Predictive accuracy of physicians' estimates of outcome after severe stroke

Accuracy of Early Neuroprognostication in Pediatric Severe Traumatic Brain Injury

BACKGROUND

Children with severe traumatic brain injury (sTBI) are at risk for neurological sequelae impacting function. Clinicians are tasked with neuroprognostication to assist in decision-making. We describe a single-center study assessing clinicians' neuroprognostication accuracy.

METHODS

Clinicians of various specialties caring for children with sTBI were asked to predict their patients' functioning three to six months postinjury. Clinicians were asked to participate in the study if their patient had survived but not returned to baseline between day 4 and 7 postinjury. The outcome tool utilized was the functional status scale (FSS), ranging from 6 to 30 (best-worst function). Predicted scores were compared with actual scores three to six months postinjury. Lin concordance correlation coefficients were used to estimate agreement between predicted and actual FSS. Outcome was dichotomized as good (FSS 6 to 8) or poor (FSS ≥9). Positive and negative predictive values for poor outcome were calculated. Pessimistic prognostic prediction was defined as predicted worse outcome by ≥3 FSS points. Demographic and clinical variables were collected.

RESULTS

A total of 107 surveys were collected on 24 patients. Two children died. Fifteen children had complete (FSS = 6) or near-complete (FSS = 7) recovery. Mean predicted and actual FSS scores were 10.8 (S.D. 5.6) and 8.6 (S.D. 4.1), respectively. Predicted FSS scores were higher than actual scores (P < 0.001). Eight children had collective pessimistic prognostic prediction.

CONCLUSIONS

Clinicians predicted worse functional outcomes, despite high percentage of patients with near-normal function at follow-up clinic. Certain patient and provider factors were noted to impact accuracy and need to be studied in larger cohorts.

Doctors and nurses subjective predictions of 6-month outcome compared to actual 6-month outcome for adult patients with spontaneous intracerebral haemorrhage (ICH) in neurocritical care: An observational study

Background

Acute spontaneous intracerebral haemorrhage is a devastating form of stroke. Prognostication after ICH may be influenced by clinicians' subjective opinions.

Purpose

To evaluate subjective predictions of 6-month outcome by clinicians' for ICH patients in a neurocritical care using the modified Rankin Scale (mRS) and compare these to actual 6-month outcome.

Method

We included clinicians' predictions of 6-month outcome in the first 48 h for 52 adults with ICH and compared to actual 6-month outcome using descriptive statistics and multilevel binomial logistic regression.

Results

35/52 patients (66%) had a poor 6-month outcome (mRS 4-6); 19/52 (36%) had died. 324 predictions were included. For good (mRS 0-3) versus poor (mRS 4-6), outcome, accuracy of predictions was 68% and exact agreement 29%. mRS 6 and mRS 4 received the most correct predictions. Comparing job roles, predictions of death were underestimated, by doctors (12%) and nurses (13%) compared with actual mortality (36%). Predictions of vital status showed no significant difference between doctors and nurses: OR = 1.24 {CI; 0.50-3.05}; (p = 0.64) or good versus poor outcome: OR = 1.65 {CI; 0.98-2.79}; (p = 0.06). When predicted and actual 6-month outcome were compared, job role did not significantly relate to correct predictions of good versus poor outcome: OR = 1.13 {CI;0.67-1.90}; (p = 0.65) or for vital status: OR = 1.11 {CI; 0.47-2.61}; p = 0.81).

Conclusions

Early prognostication is challenging. Doctors and nurses were most likely to correctly predict poor outcome but tended to err on the side of optimism for mortality, suggesting an absence of clinical nihilism in relation to ICH.

Development and Validation of a Postprocedural Model to Predict Outcome After Endovascular Treatment for Ischemic Stroke

Importance

Outcome prediction after endovascular treatment (EVT) for ischemic stroke is important to patients, family members, and physicians.

Objective

To develop and validate a model based on preprocedural and postprocedural characteristics to predict functional outcome for individual patients after EVT.

Design, Setting, and Participants

A prediction model was developed using individual patient data from 7 randomized clinical trials, performed between December 2010 and December 2014. The model was developed within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration and external validation in data from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry of patients treated in clinical practice between March 2014 and November 2017. Participants included patients from multiple centers throughout different countries in Europe, North America, East Asia, and Oceania (derivation cohort), and multiple centers in the Netherlands (validation cohort). Included were adult patients with a history of ischemic stroke from an intracranial large vessel occlusion in the anterior circulation who underwent EVT within 12 hours of symptom onset or last seen well. Data were last analyzed in July 2022.

Main Outcome(s) and Measure(s)

A total of 19 variables were assessed by multivariable ordinal regression to predict functional outcome (modified Rankin Scale [mRS] score) 90 days after EVT. Variables were routinely available 1 day after EVT. Akaike information criterion (AIC) was used to optimize model fit vs model complexity. Probabilities for functional independence (mRS 0-2) and survival (mRS 0-5) were derived from the ordinal model. Model performance was expressed with discrimination (C statistic) and calibration.

