Having a loved one fall into a coma after brain injury is one of the most frightening things that can happen to you.
This article is here to explain what a coma means for brain injury patients and their families, and what kind of treatment is available.
While we do not want to encourage any false sense of hope, you also should not give up on seeing your loved one wake up again just because they are in a coma.
The chances of recovery are all dependent on what type of coma the person may have, where the damage is located, and the duration of the coma.
With that said, here is the most important information you need to know about comas after brain injury.
Coma After Brain Injury: Definition and Stages
To understand what a coma is, we need to understand the two components necessary for consciousness: wakefulness and awareness. Two different parts of the brain control these functions.
This means that sometimes a person can be awake without being aware of anything around them, in which case they are still considered unconscious.
In fact, being awake but not aware is one of the four disorders of consciousness that a person usually passes through as they are recovering from a brain injury.
To determine what level of consciousness a person is at, doctors use several different scales. We’ll take a look at the most widely used scale next.
Measuring a TBI with the Glasgow Coma Scale
The most common way to measure a patient’s level of consciousness after TBI is with the Glasgow Coma Scale. (GCS)
The Glasgow Coma Scale is a simple test that gauges the severity of a TBI and is used to predict the outcome of an injury.
The scale consists of 15 points total, with points used to measure various functions such as eye opening and verbal response. The higher the points, the higher the level of function, which means a higher likelihood of making a full recovery.
The GCS measure points in the following way:
Eye opening (E)
- 4 pts = spontaneous eye opening
- 3 pts = eyes open in response to sound
- 2 pts = eyes open in response to pressure
- 1 pt = none
Verbal Response (V)
- 5 = Alert and Oriented
- 4 = Confused, but coherent, speech
- 3 = Words, but not coherent
- 2 = Sounds, but no words
- 1 = none
Motor Response (M)
- 6 = obeys command
- 5 = localizing
- 4 = normal flexion
- 3 = abnormal flexion
- 2 = extension
- 1 = none
The final score is the sum of all these numbers.
Depending on the final score, a brain injury can be classified in four possible levels. These levels are used to predict a person’s most likely outcome for survival:
- Mild: GCS 13-15
- Moderate Disability: GCS 9-12
- Severe Disability: GCS 4-8
- Persistent Vegetative State: GCS 3
Again, the higher the score, the better a patient’s chance of recovery.
However, it’s important to note that even with a low GCS score, it is still possible for a person to make a good recovery. With that said, the longer a person stays at a low level of consciousness, the harder their recovery will be.
Now that we know how doctors determine what level of consciousness a person is at, it’s time to explore the different stages a person will pass through as they recover from a coma after brain injury.
Stage 1. Coma
A coma is the deepest state of unconsciousness, where a person is unresponsive to their environment and cannot wake up, even when stimulated. This corresponds to a 3-point score on the Glasgow Coma Scale.
A person can fall into a coma through many different ways, including infections, traumatic brain injury, and oxygen deprivation.
In most of these instances, the same thing happens. The brain swells, pushing up against the skull, which damages the Reticular Activating System, (RAS) the part of the brain stem that controls arousal from sleep.
The defining characteristics of a coma are:
- No eye opening
- No speech or other forms of communication
- No purposeful movement
An actual coma rarely lasts more than four weeks. Instead, most patients who are unconscious for long periods of time have progressed to the next state of consciousness, commonly called the vegetative state.
Stage 2. The Vegetative State
If a person has eye movement, but no other signs of consciousness, then they have most likely entered a vegetative state.
In the vegetative state, a person is awake, but not aware. The eyes may sometimes open and close, they may even react to loud noises, but this is not a sign that the person is conscious yet.
Instead these actions are caused by autonomic responses of the brain which are still intact or have healed themselves enough to cause a person to wake up, but not regain full consciousness.
If a person remains in this state for an extended time, doctors consider them to be in a persistent vegetative state.
These states can last for months, even years, before the patient regains consciousness.
If a person starts to regain consciousness and begins to communicate, they enter the next phase, which is called the minimally conscious state.
Stage 3. Minimally Conscious State
As the person recovers, they may have a reduced sense of awareness of the world around them, in which case they are no longer in a vegetative state and instead are said to be minimally conscious.
A minimally conscious person sometimes can follow instructions (such as “squeeze my finger”) but sometimes cannot. This can make distinguishing between the vegetative state and the minimally conscious state difficult.
