Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

Abstract

Background The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. Methods A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. Results Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication—aside from the most clinically devastated patients—for at least the first 48–72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. Conclusions These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.

Machine Learning Identifies Variation in Timing of Palliative Care Consultations Among Traumatic Brain Injury Patients

“…This insight of clinician bias is in line with existing literature that highlights disparities in end-of-life care for patients with TBI. 6 , 7 , 21 , 22 , 35 It also supports the increasing recognition that demographics, often unconsciously, influence medical decision-making and care pathways. 36 , 37 Our study thus stresses the critical need for increased awareness and the development of strategies to mitigate potential biases in clinical practice.…”

Coma Prognostication After Acute Brain Injury

“…Degree of gray vs white matter differentiation predictive 6,47,48,50 Some features, such as edema and subarachnoid and intraventricular hemorrhage, may be predictive 42,51 Location and size of intraparenchymal hemorrhage may be predictive, 67 although this remains uncertain 54 Not sufficiently studied…”

Prognostication in Neurocritical Care

“…It would also provide a grounding framework for less experienced clinicians. 67 Because of the profound impact of neuroprognostication on families who face high-stakes decisions severe acute brain injuries, several guidelines and expert consensus documents have begun to offer recommendations on neuroprognostication (TABLE 12-3 [68][69][70][71][72][73] ). A collaborative practice guideline on disorders of consciousness, published by the American Academy of Neurology; American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research in 2018, provided recommendations regarding what clinicians should avoid when making prognostications for patients with disorders of consciousness.…”

“…After this gap analysis, an international multidisciplinary author panel (including physicians from neurocritical care, neurosurgery, ethics, and neuropalliative care; nurses; pharmacists; and family or patient representatives) from the same societies has embarked on publishing evidencebased guidelines on the neuroprognostication of the eight most common diseases in neurocritical care: ischemic encephalopathy after cardiac arrest, ICH, acute ischemic stroke, subarachnoid hemorrhage, TBI, traumatic spinal cord injury, status epilepticus, and Guillain-Barré syndrome. At the time of the writing of this article, the guidelines for neuroprognostication after cardiac arrest, Guillain-Barré syndrome, traumatic spinal cord injury, ICH, and traumatic brain injury have been published, [69][70][71][72][73] and others are under review, with the anticipation that all of them will be published by late 2024 or early 2025. These neuroprognostication guidelines are unique because of their inclusion of the most extensive and up-to-date systematic review conducted thus far on the quality of the existing literature in eight diseases.…”