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Neuroprognostication: a conceptual framework

Nature Reviews Neurology volume 18, pages 419–427 (2022)Cite this article

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Abstract

Neuroprognostication, or the prediction of recovery from disorders of consciousness caused by severe brain injury, is as critical as it is complex. With profound implications for mortality and quality of life, neuroprognostication draws upon an intricate set of biomedical, probabilistic, psychosocial and ethical factors. However, the clinical approach to neuroprognostication is often unsystematic, and consequently, variable among clinicians and prone to error. Here, we offer a stepwise conceptual framework for reasoning through neuroprognostic determinations — including an evaluation of neurological function, estimation of a recovery trajectory, definition of goals of care and consideration of patient values — culminating in a clinically actionable formula for weighing the risks and benefits of life-sustaining treatment. Although the complexity of neuroprognostication might never be fully reducible to arithmetic, this systematic approach provides structure and guidance to supplement clinical judgement and direct future investigation.

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Fig. 1: Schematization of neuroprognostication: steps 1 and 2.
Fig. 2: Sources of information about a patient’s goals of care.
Fig. 3: Schematization of neuroprognostication: steps 3 and 4.
Fig. 4: Schematization of neuroprognostication: steps 5 and 6.

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Acknowledgements

The authors have received funding from the NIH National Institute of Neurological Disorders and Stroke (R25NS06574309, R21NS109627), the NIH Director’s Office (DP2HD101400), James S. McDonnell Foundation, the Tiny Blue Dot Foundation, and the National Institute on Disability, Independent Living and Rehabilitation Research (90DPTB0011).

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Author notes

  1. These authors contributed equally: Brian L. Edlow, Joseph T. Giacino and David M. Greer.

Authors and Affiliations

  1. Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    David Fischer & Brian L. Edlow

  2. Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    David Fischer

  3. Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Brian L. Edlow

  4. Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA

    Joseph T. Giacino

  5. Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA

    David M. Greer

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Glossary

Advance directives

Legal documents that individuals prepare to specify their preferences about medical care, to be used if they are unable to make those decisions themselves in the future.

Surrogates

Individuals who have been designated to make decisions on a patient’s behalf, if the patient is unable to make those decisions themselves.

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Fischer, D., Edlow, B.L., Giacino, J.T. et al. Neuroprognostication: a conceptual framework. Nat Rev Neurol 18, 419–427 (2022). https://doi.org/10.1038/s41582-022-00644-7

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