The Unsteady Return of Command-Following: Recovery and Instability of Bedside Motor Command-Following After Acute Brain Injury

Background/Objective: Following a verbal command marks the bedside transition from unresponsiveness to overt recovery of consciousness after acute brain injury. Its timing across phenotypes, stability once present, and dependence on sedation are uncharacterized at scale. Methods: Retrospective cohort of adults with acute brain injury, first intensive care unit stay, MIMIC-IV. Command-following was the Glasgow Coma Scale motor response "Obeys Commands." Among patients not following commands at admission, cumulative incidence was estimated with death or hospice and discharge without recovery as competing events. Instability was quantified as transient first recovery and threshold crossings; examinations were tagged for concurrent sedation. Principal findings were externally validated in the multicenter eICU Collaborative Research Database. Results: Of 13,900 brain-injured patients with three or more motor examinations, 5,498 (39.6%) were not following commands at admission. The cumulative incidence of first command-following was 43.5% by 24 hours and 65.0% by 14 days, ranging at 14 days from 36.9% in anoxic injury to 77.2% in ischemic stroke (anoxic versus ischemic stroke at 72 hours, difference 0.41; adjusted P = .002). Among 3,573 patients who recovered, the first recovery was transient in 22.2%, and 62.4% crossed the threshold repeatedly. Non-following was strongly associated with sedation, consistent with an arousal-dependent examination. In eICU, the 14-day incidence was 64.8%, and transient first recovery was 22.7%, closely matching the primary cohort. Conclusions: After acute brain injury, overt bedside command-following returns early but unsteadily, with phenotype-dependent timing, threshold fluctuation, and strong dependence on sedation. A single charted observation is an unreliable index of the underlying state.