Intended for healthcare professionals


Predicting decline and survival in severe acute brain injury: the fourth trajectory

BMJ 2015; 351 doi: (Published 06 August 2015) Cite this as: BMJ 2015;351:h3904
  1. Claire J Creutzfeldt, vascular neurologist 1,
  2. W T Longstreth , vascular neurologist1,
  3. Robert G Holloway, professor of neurology23
  1. 1Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
  2. 2Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
  3. 3 Department of Medicine, Division of Palliative Care, University of Rochester Medical Center, Rochester, NY, USA
  1. Correspondence to: C J Creutzfeldt clairejc{at}

Illness trajectories depicting how function declines to death with certain diseases, such as cancer, can help with palliative care. Creutzfeldt and colleagues propose a fourth trajectory is needed for patients with severe acute brain injury to improve decision making and standards of care

Three illness trajectories have been proposed to conceptualise how function declines as diseases advance to death: a short decline as with cancer; an episodic decline as with heart failure; and a prolonged decline as with dementia (fig 1).1 2 These frameworks allow patients, family members, providers, and healthcare planners to prepare for next steps as they confront the limits of modern medicine and to develop compassionate healthcare systems that allow patients to live, age, and die with self respect and grace.

Fig 1 Trajectories of chronic illness1 2

None of the existing trajectories is suitable for patients with severe acute brain injury,3 a distinct group of neurological catastrophes for which the patient and their families are typically unprepared. Examples include vascular brain injury (both focal as with stroke and global as after cardiac arrest); inflammatory brain injury (infectious and non-infectious); and traumatic brain injury. Patients present acutely neurologically devastated and face a trajectory that often results in either early death or a more uncertain prognosis that may resemble the chronic disease trajectory with prolonged dwindling.

Although the exact number of patients affected by this heterogeneous group of diseases is unknown, the numbers of deaths worldwide every year from stroke (6.7 million), sudden cardiac arrest (3.7 million), and traumatic brain injury (>1 million) suggest that their contribution to both death and adult disability are large enough to warrant attention.4 5 6 Improved emergency response services and advances in acute and critical care management across all of these conditions, are likely to increase …

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