Guidelines for Neuroprognostication in Critically Ill Adults with Moderate–Severe Traumatic Brain Injury
Neurocritical Care Society · 2024 · USA
Source and licence
- Authors
- Susanne Muehlschlegel, Venkatakrishna Rajajee, Katja E. Wartenberg et al.
- Title
- Guidelines for Neuroprognostication in Critically Ill Adults with Moderate–Severe Traumatic Brain Injury
- Journal
- Neurocritical Care, 2024
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC10959796
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Good Practice Statements
- We recommend that prognostication should be performed with consideration of the complete clinical condition and not be based on a single variablestrong recommendation, evidence cannot be graded
- We recommend that prognostication should not be performed based only on ultra-early injury characteristics in the first 3 days. TBI is characterized by a primary injury and secondary injuries, including growing hemorrhagic lesions and microcellular processes with possible neurological worsening. In addition, patients with msTBI may have additional nonneurologic trauma (“polytrauma”), which may influence a patient’s hospital course and outcome. Unless irreversible brain stem damage has occurred with imminent death or unless there are documented predetermined wishes by the patient not to receive any critical care support even when the prognosis is uncertain, we suggest a minimum of 3 days or longer of full critical care support, including surgical procedures and, if possible, at least 1–2 weeks of full critical care or medical support before attempting neuroprognostication. Even after 2 weeks, prognosis may be uncertain, especially when patients remain unconsciousstrong recommendation, evidence cannot be graded
- We recommend that prognostication should be performed carefully with an acknowledgment of uncertainty and without nihilism and should only be performed with consideration of all available evidence and not be based on personal anecdotal experience alonestrong recommendation, evidence cannot be graded
PICOT Question 1
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that age alone not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation; low-quality evidence
PICOT Question 2
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that bilateral pupillary nonreactivity measured on admission be considered a moderately reliable predictor of in-hospital mortality, conditional on accurate assessment without confounding medications or injuriesweak recommendation, low-quality of evidence
PICOT Question 3
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that single pupillary nonreactivity alone not be considered a reliable predictor of in-hospital mortalityweak recommendation; low-quality evidence
PICOT Question 4
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the GCS score or the motor subscore of the GCS alone, assessed on admission after adequate resuscitation, not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation; low-quality evidence
PICOT Question 5
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that hypotension (SBP < 90 mm Hg) alone, assessed prehospitalization or in the emergency department, not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation; low-quality evidence
PICOT Question 6
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that hypoxia alone, assessed prehospitalization, on admission, or during the ICU treatment (oxygen saturation < 90% or PaO2 < 110 mm Hg), not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation; low-quality evidence
PICOT Question 7
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that elevated ICP, including the duration (dose) of early or delayed intracranial hypertension, alone not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation; very low-quality evidence
PICOT Question 8
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that major extracranial injury alone not be considered a reliable predictor for hospital mortality or disease-related mortality beyond dischargeweak recommendation, moderate-quality evidence
PICOT Question 10
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that positive testing for alcohol on admission alone not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation, low-quality evidence
PICOT Question 11
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that hypernatremia during ICU treatment alone not be considered a reliable predictor of hospital mortality or disease-related mortality beyond dischargeweak recommendation, very low-quality evidence
PICOT Question 12
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that age alone not be considered a reliable predictor of functional outcome at 6 months and beyondweak recommendation, moderate-quality evidence
PICOT Question 13
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that bilateral pupillary nonreactivity alone, measured on admission, is a moderately reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 14
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that unilateral pupillary nonreactivity alone, measured on admission, not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 15
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the GCS score (or GCS motor score) alone, measured on admission and following adequate resuscitation, not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 16
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that hypotension alone, prior to or at the time of hospital admission, not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 17
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that hypoxia alone, prior to or at the time of hospital admission, not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 18
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that elevated ICP alone during the treatment in the ICU not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 19
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that AKI alone not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 20
