Guidelines for Neuroprognostication in Critically ill Adults with Acute Ischemic Stroke

BACKGROUND: Patients with acute ischemic stroke (AIS) may require intensive care unit admission for several reasons, including post-procedural care, management of large hemispheric infarction, and cardiopulmonary instability. The objective of this document is to provide recommendations on the reliability of select individual predictors of outcome, and multivariate prediction models, in the context of counseling critically ill patients with AIS and their surrogates. In addition, broad principles of neuroprognostication in this population were identified. METHODS: A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, including clinical variables and prediction models, were selected on the basis of clinical relevance and the presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting (PICOTS) question was framed as follows: "When counseling critically ill adults with AIS or their surrogates, should <predictor> be considered a reliable predictor of poor functional outcome at 3 months or later?" Recommendations were based on quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Recommendations that met GRADE criteria for good practice statements addressed broad principles of neuroprognostication. RESULTS: A total of 518 articles met eligibility criteria to guide recommendations. Good practice recommendations include avoiding premature neuroprognostication, avoiding confounders, the use of multimodal assessment, predicting recovery of swallow function, predicting tracheostomy decannulation, and counseling of patients with large hemispheric infarction and their surrogates prior to neurological decline. Early neurological improvement within 24 h of revascularization was identified as a moderately reliable predictor of good functional outcome. No other individual predictor was considered reliable for the prediction of mortality or functional outcome. CONCLUSIONS: These guidelines suggest broad principles of neuroprognostication and provide recommendations on the reliability of predictors of functional outcome in the context of counseling critically ill patients with AIS and their surrogates.