Results

A total of 781 patients (median [IQR] age, 67 [57-76] years; 414 men [53%]) constituted the derivation cohort, and 3260 patients (median [IQR] age, 72 [61-80] years; 1684 men [52%]) composed the validation cohort. Nine variables were included in the model: age, baseline National Institutes of Health Stroke Scale (NIHSS) score, prestroke mRS score, history of diabetes, occlusion location, collateral score, reperfusion grade, NIHSS score at 24 hours, and symptomatic intracranial hemorrhage 24 hours after EVT. External validation in the MR CLEAN Registry showed excellent discriminative ability for functional independence (C statistic, 0.91; 95% CI, 0.90-0.92) and survival (0.89; 95% CI, 0.88-0.90). The proportion of functional independence in the MR CLEAN Registry was systematically higher than predicted by the model (41% vs 34%), whereas observed and predicted survival were similar (72% vs 75%). The model was updated and implemented for clinical use.

Conclusion and relevance

The prognostic tool MR PREDICTS@24H can be applied 1 day after EVT to accurately predict functional outcome for individual patients at 90 days and to provide reliable outcome expectations and personalize follow-up and rehabilitation plans. It will need further validation and updating for contemporary patients.

Inpatient Rehabilitation After Acute Severe Stroke: Predictive Value of the National Institutes of Health Stroke Scale Among Other Potential Predictors for Discharge Destination

Background

Research focusing on predictors for discharge destination after rehabilitation of inpatients recovering from severe stroke is scarce. The predictive value of rehabilitation admission NIHSS score among other potential predictors available on admission to rehabilitation has not been studied.

Aim

The aim of this retrospective interventional study was to determine the predictive accuracy of 24 hours and rehabilitation admission NIHSS scores among other potential socio-demographic, clinical and functional predictors for discharge destination routinely collected on admission to rehabilitation.

Material and Methods

On a university hospital specialized inpatient rehabilitation ward 156 consecutive rehabilitants with 24 hours NIHSS score ⩾15 were recruited. On admission to rehabilitation, routinely collected variables potentially associated with discharge destination (community vs institution) were analyzed using logistic regression.

Results

70 (44.9%) of rehabilitants were discharged to community, and 86 (55.1%) were discharged to institutional care. Those discharged home were younger and more often still working, had less often dysphagia/tube feeding or DNR decision in the acute phase, shorter time from stroke onset to rehabilitation admission, less severe impairment (NIHSS score, paresis, neglect) and disability (FIM score, ambulatory ability) on admission, and faster and more significant functional improvement during the in-stay than those institutionalized.

Conclusion

The most influential independent predictors for community discharge on admission to rehabilitation were lower admission NIHSS score, ambulatory ability and younger age, NIHSS being the most powerful. The odds of being discharged to community decreased with 16.1% for every 1 point increase in NIHSS. The 3-factor model explained 65.7% of community discharge and 81.9% of institutional discharge, the overall predictive accuracy being 74.7%. The corresponding figures for admission NIHSS alone were 58.6%, 70.9% and 65.4%.

Evolution of Making Clinical Predictions in Neurosurgery

Prediction of clinical outcomes is an essential task for every physician. Physicians may base their clinical prediction of an individual patient on their intuition and on scientific material such as studies presenting population risks and studies reporting on risk factors (prognostic factors). A relatively new and more informative approach for making clinical predictions relies on the use of statistical models that simultaneously consider multiple predictors that provide an estimate of the patient's absolute risk of an outcome. There is a growing body of literature in the neurosurgical field reporting on clinical prediction models. These tools have high potential in supporting (not replacing) neurosurgeons with their prediction of a patient's outcome. If used sensibly, these tools pave the way for more informed decision-making with or for individual patients. Patients and their significant others want to know their risk of the anticipated outcome, how it is derived, and the uncertainty associated with it. Learning from these prediction models and communicating the output to others has become an increasingly important skill neurosurgeons have to master. This article describes the evolution of making clinical predictions in neurosurgery, synopsizes key phases for the generation of a useful clinical prediction model, and addresses some considerations when deploying and communicating the results of a prediction model. The paper is illustrated with multiple examples from the neurosurgical literature, including predicting arachnoid cyst rupture, predicting rebleeding in patients suffering from aneurysmal subarachnoid hemorrhage, and predicting survival in glioblastoma patients.

The intersection of prognostication and code status in patients with severe brain injury

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.

