The Severely Wounded Brain Healed: Outcome Prognostication in Neurology

Zachary D. Threlkeld, MD

David Y. Hwang, MD, FAAN, FCCM, FNCS

Prognostication in the context of neurologic injury and disease has long been critical to clinical practice. In addition to questions about the treatment, cure, arrest, or reversal of neurologic injury, questions about prognosis doubtless remain among the highest priorities for patients and family members of patients with neurologic disease. Neurologists are thus frequently asked to comment on prognosis and must, in response, strive to balance the confident presentation of a realistic estimate of outcome with transparency about the uncertainty inherent within that estimate.

Wilder Penfield, manifesting a tenacious optimism, had the words of Galen engraved into the ceiling of the Montreal Neurological Institute that he founded: “But I have seen a severely wounded brain healed.”[1] Simultaneously refuting clinical nihilism and granting hope to individuals with ostensibly irreversible brain injury and their families, these words reflect the neurologist's prognostic charge. We must not only diagnose and treat but also educate patients and families about prognosis as accurately as possible—for both inaccurate optimism and pessimism may incite distress and the delivery of goal-discordant care.

This issue of Seminars in Neurology, “Neuroprognostication,” is intended to summarize the scientific literature on prognostication for a variety of neurologic diseases. We have divided the issue approximately in two parts, with the first part representing prognostic challenges in acute brain injury, and the second part aiming to survey prognostic science in representative chronic neurologic illnesses.

We begin with a discussion of the numerous clinical grading scales that have been developed in acute brain injury, with an emphasis on critical evaluation of prognostic scales and consideration of the key features that characterize an ideal scale. Consideration of prognostic scales naturally leads to discussion of biomarkers of acute brain injury, and the following three articles review the scientific literature on electroencephalographic, serum, and neuroimaging biomarkers, respectively.

Neuroprognostication is rendered ever more complex with the increasing recognition of covert consciousness—or cognitive motor dissociation—and the impact that covert consciousness may have on prognosis. We thus devote an article to the emerging clinical use of functional MRI in acute disorders of consciousness.

While the neurologist is charged with estimating prognosis, an individual patient's prognosis is not conceived and communicated in isolation. Indeed, the prognosis described to families often informs crucial decisions around invasive interventions, life-sustaining treatments, and goals of care. The next article embraces this challenge and offers a scientific appraisal of the cognitive biases to which we are all subject, as well as techniques to mitigate this bias as part of the process of shared decision making. The subsequent article discusses ethical considerations in neuroprognostication, particularly in the setting of acute brain injury—where neurologists, patients, and surrogates often grapple with the myriad ethical implications of prognosis and uncertainty in the context of critical, time-sensitive decisions.

Transitioning from acute brain injury to chronic neurologic disease, we continue with a discussion of prognostication in chronic disorders of consciousness (DoC), and the considerations that distinguish prognostication in this population from (but also inform prognostication about) patients with acute DoC. It was, after all, in a young woman with a chronic DoC that covert consciousness was first identified.[2]

Finally, we close with a survey of prognostication in representative chronic neurologic diseases, including neurooncology, amyotrophic lateral sclerosis (ALS), Guillain-Barre syndrome, and myasthenia gravis. A growing body of literature brings ever-increasing clarity to factors predictive of not only mortality but also other important patient-centered outcomes like the timing and need for tracheostomy and gastrostomy in patients with ALS.

We are encouraged by the diversity and tenacity of ongoing efforts to study and characterize prognosis across the range of neurologic disease. Furthermore, equal efforts aim to translate this new knowledge into actionable, patient-centered, goal-concordant treatments and interventions. With such great innovation, though, comes great responsibility, and we are likewise encouraged by ongoing, frank discussions about the challenges in ethics and equity exposed by such rapid innovation. This issue of Seminars in Neurology, then, is dedicated not only to the meticulous and increasingly accurate neuroprognostication that current science affords—but also to our patients, each of whom deserves the most accurate prognosis possible. Above all, this issue is dedicated to the patients who yet lack access to the clinical expertise, facilities, and techniques that allow such sophisticated neuroprognostication—in hopeful anticipation of the more equitable future that we are all charged with helping to create.

Publikationsverlauf

Artikel online veröffentlicht:
02. November 2023

• References

• 1 Adams ZM, Fins JJ. Penfield's ceiling: seeing brain injury through Galen's eyes. Neurology 2017; 89 (08) 854-858
• 2 Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Detecting awareness in the vegetative state. Science 2006; 313 (5792): 1402