What rehabilitation options are available for a female patient with severe neurological deficits, including quadriplegia and impaired consciousness (Glasgow Coma Scale (GCS) score of 4/15), following acute basilar artery thrombosis, who is currently on nasogastric (NG) tube feeding and medical therapy including antiplatelet therapy, antihypertensive medication, and statin therapy for vascular disease risk factor control?

Rehabilitation and Recovery Potential After Severe Basilar Artery Thrombosis

The prognosis for meaningful neurological recovery in this patient with GCS 4/15 and grade 1 quadriplegia following basilar artery thrombosis is extremely poor, but rehabilitation should still be initiated as early as medically stable, focusing primarily on preventing complications rather than expecting functional independence.

Realistic Prognostic Assessment

The severity of neurological deficit is the strongest predictor of outcome:

• Patients with severe deficits (coma, locked-in state, or tetraplegia) at presentation have approximately 68% risk of poor outcome (mRS 4-5 or death) even with optimal acute treatment 1
• A GCS of 4/15 places this patient in the most severe category, where the likelihood of achieving functional independence (mRS 0-3) is approximately 16-22% 2
• NIHSS scores >16 forecast high probability of death or severe disability, and this patient's clinical picture suggests an NIHSS well above this threshold 2

Rehabilitation Strategy

Timing and Intensity

Initiate rehabilitation therapy immediately once medical stability is achieved 2:

• Begin range-of-motion exercises and physiologically sound position changes as soon as tolerated 2
• Early mobilization prevents deep vein thrombosis, skin breakdown, contracture formation, constipation, and pneumonia 2
• The patient should receive "as much therapy as needed" to adapt and establish optimal functional level, though expectations must be realistic 2

Primary Rehabilitation Goals

Given the severity, focus on:

• Prevention of complications (DVT prophylaxis with anticoagulation already in place, pressure ulcer prevention, contracture prevention) 2
• Maintenance of joint range of motion 2
• Swallowing assessment and optimization of nutritional support (NG tube feeding already established) 2
• Bowel and bladder management 2
• Family education and support regarding realistic expectations 2

Medical Optimization to Support Recovery

Continued Secondary Prevention

The current regimen is appropriate 2:

• Antiplatelet therapy (continue lifelong) 2
• Antihypertensive therapy (critical for preventing recurrent events) 2
• Statin therapy (even with normal LDL cholesterol in stroke patients) 2

Monitoring for Complications

• Assess for deep vein thrombosis despite prophylactic anticoagulation 2
• Monitor for aspiration pneumonia given severe neurological impairment 2
• Screen for and treat depression, which is common post-stroke 2
• Monitor nutritional status and consider PEG tube placement if prolonged feeding support needed 2

Critical Caveats

The time window for acute intervention has passed - this patient is now weeks post-event, and the acute treatment window (within 24 hours) for potential endovascular therapy is no longer applicable 2

GCS alone does not absolutely predict outcome - while a GCS of 4/15 is extremely concerning, there are rare cases where patients with very low GCS scores (≤6) achieved good outcomes (mRS ≤1 in 33% in one series), though this was in the context of successful acute recanalization therapy 3. However, this patient is beyond the acute treatment window.

Locked-in syndrome possibility - With basilar artery occlusion and quadriplegia, consider whether the patient has locked-in syndrome rather than true coma, as this affects communication strategies and prognostication 1, 4

Realistic Counseling for Family

Based on the evidence:

• Most patients with severe deficits at presentation (68%) have poor outcomes defined as severe disability, vegetative state, or death 1
• Even among those who underwent successful acute recanalization, patients with severe initial deficits had limited recovery 1
• The focus should be on comfort, dignity, and prevention of complications rather than expectation of functional independence 2
• Consider goals-of-care discussions given the poor prognosis 2

Rehabilitation should proceed, but expectations must be tempered by the reality that meaningful functional recovery from this severity of basilar artery stroke with such profound deficits is unlikely 2, 1.