Faiver Laura, Steinberg Alexis
Department of Critical Care Medicine.
Department of Neurology and Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Curr Opin Crit Care. 2025 Apr 1;31(2):155-161. doi: 10.1097/MCC.0000000000001241. Epub 2025 Jan 9.
Neuroprognostication after acute brain injury (ABI) is complex. In this review, we examine the threats to accurate neuroprognostication, discuss strategies to mitigate the self-fulfilling prophecy, and how to approach the indeterminate prognosis.
The goal of neuroprognostication is to provide a timely and accurate prediction of a patient's neurologic outcome so treatment can proceed in accordance with a patient's values and preferences. Neuroprognostication should be delayed until at least 72 h after injury and/or only when the necessary prognostic data is available to avoid early withdraw life-sustaining treatment on patients who may otherwise survive with a good outcome. Clinicians should be aware of the limitations of available predictors and prognostic models, the role of flawed heuristics and the self-fulfilling prophecy, and the influence of surrogate decision-maker bias on end-of-life decisions.
The approach to neuroprognostication after ABI should be systematic, use highly reliable multimodal data, and involve experts to minimize the risk of erroneous prediction and perpetuating the self-fulfilling prophecy. Even when such standards are rigorously upheld, the prognosis may be indeterminate. In such cases, clinicians should engage in shared decision-making with surrogates and consider the use of a time-limited trial.
急性脑损伤（ABI）后的神经预后评估很复杂。在本综述中，我们探讨影响准确进行神经预后评估的因素，讨论减轻自我实现预言的策略，以及如何处理不确定的预后情况。
神经预后评估的目标是及时、准确地预测患者的神经功能结局，以便治疗能够根据患者的价值观和偏好进行。神经预后评估应推迟至受伤后至少72小时和/或仅在获得必要的预后数据时进行，以避免对可能最终获得良好结局的患者过早停止维持生命的治疗。临床医生应意识到现有预测指标和预后模型的局限性、有缺陷的启发式方法和自我实现预言的作用，以及替代决策者偏差对临终决策的影响。
ABI后进行神经预后评估的方法应系统，使用高度可靠的多模态数据，并让专家参与，以尽量减少错误预测和延续自我实现预言的风险。即使严格遵守这些标准，预后仍可能不确定。在这种情况下，临床医生应与代理人进行共同决策，并考虑采用限时试验。
