What criteria for neuropronostication: consciousness or ability? The neuro-intensivist’s dilemma

Rohaut et al. published the results of a remarkable 12-year evolutionary project, showing a positive association between substantial improvement in consciousness 1 month after brain injury and a favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] score ≥ 4) 1 year later, with an odds ratio of 14.6 [1]. This is a major new finding on neuropronostication, a fundamental issue in neurocritical care.

The multimodal assessment (MMA) based on seven objective criteria, combined with a critical reading by a panel of experts (the “DoC team”) comprising neuro-intensivists, neurologists, neurophysiologists, neuroradiologists and neuroscientists, allowed for predicting GOS-E score 1–3 at 1 year with 100% accuracy in the group with predicted poor prognosis. Assuming that the aim of the MMA is to give a chance for neurological recovery to every patient with a capacity for recovery, these results are highly effective. This also means that at 1 month after brain injury, when the MMA and DoC team predicted a poor 1-year prognosis, they were right. So, the first important lesson for neuro-intensivists is that they can withhold or even withdraw life-sustaining therapies according to this result, without compromising a significant chance of neurological recovery, sparing the patient 1 year of invasive care and rehabilitation.

However, only 39% of the group with predicted good prognosis achieved a GOS-E score ≥ 4 (excluding withdrawal of life-sustaining therapies and unknown decisions). Similarly, only 24% of patients in the group with an uncertain prognosis achieved this good result. Therefore, the MMA’s prediction of an uncertain or favorable outcome exposed the patient to the risk of continuing treatment inappropriately, thus leading to a large number of disabilities and dependencies. In other words, there were very few early “good-prognosis patients,” and even after the MMA, 83% of the 277 patients had a GOS-E score < 4. So, although increasing the number of modalities improved accuracy, the MMA still remained not able to reliably detect long-term ability.

These results raise the question of the goal of neurocritical care.

Although it is known that all patients ultimately recover wakefulness after severe brain injury [2] and many even recover substantial consciousness [3], some will never regain the ability to interact with their environment. These latter conditions, classified as unresponsive wakefulness syndrome or vegetative state without consciousness, are widely considered failure of care. However, what about a conscious but highly dependent patient with modified Rankin Scale (mRS) score 4 or 5 or GOS-E score 4 or 3? In neurovascular studies, an mRS score of 4 (often even 3) is considered failure. For example, this score is considered an outcome to be avoided in decompressive craniectomy studies [4] (with the exception of the recent Switch study [5]) but considered a success in studies of consciousness recovery [6].

Also, patients with an mRS score of 4 may have a lower long-term quality of life (QoL) than those with an mRS score of 2 or 3 [7]. However, long-term satisfaction studies remain quite positive, even for patients with an mRS score of 5 and those with locked-in syndrome, for example [8, 9].

Hence, the neuro-intensivists’ goal of care is sometimes at odds with that of their neurologist and neurosurgeon colleagues, who demand an mRS score of ≤ 2 or 3, and consciousness specialists, who recommend continuing treatments as soon as there is the slightest hope of contact, with a QoL that seems acceptable, or in any case accepted by most patients.

The great merit of the Rohaut et al. study is to have made the link between lack of early consciousness recovery and remote disability/dependence. Nevertheless, was not the large number of highly dependent patients generated helped by the fact that all clinical and para-clinical examinations included in the MMA processes (with the exception of DTI-MRI) focused on patients’ current state of consciousness? Would not one solution to better target remote GOS-E or mRS scores be to include rehabilitation physicians in the multidisciplinary assessment team as well as geriatricians in the case of older patients?

In fact, the goal of neurocritical care is even more questionable. Although historically, prognostic studies in intensive care first focused on survival, then on expected disability, they could now focus on the quality-adjusted life years (including both the quality and quantity of life lived) or even satisfaction of the conscious but disabled patient, although more difficult to quantify [8, 10], particularly because of cognitive barriers in patients with aphasia or significant cognitive impairment. Further progress should consist of better predicting a GOS-E or an mRS score and comparing this prognosis with the patient’s advance directives, bearing in mind that advance directives themselves have serious limitations, particularly in the case of acute cerebral injury [11]. Moreover, this question arises not only after a month of intensive neurological care but also, and probably even more sensitive, during the initial care of the brain-injured patient, as Rohaut et al. pointed out in another article [12]. In the case of intracranial hematoma and intraventricular hemorrhage, for example, prognostication needs to be delayed until after the initial treatment to obtain a reliable prediction of future recovery [13].

By way of summary, there are a few key issues concerning the goal of neurocritical care. First, even if a favorable evaluation at 1 month was statistically associated with better patient autonomy at 1 year, we must bear in mind that specificity remained low, with the risk of inducing “paradoxical unreasonable obstinacy,” contrary to the initial objective of the MMA. Above all, remote QoL and patient satisfaction could be more relevant endpoints of our care. As physicians, we should perhaps be prepared for the person to decide, even if unable to express their will, and for us to become mere executors. This is a societal, ethical, political, financial [12] and even ecological issue, not to mention the QoL and satisfaction of loved ones. Of note, tools such as the Rehabilitation Complexity Scale-Extended [14], now integrated into some European healthcare systems, have been developed to quantify the complexity of a patient’s rehabilitation needs, considering the costs and sustainability.

In any case, in the current situation, in most centers, the neuro-intensivist still cannot avoid assessing whether the outcome is acceptable or not at the time the question arises. Finally, considering this type of publication, will we still have the right to suggest withholding or withdrawing life-sustaining therapies without having to go through this type of MMA, (independent of clinical ethics consultations)? The need to develop early MMA platforms and remote consultation systems after neurological critical care will undoubtedly become crucial.

No datasets were generated or analysed during the current study.

GOSE:

Glasgow outcome scale-extended score

MMA:

Multimodal assessment

mRS:

Modified Rankin scale

QoL:

Quality of life

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1. Neuro-Intensive Care Unit, Rothschild Hospital Foundation, 29 Rue Manin, 75019, Paris, France

   Nicolas Engrand, Armelle Nicolas-Robin, Pierre Trouiller & Stéphane Welschbillig

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Engrand, N., Nicolas-Robin, A., Trouiller, P. et al. What criteria for neuropronostication: consciousness or ability? The neuro-intensivist’s dilemma. Crit Care 28, 322 (2024). https://doi.org/10.1186/s13054-024-05098-5

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• Received: 31 July 2024

• Accepted: 14 September 2024

• Published: 03 October 2024

• DOI: https://doi.org/10.1186/s13054-024-05098-5

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