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

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What criteria for neuropronostication: consciousness or ability? The neuro-intensivist’s dilemma
Critical Care ( IF 8.8 ) Pub Date : 2024-10-03 , DOI: 10.1186/s13054-024-05098-5
Nicolas Engrand, Armelle Nicolas-Robin, Pierre Trouiller, Stéphane Welschbillig

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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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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NE, ANR, PT and SW participated in the reflection work, drafting and revision of the manuscript.

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

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中文翻译：

神经前言的标准是什么：意识还是能力？神经重症监护医师的困境

罗豪特等人。发表了一项引人注目的 12 年进化项目的结果，显示脑损伤后 1 个月意识的实质性改善与 1 年后的良好结果（格拉斯哥结果量表扩展 [GOS-E] 评分≥ 4）之间呈正相关，优势比为 14.6 [1]。这是神经前言的一项重大新发现，神经前言是神经重症监护中的一个基本问题。

基于七项客观标准的多模式评估 (MMA)，结合由神经重症医师、神经科医生、神经生理学家、神经放射科医生和神经科学家组成的专家小组（“DoC 团队”）的批判性阅读，可以预测 GOS-E 评分 1 1 年时 –3，在预测预后不良的组中准确度为 100%。假设 MMA 的目标是为每一位有康复能力的患者提供神经功能康复的机会，那么这些结果是非常有效的。这也意味着，在脑损伤后 1 个月，MMA 和 DoC 团队预测 1 年预后不佳时，他们是正确的。因此，神经重症医生的第一个重要教训是，他们可以根据这一结果暂停甚至撤回维持生命的治疗，而不会影响神经功能恢复的显着机会，从而使患者节省一年的侵入性护理和康复时间。

然而，只有 39% 的预测良好预后的患者的 GOS-E 评分≥ 4（不包括停止生命维持治疗和未知决定）。同样，在预后不确定的组中，只有 24% 的患者取得了这一良好的结果。因此，MMA 对不确定或有利结果的预测使患者面临继续不适当治疗的风险，从而导致大量残疾和依赖。换句话说，早期“预后良好的患者”很少，即使在 MMA 后，277 名患者中的 83% 的 GOS-E 评分为 < 4。因此，虽然增加治疗方式的数量提高了准确性，但MMA 仍然无法可靠地检测长期能力。

这些结果提出了神经重症监护的目标问题。

尽管众所周知，所有患者在严重脑损伤后最终都会恢复清醒[2]，许多人甚至恢复了实质意识[3]，但有些患者永远无法恢复与环境互动的能力。后一种情况被归类为反应迟钝的觉醒综合症或没有意识的植物人状态，被广泛认为是护理失败。然而，对于一个清醒但高度依赖且改良兰金量表 (mRS) 评分为 4 或 5 或 GOS-E 评分为 4 或 3 的患者呢？在神经血管研究中，mRS 评分为 4（通常甚至为 3）被视为失败。例如，该评分被认为是去骨瓣减压研究中应避免的结果[4]（最近的 Switch 研究 [5] 除外），但在意识恢复研究中被认为是成功的结果 [6]。

此外，mRS 评分为 4 的患者的长期生活质量 (QoL) 可能低于 mRS 评分为 2 或 3 的患者[7]。然而，长期满意度研究仍然相当积极，即使对于 mRS 评分为 5 的患者和患有锁定综合征的患者也是如此 [8, 9]。

因此，神经重症医师的护理目标有时与神经科医生和神经外科医生同事的目标不一致，后者要求 mRS 评分≤ 2 或 3，而意识专家则建议只要有一丝希望就继续治疗的接触，其生活质量似乎可以接受，或者无论如何都被大多数患者接受。

Rohaut 等人的伟大功绩。研究的目的是建立缺乏早期意识恢复与远程残疾/依赖之间的联系。然而，MMA 过程中包含的所有临床和临床旁检查（DTI-MRI 除外）都集中于患者当前的意识状态，这难道不是对产生大量高度依赖的患者有所帮助吗？更好地定位远程 GOS-E 或 mRS 评分的一种解决方案不是将康复医生纳入多学科评估团队，并在老年患者中纳入老年科医生吗？

事实上，神经重症监护的目标甚至更值得怀疑。尽管从历史上看，重症监护的预后研究首先关注生存，然后关注预期残疾，但现在他们可以关注质量调整生命年（包括生活质量和数量），甚至是意识清醒但残疾患者的满意度，尽管更难以量化 [8, 10]，特别是因为失语症或显着认知障碍患者存在认知障碍。进一步的进展应该包括更好地预测 GOS-E 或 mRS 评分，并将这种预后与患者的预先指示进行比较，记住预先指示本身有严重的局限性，特别是在急性脑损伤的情况下 [11]。此外，这个问题不仅在一个月的强化神经护理后出现，而且可能在脑损伤患者的初步护理期间出现，甚至可能更加敏感，正如 Rohaut 等人所言。另一篇文章中指出[12]。例如，在颅内血肿和脑室内出血的情况下，预测需要推迟到初始治疗之后才能获得对未来恢复的可靠预测[13]。

总而言之，有几个与神经重症监护目标相关的关键问题。首先，即使 1 个月时的良好评估在统计学上与 1 年时更好的患者自主权相关，我们也必须记住，特异性仍然很低，有诱发“自相矛盾的不合理固执”的风险，这与 MMA 的最初目标相反。最重要的是，远程生活质量和患者满意度可能是我们护理的更相关的终点。作为医生，我们或许应该做好准备，让病人自己做出决定，即使他们无法表达自己的意愿，而我们也应该成为纯粹的执行者。这是一个社会、伦理、政治、金融[12]甚至生态问题，更不用说亲人的生活质量和满意度了。值得注意的是，诸如康复复杂性量表扩展[14]之类的工具现已集成到一些欧洲医疗保健系统中，已开发用于量化患者康复需求的复杂性，同时考虑成本和可持续性。

无论如何，在目前的情况下，在大多数中心，神经重症监护医生仍然无法避免在问题出现时评估结果是否可以接受。最后，考虑到此类出版物，我们是否仍然有权建议扣留或撤回生命维持治疗，而无需经过此类 MMA（独立于临床伦理咨询）？神经重症监护后开发早期MMA平台和远程会诊系统的需求无疑变得至关重要。

当前研究期间没有生成或分析数据集。

高斯：: 格拉斯哥结果量表扩展分数
综合格斗：: 多模式评估
太太：: 改良兰金量表
生活质量：: 生活质量

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