Guidelines for Neuroprognostication in Critically ill Adults with Acute Ischemic Stroke
Neurocritical Care Society · 2026 · USA
Source and licence
- Authors
- Shraddha Mainali, Gabriel V Fontaine, Venkatakrishna Rajajee et al.
- Title
- Guidelines for Neuroprognostication in Critically ill Adults with Acute Ischemic Stroke
- Journal
- Neurocritical Care, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13249629
Licence statement of the original publication
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Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Recommendations: Clinical Variables as Predictors of Functional Outcome
- RecommendationWhen counseling critically ill adults with AIS or their surrogates, we suggest age alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill adults with AIS or their surrogates, we suggest the NIHSS alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest hemorrhagic transformation alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest infarct size alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling of critically ill patients with AIS or their surrogates, we suggest a history of previous stroke alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest successful revascularization alone not be considered a reliable predictor of good functional outcome assessed at 3 months or laterweak recommendation; low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest early neurological improvement (ENI) assessed 24 h following revascularization, or 24 h following admission for patients who are not candidates for revascularization, be considered a moderately reliable predictor of good functional outcome assessed at 3 months or later. A good outcome is expected in patients with recovery to an NIHSS of 0 to 1 at 24 hweak recommendation; low quality evidence
Recommendations: Clinical Prediction Models as Predictors of Functional Outcome
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest the ASTRAL score not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest the DRAGON, MR-DRAGON, and MT-DRAGON scores not be considered reliable predictors of poor functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest the iScore prediction model not be considered a reliable predictor of functional outcome assessed at 3 months or laterweak recommendation; very low quality evidence
- RecommendationWhen counseling critically ill patients with AIS or their surrogates, we suggest the THRIVE/THRIVE-c/THRIVE-EVT scores not be considered reliable predictors of good functional outcome assessed at 3 months or laterweak recommendation; low quality evidence
Abstract
Background: Patients with acute ischemic stroke (AIS) may require intensive care unit admission for several reasons, including post-procedural care, management of large hemispheric infarction, and cardiopulmonary instability. The objective of this document is to provide recommendations on the reliability of select individual predictors of outcome, and multivariate prediction models, in the context of counseling critically ill patients with AIS and their surrogates. In addition, broad principles of neuroprognostication in this population were identified.
Methods: A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected on the basis of clinical relevance and the presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting (PICOTS) question was framed as follows: “When counseling critically ill adults with AIS or their surrogates, should <predictor> be considered a reliable predictor of poor functional outcome at 3 months or later?” Recommendations were based on quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Recommendations that met GRADE criteria for good practice statements addressed broad principles of neuroprognostication.
Results: A total of 518 articles met eligibility criteria to guide recommendations. Good practice recommendations include avoiding premature neuroprognostication, avoiding confounders, the use of multimodal assessment, predicting recovery of swallow function, predicting tracheostomy decannulation, and counseling of patients with large hemispheric infarction and their surrogates prior to neurological decline. Early neurological improvement within 24 h of revascularization was identified as a moderately reliable predictor of good functional outcome. No other individual predictor was considered reliable for the prediction of mortality or functional outcome.
Conclusions: These guidelines suggest broad principles of neuroprognostication and provide recommendations on the reliability of predictors of functional outcome in the context of counseling critically ill patients with AIS and their surrogates.
Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-026-02486-3.
Contents of the original publication
The section headings of the original.
- Introduction
- Scope of the Guidelines
- How to Use These Guidelines
- Methods
- Selection of Candidate Predictors
- PICOTS Question
- Selection of Outcomes
- Functional Outcome Assessment
- Systematic Review Methodology
- Article Screening
- Risk of Bias (RoB) Assessment
- GRADE Assessment and Evidence Profile
- Evidence to Recommendation Criteria
- Recommendations: Clinical Variables as Predictors of Functional Outcome
- Recommendations: Clinical Prediction Models as Predictors of Functional Outcome
- Good Practice Statements
- Approach to Neuroprognostication
- Gaps and Opportunities in the AIS Neuroprognostication Literature
- Future Directions
- Conclusions
- Source of support
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