716 - Beyond the Images: How Timely IPR Admission Improved Prognosis in a Case of Diffuse Axonal Injury (DAI) Despite Radiologic Severity

Case Diagnosis: A 30-year-old woman arrived in inpatient rehabilitation following a severe traumatic brain injury sustained in a motor vehicle accident. Her initial Glasgow Coma Scale was 7, she experienced loss of consciousness under five hours, and displayed right spastic hemiplegia. Radiology over-read her imaging as grade III diffuse axonal injury, fostering an overly pessimistic horizon, exacerbated by the setting of limited resources, lack of insurance, and minimal family understanding of TBI recovery.

Case Description: Despite projection toward a guarded prognosis, her clinical trajectory shifted. Within days, orientation significantly improved even as post-traumatic amnesia persisted. Serial O-Log assessments revealed scores of 23/30 then 24/30 by second week of IPR, approaching the 25-point threshold suggestive of orientation resolution. She remained amnesic to events surrounding the accident, but recall of remote information steadily returned.

Discussions: This case illustrates the danger of anchoring prognosis solely on radiology and early impressions, especially in low-resource environments where implicit bias may lead to premature decisions. Post-traumatic amnesia remains one of the most robust predictors of outcome in moderate TBI, surpassing initial imaging severity and Glasgow Coma Scale scores. In stroke rehabilitation, the AVERT trial cautioned that very early, high-dose mobilization may reduce favorable outcomes, supporting a measured approach analogous to our patient’s rehabilitation path. By analogy, a measured, patient-specific approach (guided by serial clinical observations and family education) allowed this patient’s recovery to emerge. For physiatrists, this posits a time-honored pearl: prognosis must remain fluid, and care decisions must be anchored in evolving clinical evidence, not initial pessimism.

Conclusions: In severe TBI, especially when radiology is over-read and social determinants complicate care, physiatrists should resist premature nihilism. Serial clinical reassessment, especially of orientation and PTA, should guide ongoing rehabilitation decisions. Early pessimistic projections may need reassessment as the neuroplastic window unfolds with supportive clinical observation.