Michael Schumacher Out of Coma and Transferred to Rehab

After months following a skiing accident and subsequent brain injury, Formula One legend Michael Schumacher is no longer in a coma and has left the hospital, according to his family. The 45-year-old has been transferred to Lausanne University Hospital in Switzerland, a country in which he has a home.

Schumacher was placed in a medically induced coma after suffering a severe head injury in a skiing accident in the French Alps on December 29, 2013. He sustained life-threatening head injuries after falling onto a rock, despite the fact he was wearing a helmet and is an experienced skier.

He subsequently underwent two operations in Grenoble to remove blood clots on the brain. The updated news was released on Monday, June 16, 2014, and was the first public update regarding Schumacher since April 4th, when he was reportedly making small signs of progress and was showing “some moments of communication.”

A medically induced coma is when a patient receives a controlled dose of an anesthetic, typically propofol, pentobarbital or thiopental, to cause a temporary coma or a deep state of unconsciousness. This type of coma is used to protect the brain from swelling by reducing the metabolic rate of brain tissue, as well as the cerebral blood flow.

When the brain swells it can be life-threatening, as it can constrict blood supply and destroy additional brain tissue. When a patient is put in a medically induced coma or deep state of unconsciousness, the brain is able to rest and swelling is more likely to decrease. When swelling is relieved, pressure on the brain also reduces, hopefully preventing some or all brain damage from occurring.

A medically induced coma can be understood via the science behind general anesthesia, which some 60,000 patients undergo every day. Anesthesia is, essentially, a reversible coma. When patients go under general anesthesia that entire process is actually a reversible coma. Often the same drugs are used in both routine anesthesia and a medically induced coma.

However, use of these drugs for an extended period of time causes the possibilities those drugs can accumulate, taking them a while to be flushed out of the system.

It is not clear exactly what Schumacher’s condition is and thus difficult to speculate on the process of recovery, except to assume it will be a long one. In fact, it can take years, depending on the injury and the age and fitness of the patient.

According to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, in the United States annually at least 1.4 million people sustain a traumatic brain injury (TBI), and approximately 50,000 people die from such injuries. Michael Schumacher is a high-profile example of the long and complicated road back from TBI. Dr. Arno Fried, who has significant surgical and research experience with TBI, answers some key questions on the topic below.

What is the general nature of brain injury?
To understand serious head injury, it is useful to know that there are two categories to which we refer: primary brain injury, which is the damage at the time of impact or injury, the immediate effect. You can’t do anything about that; you can’t undamage those cells. Secondary brain injury refers to damage that evolves over time, following the trauma. During this time, the danger is that the brain swells. Think of the skull like a closed box, where there is no room for that swelling. So, the goal in traumatic brain injury treatment is to control the secondary effects.

What is the treatment for TBI?
With traumatic brain injury (TBI), there is a sequence of treatment. The most serious step to take is to put the patient into an induced coma. The purpose of the induced coma is to reduce pressure in the brain. This means Michael Schumacher’s head injury was sufficient that it caused swelling and subsequent pressure in the brain. An induced coma is done when you have exhausted other, simpler things to do. It allows the brain to begin to heal, and gives the patient a fighting chance. The issue with an induced coma, however, is that it affects not only the brain, but other organs and functions as well: the heart, kidneys and blood pressure. Once Schumacher was past the period in which his brain swelling had reached maximal, he was probably weaned off the induced coma treatment. However, it seems that once the induced coma was withdrawn, he was still in a coma, albeit a natural coma. That just has to run its course.

It was said that Michael Schumacher underwent surgery following his accident, and that doctors removed blood clots. What else might surgery have entailed?
There are surgical procedures to remove blood clots. Secondly, they would insert pressure monitors; we do this all the time so there is a constant reading. Third, there is a surgical procedure done sometimes in which a portion of the skull is removed to allow the brain to swell outward.

What is the prognosis for recovery from TBI?
Once it’s clear that someone will not die of a head injury, they undergo a slow recovery that can take months to years. I always tell patients’ families that recovery is “an inch at a time”. It is impossible to tell if there is improvement day to day, but from week to week, maybe you notice more eye movements, or the eyes opening. The goal is that the recovery doesn’t stop, but keeps going. The hope is that the person makes a meaningful functional recovery.

Despite the little made public, how do you view Michael Schumacher’s case?
Although I obviously never saw his brain scans and so don’t know the details, just knowing he’s been in a coma for several months tells you he has had a very serious head injury. There are variable possible outcomes. It’s unlikely that he’ll be perfectly normal. I don’t think that driving is the expectation. The question is will he be independent. On the other hand, I’ve had many cases that progressed. I had a young man with a similar case, a serious head injury. He was in an induced coma for six weeks. Now he’s back working at a bank. I’ve had other patients whose recovery just kind of lags, slows down, and then plateaus.

It depends on how extensive the initial impact is, and whether is it on one side of the brain, both sides, and if the brain stem is involved. The younger the patient, the better. I’ve had five-year-olds with similar injuries make excellent recoveries. The younger the person and the more brain plasticity, the better the recovery. Also, it changes the prognosis if the injury is isolated to the head, versus if there are other associated injuries such as to the lung, chest, or abdomen.

What is your experience with TBI?
Traumatic brain injury has been a major part of my practice for 30 years. It is especially a problem in children and young adults. What we’ve learned is to be super aggressive in terms of surgery and brain management in order to foster a better outcome. Years ago someone with a bad brain injury would do poorly, and there was very little doctors could do to change that. I started at CHOP (Children’s Hospital of Philadelphia), which was one of first places where patients with TBI could have a better outcome. Now, that aggressive treatment is what we do. The movement for change began in the mid-1980s when we looked very carefully at intracranial pressure (ICP) and cerebral perfusion pressure (CPP, the pressure of blood flowing to the brain). We looked at advanced ways of controlling brain swelling. Prior to this time, these measures were not as carefully tracked.*

*Early in Dr. Fried’s career, during the 1980’s, he conducted two years of research on the physiology of intracranial pressure and the use of pressure monitoring for the management of head trauma. His unique and cutting-edge approach to brain compliance (the capability to buffer an intracranial volume increase while avoiding a rise in intracranial pressure) was the subject of various pilot studies on which he bases his current treatments. His treatment recommendations include the use of pressure volume index (PVI), a useful tool to measure brain compliance and which he has used to perform lifesaving care. Dr. Fried has found PVI, his predictive measure, to be a much earlier and accurate guideline to care. In addition to brain trauma, brain compliance is also of major relevance in other common neurosurgical conditions such as hydrocephalus and pseudo tumor. 

UPDATE 9/11/2014: Michael Schumacher Comes Home

Former Formula One champion Michael Schumacher has left hospital to continue his recuperation at home.

Nine months after his skiing accident. In June, Schumacher woke up from his medically-induced coma, and while he has reportedly made progress since that time, the 45-year-old still faces a long road ahead. Fans have loyally awaited news of his progress. Schumacher’s home has been remodeled to suit his recovery. At the time of the last update of Schumacher’s awaking from the coma in June,  medical experts expressed skepticism about the seven-time world champion’s chances of escaping permanent damage. As of his current return home, there is no significant update on the state of Schumacher’s condition.