Neurologic Prognostication in Neurocritical Care

Neurological prognostication is an indispensable component of neurointensive care with significant ramifications—not just for patients with regard to survival and functional outcomes, or for families and caregivers, but also for the scientific advancement for a particular neurologic pathology. Accurate, reliable, and objective determination of prognosis after acute brain injury requires a multifaceted approach and consideration of all aspects of the patient’s condition, including the pathophysiology of the specific acute neurologic injury, its clinical course, pertinent neurologic clinical assessment, neuroimaging information, neurophysiologic data, blood/CSF-based biomarkers, and importantly the timing of these parameters in relation to the injury and subsequent interventions. Despite some advances, there is a growing realization that existing neuro-prognostic markers have serious limitations that may impact both patient care and clinical research after life-threatening neurologic injury. In particular, the majority of prognostication models are confounded by self-fulfilling prophecies created by the bias of early care limitations and do not take into account the influence of post-hospitalization events such as treatment response and exposure to factors causing secondary neurologic injury. Additionally, patient and caregiver perspectives regarding what constitutes an acceptable level of disability is often not incorporated into prognostication methods. This chapter will present the state of the science vis-à-vis the prevailing practices in neurologic prognostication in common acute life-threatening neurologic illnesses and highlight these important limitations and their impact on patient care.