cardiac arrest have worse prognosis. Other factors like the patient’s age and the preexisting conditions affect outcome as well.

In conclusion, when discussing the extent of the brain damage and the possibility of the recovery, it is important to look at things from the patient’s perspective. Recovering some brain function and regaining consciousness would be considered a very good recovery after a massive brain injury. From the patient’s perspective, though, anything less than a completely independent living is often unacceptable.

Few weeks ago I was called to admit a patient with “a likely stroke” He was having intermittent right-sided weakness, vision problems and impaired coordination. The Neurologist saw him in ER. The diagnosis of the posterior circulation stroke was made. The patient was started on tPA (thrombolytic, clot dissolving medicine). I saw him in ICU. He was awake and joking around – “Oh, this is nothing, Doc”. Few hours later he became less responsive and I had to intubate him. Repeat CT head showed no bleed; Extensive posterior-circulation ischemic changes were noted (see image above). Now the patient is unresponsive and prognosis for his recovery is quite poor. The family decided to withdraw care.
Stroke could be a devastating disease. Most patients survive, but left with motor deficits, weakness in their arms, legs or inability to speak or even understand human speech. What strikes me is how little we can do to treat this disease. Aspirin is commonly used to prevent further strokes. Clot dissolving medications (tPA in the case above) could improve your chances for survival and recovery. The problem is, a lot of the patients come to us too late for this medicine to be administered. And even when it’s given, it doesn’t work all the time and the complications could be even more disabling or lethal (bleed into brain). This could be very frustrating. In the case above the patient “was lucky” to be with a window of opportunity for the medication to be administered. Yet it did not work. The patient decompensated right in front of your eyes and there is not much you can do. Modern medicine can do wonders for our patients. Testing the limits of it is what makes this job difficult.