Favourable outcome in a subset of ultra-severe traumatic brain injury patients - a single-centre retrospective study.

Introduction: Ultra-severe traumatic brain injury (us-TBI), defined as Glasgow Coma Scale score (GCS) of five-three, is associated with high mortality and severe morbidity amongst survivors. However, in selected patients a favourable recovery may still be achieved. Research question: We aimed to characterise what clinical parameters can be used as prognosticators in us-TBI patients. Material and method: A retrospective, single-centre study of 70 us-TBI patients admitted between the years of 2014-2024. Early clinical, and radiological factors were assessed, and patient outcome (Glasgow outcome scale extended- GOSE) was obtained at 3-12 months. Results: The median age was 52.5 years, 21 had GCS five on admission, 23 GCS four and 26 had GCS three. Four patients had on admission bilaterally dilated pupils, 35 patients had unilateral mydriasis, 11 had miotic pupils and 20 had normal pupils. Thirty-one patients (44%) succumbed to their injuries. Median GOSE was three, and nine patients (13%) achieved an excellent outcome (GOSE 7-8) - these patients were younger (median age 26 years) and showed normalised pupil reactivity post-operatively. A favourable outcome (GOSE≥5) was achieved in 19 patients (28%). A combination of GCS 3 and bilaterally dilated pupils was uniformly fatal. Discussion and conclusion: Despite presenting with a low level of consciousness (GCS 3-5) and pupillary abnormalities in 71%, survival was observed in 56% of us-TBI patients, and nine (13%) made an excellent recovery (GOSE 7-8). Improved pupillary reactivity post-intervention may be a positive prognosticator. Our data argue against therapeutic nihilism in us-TBI patient presenting with GCS scores of 5-3.