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that posttraumatic cerebral infarction alone not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 21
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the CRASH-basic and CRASH-CT clinical prediction models be considered moderately reliable predictors of short-term (14-day) mortalityweak recommendation; moderate-quality evidence
PICOT Question 22
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the IMPACT-core and IMPACT-extended (core + CT) clinical prediction models be considered moderately reliable predictors of 6-month mortalityweak recommendation; moderate-quality evidence
PICOT Question 23
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the IMPACT core + CT + lab clinical prediction model be considered a moderately reliable predictor of 6-month mortalityweak recommendation; moderate-quality evidence
PICOT Question 24
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Marshall CT classification not be considered a reliable predictor of mortality assessed at 6 months or beyondweak recommendation; moderate-quality evidence
PICOT Question 25
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Rotterdam CT score not be considered a reliable predictor of 6-month mortalityweak recommendation; low-quality evidence
PICOT Question 26
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Helsinki CT score not be considered a reliable predictor of 6-month mortalityweak recommendation; moderate-quality evidence
PICOT Question 27
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Stockholm CT score not be considered a reliable predictor of 6-month mortalityweak recommendation; low-quality evidence
PICOT Question 28
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the CRASH-basic and CRASH-CT clinical prediction models be considered moderately reliable predictors of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 29
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the IMPACT-core and IMPACT-extended (core + CT) clinical prediction models be considered moderately reliable predictors of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 30
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the IMPACT core + CT + lab clinical prediction model be considered a moderately reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; moderate-quality evidence
PICOT Question 31
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Marshall CT classification alone not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 32
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Rotterdam CT model alone not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
PICOT Question 33
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Helsinki CT model alone not be considered a reliable predictor of poor outcome at 6 monthsstrong recommendation; low-quality evidence
PICOT Question 34
- RecommendationWhen counseling family members and/or surrogates of patients with msTBI admitted to an ICU, we suggest that the Stockholm CT model alone not be considered a reliable predictor of poor functional outcome at 6 months and beyondweak recommendation; low-quality evidence
Abstract
Background: Moderate–severe traumatic brain injury (msTBI) carries high morbidity and mortality worldwide. Accurate neuroprognostication is essential in guiding clinical decisions, including patient triage and transition to comfort measures. Here we provide recommendations regarding the reliability of major clinical predictors and prediction models commonly used in msTBI neuroprognostication, guiding clinicians in counseling surrogate decision-makers.
Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we conducted a systematic narrative review of the most clinically relevant predictors and prediction models cited in the literature. The review involved framing specific population/intervention/comparator/outcome/timing/setting (PICOTS) questions and employing stringent full-text screening criteria to examine the literature, focusing on four GRADE criteria: quality of evidence, desirability of outcomes, values and preferences, and resource use. Moreover, good practice recommendations addressing the key principles of neuroprognostication were drafted.
Results: After screening 8125 articles, 41 met our eligibility criteria. Ten clinical variables and nine grading scales were selected. Many articles varied in defining “poor” functional outcomes. For consistency, we treated “poor” as “unfavorable”. Although many clinical variables are associated with poor outcome in msTBI, only the presence of bilateral pupillary nonreactivity on admission, conditional on accurate assessment without confounding from medications or injuries, was deemed moderately reliable for counseling surrogates regarding 6-month functional outcomes or in-hospital mortality. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting 14-day to 6-month mortality and functional outcomes at 6 months and beyond. When using “moderately reliable” predictors or prediction models, the clinician must acknowledge “substantial” uncertainty in the prognosis.
Conclusions: These guidelines provide recommendations to clinicians on the formal reliability of individual predictors and prediction models of poor outcome when counseling surrogates of patients with msTBI and suggest broad principles of neuroprognostication.
Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-023-01902-2.
Contents of the original publication
The section headings of the original.
- Introduction
- Scope, Purpose, and Target Audience
- How to Use These Guidelines
- Methods
- Selection of Guideline Questions
- Selection of Outcomes
- Systematic Review Methodology
- Evidence to Recommendation Criteria
- Good Practice Statements
- Recommendations: Clinical Variables as Predictors
- Outcome: Mortality
- Outcome: Functional Outcome at 6 Months and Beyond
- PICOT Question 14
- Recommendations: Clinical Prediction Models
- Outcome: Mortality at Hospital Discharge and Beyond
- Outcome: Functional Outcome at 6 Months and Beyond
- Future Directions
- Conclusions
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