Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

doi:10.1007/s12028-023-01902-2

. 2024 Apr;40(2):448-476.

doi: 10.1007/s12028-023-01902-2. Epub 2024 Feb 17.

Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

Susanne Muehlschlegel¹, Venkatakrishna Rajajee², Katja E Wartenberg³, Sheila A Alexander⁴, Katharina M Busl⁵, Claire J Creutzfeldt⁶, Gabriel V Fontaine⁷, Sara E Hocker⁸, David Y Hwang⁹, Keri S Kim¹⁰, Dominik Madzar¹¹, Dea Mahanes¹², Shraddha Mainali¹³, Juergen Meixensberger¹⁴, Oliver W Sakowitz¹⁵, Panayiotis N Varelas¹⁶, Christian Weimar^{17

18}, Thomas Westermaier^{19

20}

Affiliations

¹ Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Departments of Neurology and Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
³ Department of Neurology, University of Leipzig, Leipzig, Germany.
⁴ School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
⁵ Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
⁶ Department of Neurology, University of Washington, Seattle, WA, USA.
⁷ Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA.
⁸ Department of Neurology, Saint Luke's Health System, Kansas City, MO, USA.
⁹ Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
¹⁰ Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA.
¹¹ Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.
¹² Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA.
¹³ Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.
¹⁴ Department of Neurosurgery, University of Leipzig, Leipzig, Germany.
¹⁵ Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany.
¹⁶ Department of Neurology, Albany Medical College, Albany, NY, USA.
¹⁷ Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany.
¹⁸ BDH-Klinik Elzach, Elzach, Germany.
¹⁹ Department of Neurosurgery, Helios Amper Klinikum Dachau, Dachau, Germany. Thomas.Westermaier@helios-gesundheit.de.
²⁰ Faculty of Medicine, University of Würzburg, Würzburg, Germany. Thomas.Westermaier@helios-gesundheit.de.

PMID: 38366277
PMCID: PMC10959796
DOI: 10.1007/s12028-023-01902-2

Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

Susanne Muehlschlegel et al. Neurocrit Care. 2024 Apr.

. 2024 Apr;40(2):448-476.

doi: 10.1007/s12028-023-01902-2. Epub 2024 Feb 17.

Authors

Affiliations

¹ Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² Departments of Neurology and Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
³ Department of Neurology, University of Leipzig, Leipzig, Germany.
⁴ School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
⁵ Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
⁶ Department of Neurology, University of Washington, Seattle, WA, USA.
⁷ Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA.
⁸ Department of Neurology, Saint Luke's Health System, Kansas City, MO, USA.
⁹ Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
¹⁰ Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA.
¹¹ Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.
¹² Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA.
¹³ Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.
¹⁴ Department of Neurosurgery, University of Leipzig, Leipzig, Germany.
¹⁵ Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany.
¹⁶ Department of Neurology, Albany Medical College, Albany, NY, USA.
¹⁷ Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany.
¹⁸ BDH-Klinik Elzach, Elzach, Germany.
¹⁹ Department of Neurosurgery, Helios Amper Klinikum Dachau, Dachau, Germany. Thomas.Westermaier@helios-gesundheit.de.
²⁰ Faculty of Medicine, University of Würzburg, Würzburg, Germany. Thomas.Westermaier@helios-gesundheit.de.

PMID: 38366277
PMCID: PMC10959796
DOI: 10.1007/s12028-023-01902-2

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.

Keywords: Neurocritical care; Outcome; Prognosis; Prognostication; Traumatic brain injury.

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Conflict of interest statement

Susanne Muehlschlegel has received research funding from the National Institutes of Health (R21NR020231, U01NS119647 and U01NS099046) and honoraria from the American Academy of Neurology as a speaker. Thomas Westermaier has received research funding from the Else-Kroener-Fresenius-Stiftung, consulting fees and honoraria from Medtronic Navigation.

Figures

**Fig. 1**
Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) flow diagram depicting the method of systematic review

See this image and copyright information in PMC

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References

1. Centers for Disease Control and Prevention (2022) Get the Facts: TBI Data. 2021 (Accessed 9/30/2021) at https;//www.cdc.gov/traumaticbraininjury/data/index/html. https;//www.cdc.gov/traumaticbraininjury/data/index/html.
1. Iaccarino C, Carretta A, Nicolosi F, Morselli C. Epidemiology of severe traumatic brain injury. J Neurosurg Sci. 2018;62(5):535–541. - PubMed
1. Centers for Disease Control and Prevention (2022) Moderate to Severe TBI is a life-long condition. 2021. Accessed 30 June 2021. https://www.cdc.gov/traumaticbraininjury/pdf/Moderate_to_Severe_TBI_Life....
1. Centers for Disease Control and Prevention (2022) TBI report to Congress. 2016. (Accessed 9/30/2021). https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.htm... 3%20million,full%20human%20cost%20is%20incalculable.
1. Turgeon AF, Lauzier F, Simard JF, et al. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ. 2011;183(14):1581–1588. - PMC - PubMed

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[1] Centers for Disease Control and Prevention (2022) Get the Facts: TBI Data. 2021 (Accessed 9/30/2021) at https;//www.cdc.gov/traumaticbraininjury/data/index/html. https;//www.cdc.gov/traumaticbraininjury/data/index/html.

[2] Centers for Disease Control and Prevention (2022) Get the Facts: TBI Data. 2021 (Accessed 9/30/2021) at https;//www.cdc.gov/traumaticbraininjury/data/index/html. https;//www.cdc.gov/traumaticbraininjury/data/index/html.

[3] Iaccarino C, Carretta A, Nicolosi F, Morselli C. Epidemiology of severe traumatic brain injury. J Neurosurg Sci. 2018;62(5):535–541. - PubMed

[4] Iaccarino C, Carretta A, Nicolosi F, Morselli C. Epidemiology of severe traumatic brain injury. J Neurosurg Sci. 2018;62(5):535–541. - PubMed

[5] Centers for Disease Control and Prevention (2022) Moderate to Severe TBI is a life-long condition. 2021. Accessed 30 June 2021. https://www.cdc.gov/traumaticbraininjury/pdf/Moderate_to_Severe_TBI_Life....

[6] Centers for Disease Control and Prevention (2022) Moderate to Severe TBI is a life-long condition. 2021. Accessed 30 June 2021. https://www.cdc.gov/traumaticbraininjury/pdf/Moderate_to_Severe_TBI_Life....

[7] Centers for Disease Control and Prevention (2022) TBI report to Congress. 2016. (Accessed 9/30/2021). https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.htm... 3%20million,full%20human%20cost%20is%20incalculable.

[8] Centers for Disease Control and Prevention (2022) TBI report to Congress. 2016. (Accessed 9/30/2021). https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.htm... 3%20million,full%20human%20cost%20is%20incalculable.

[9] Turgeon AF, Lauzier F, Simard JF, et al. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ. 2011;183(14):1581–1588. - PMC - PubMed

[10] Turgeon AF, Lauzier F, Simard JF, et al. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ. 2011;183(14):1581–1588. - PMC - PubMed

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Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

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Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury

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