Another difficulty is in rare cases a coma patient can develop something called Locked-in syndrome, which is where the person is fully aware and conscious, but completely paralyzed. This can make it seem as though the person is minimally conscious or even vegetative, when in fact they are not.
A brain scan can help determine whether or not the person is conscious and unable to communicate, or is still unconscious.
Once the patient is consistently able to respond to instructions and communicate, they have entered the last phase of recovery, called the confusional state.
Stage 4. Acute Confusional State (Delirium)
Pretty much all patients who make it to the confusional state will eventually make a good recovery. Patients who transition from vegetative state to minimal consciousness within eight weeks are the most likely to reach this state and regain higher functions
The confusional state is characterized by disorientation, amnesia, impairments in cognitive abilities, and other symptoms that are also commonly found in concussion patients.
It’s important to note that a person’s progression between the four stages is not always linear. Recovery can cease at any one of these states and sometimes the person will skip the intermediate stages entirely and go directly from a coma to the confusional state.
Now that we know the different stages a coma patient will go through on their road to recovery, it’s time to look at the factors that can affect the odds of a person regaining consciousness after a coma.
Factors That Affect Coma Recovery
Doctors will consider a variety of factors when assessing how severe a coma is and what the person’s chances at recovery are.
Some of these factors include the duration of coma and the physical signs.
In the following sections, we will look closely at each of these factors – and what they predict for recovery.
Factor 1: Length of Coma
How long a person is in a coma will greatly affect the likeliness of their waking and regaining full consciousness.
A person in a persistent vegetative state after brain injury can regain awareness as late as 12 months after their injury.
After that, the chances of recovery are much lower, and if they do regain consciousness, they will most likely have permanent cognitive disabilities.
In general, the shorter the coma lasts, the better the chances of making a full recovery.
Factor 2. Neurological symptoms
The presence of certain symptoms after a brain injury can also predict recovery from a coma. If the patient still has brain stem reflexes and responses for example, there is a greater chance of recovery than if these responses are absent.
Some other reflexes that doctors check for is the pupillary light response. If the pupil shrinks when light is shined on it, that is a very good sign that the person may recover, though by itself it is no guarantee of recovery.
Still, even though these reflexes are helpful in predicting a good recovery, people who are missing these reflexes early after their injury have been known to regain consciousness.
Now that we know some of the factors that can influence recovery from a coma, what are some of the treatments available for patients with a coma after brain injury?
Treatment for Coma After Brain Injury
The best way to treat a coma after brain injury is to perform surgery to relieve any inter-cranial pressure and hematomas (brain bleeds) that may have developed after the initial injury. This can prevent the injury from leading to brain death.
Sometimes, relieving the pressure in the brain is enough to wake a person from their coma, in which case these patients have a very good chance at making a full recovery!
If the person does not wake up after their surgery, there are drugs that can help reduce swelling, which is also sometimes enough to wake someone up.
Otherwise, there is not much that can be done to cause someone to wake up from a coma, and the only option is to wait and hope for the best.
What doctors recommend in these cases is to focus on treating any issues that might hinder recovery, such as a build-up of fluid on the brain, or respiratory infections.
It is also a good idea to start some form of manual therapy on the patient, even when they are in a deep coma. Just passively moving the limbs has been shown to have many benefits and can prevent spasticity, which will help in recovery. It can also help prevent bed sores and other skin issues.
Advice for Interacting with a Loved One in a Coma or Vegetative State
Even though they may not respond, you should still try to talk to and interact with your loved one as normally as possible.
Not only will it help you feel connected to them, but there is a chance it may even help the person recover.
One study conducted in 2015 found that familiar sounds such as a loved one’s voice or favorite music helped improve responsiveness in people in comas.
And many people who recover from their comas report that they could hear what people in the room were saying.
Physical touch such as massaging the hands and face can also be helpful, though you will want to avoid overstimulating them, as that can lead to tightening of their muscles and fatigue.
Final Thoughts on Coma After Brain Injury
Having a loved one fall into a coma or vegetative state after brain injury is a frightening and emotionally draining ordeal.
We hope this article has given you a better understanding of comas and what can be done for the people in them.
While there may currently be no way to force someone out of a coma, you should not despair. Even if it’s been several months, there is still hope that they will awaken, and when they do, they will need your help to make a full recovery.
After a person exits a coma and regains consciousness, physical therapy exercises for brain injury and other cognitive exercises will be crucial in their recovery.
These activities are great ways to engage neuroplasticity and help their brain begin the healing process!