Uncertainty in Neurocritical Care: Recognizing Its Relevance for Clinical Decision Making

Uncertainty inprinciple entails thepresence ofdoubt. This can lead to the inabilityofdelayeddecisionmaking. Toanobserver, thiswill lead to skepticismandunwillingness toworkwith the process. Ultimately if the process continues, it will lead to mistrust and a dysfunctional working environment. William Osler was one of thefirst to recognizehow uncertainty plays a role in our medical practice. His statement “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all, he has been in the wrong”1 helps with the concept he proposed in the practice of medicine. But despite the uncertainty that surrounds medicine, the history of the disease creates challenges around the individuality of each patient. This challenge is present in the practice of neurocritical care. Acute neurological criseswere considered to be part of the black box of complex brain derangements. Over time, with extensive advancement of neurological sciences with tools like neuroimaging, neuromonitoring, surgical procedures, and protocols, the black box is more open now. The practice still has uncertainties, especially with new and complex diseases like coronavirus disease 2019 and the introduction of complex therapies including extensive use of different monoclonal antibodies. Patients with the acute neurological crisis have a multisystem presentation.2 The uncertainty of when an acute pulmonary injury happens with an acute brain crisis is always there.3 Which one is the primary and which one is the key aspect at the time of examination? The neurological examination of these patients can be unreliable due to multiple factors including sedation requirement for ventilator stability to surgical stability to avoid hemorrhagic conversion. The recognition of the presence of this uncertainty is important in neurocritical care. The goal should be to work on facts and change the management based on the response of the therapeutics that are used under the umbrella of the best clinical practice.