End-of-Life Care Decision-Making in Stroke

Stroke is one of the leading causes of death and long-term disability in the United States. Though advances in interventions have improved patient survival after stroke, prognostication of long-term functional outcomes remains challenging, thereby complicating discussions of treatment goals. Stroke patients who require intensive care unit care often do not have the capacity themselves to participate in decision making processes, a fact that further complicates potential end-of-life care discussions after the immediate post-stroke period. Establishing clear, consistent communication with surrogates through shared decision-making represents best practice, as these surrogates face decisions regarding artificial nutrition, tracheostomy, code status changes, and withdrawal or withholding of life-sustaining therapies. Throughout decision-making, clinicians must be aware of a myriad of factors affecting both provider recommendations and surrogate concerns, such as cognitive biases. While decision aids have the potential to better frame these conversations within intensive care units, aids specific to goals-of-care decisions for stroke patients are currently lacking. This mini review highlights the difficulties in decision-making for critically ill ischemic stroke and intracerebral hemorrhage patients, beginning with limitations in current validated clinical scales and clinician subjectivity in prognostication. We outline processes for identifying patient preferences when possible and make recommendations for collaborating closely with surrogate decision-makers on end-of-life care decisions.

Actigraphic Measurement of the Upper Limbs for the Prediction of Ischemic Stroke Prognosis: An Observational Study

Background: It is often challenging to formulate a reliable prognosis for patients with acute ischemic stroke. The most accepted prognostic factors may not be sufficient to predict the recovery process. In this view, describing the evolution of motor deficits over time via sensors might be useful for strengthening the prognostic model. Our aim was to assess whether an actigraphic-based parameter (Asymmetry Rate Index for the 24 h period (AR2_24 h)) obtained in the acute stroke phase could be a predictor of a 90 d prognosis. Methods: In this observational study, we recorded and analyzed the 24 h upper limb movement asymmetry of 20 consecutive patients with acute ischemic stroke during their stay in a stroke unit. We recorded the motor activity of both arms using two programmable actigraphic systems positioned on patients’ wrists. We clinically evaluated the stroke patients by NIHSS in the acute phase and then assessed them across 90 days using the modified Rankin Scale (mRS). Results: We found that the AR2_24 h parameter positively correlates with the 90 d mRS (r = 0.69, p < 0.001). Moreover, we found that an AR2_24 h > 32% predicts a poorer outcome (90 d mRS > 2), with sensitivity = 100% and specificity = 89%. Conclusions: Sensor-based parameters might provide useful information for predicting ischemic stroke prognosis in the acute phase.

Life Support Limitations in Mechanically Ventilated Stroke Patients

Supplemental Digital Content is available in the text.

Objectives:

The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions.

Design:

Multicenter prospective French observational study.

Setting:

Fourteen ICUs of the French OutcomeRea network.

PATIENTS:

From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission.

INTERVENTION:

None.

MEASUREMENTS AND MAIN RESULTS:

We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]).

Conclusions:

In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.

Neurosurgical patients admitted via the emergency department initiating comfort care measures: a prospective cohort analysis

BACKGROUND

Given the serious nature of many neurosurgical pathologies, it is common for hospitalized patients to elect comfort care (CC) over aggressive treatment. Few studies have evaluated the incidence and risk factors of CC trends in patients admitted for neurosurgical emergencies.

OBJECTIVES

To analyze all neurosurgical patients admitted to a tertiary care academic referral center via the emergency department (ED) to determine incidence and characteristics of those who initiated CC measures during their initial hospital admission.

METHODS

We performed a prospective, cohort analysis of all consecutive adult patients admitted to the neurosurgical service via the ED between October 2018 and May 2019. The primary outcome was the initiation of CC measures during the patient's hospital admission. CC was defined as cessation of life-sustaining measures and a shift in focus to maintaining the comfort and dignity of the patient.

RESULTS

Of the 428 patients admitted during the 7-month period, 29 (6.8%) initiated CC measures within 4.0 ± 4.0 days of admission. Patients who entered CC were significantly more likely to have a medical history of cerebrovascular disease (58.6% vs. 33.3%, p = 0.006), dementia (17.2% vs. 1.5%, p = 0.0004), or cancer with metastatic disease (24.1% vs. 7.0%, p = 0.001). Patients with a presenting pathology associated with cerebrovascular disease were significantly more likely to initiate CC (62.1% vs. 35.3, p = 0.04). Patients who underwent emergent surgery were significantly more likely to enter CC compared with those who had elective surgery (80.0% vs. 42.7%, p = 0.02). Only 10 of the 29 (34.5%) patients who initiated CC underwent a neurosurgical operation (p = 0.002). Twenty of the 29 (69.0%) patients died within 0.8 ± 0.8 days after the initiation of CC measures.

CONCLUSION

CC measures were initiated in 6.8% of patients admitted to the neurosurgical service via the ED, with the majority of patients entering CC before an operation and presenting with a cerebrovascular pathology.

When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings

When it is ethically justifiable to stop medical treatment? For many Muslim patients, families, and clinicians this ethical question remains a challenging one as Islamic ethico-legal guidance on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a systematic literature review to aggregate rulings from Islamic jurists and juridical councils on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. A total of 16 fatwās were found, 8 of which were single-author rulings, and 8 represented the collective view of a juridical council. The fatwās are similar in that nearly all judge that Islamic law, provided certain conditions are met, permits abstaining from life-sustaining treatment. Notably, the justifying conditions appear to rely on physician assessment of the clinical prognosis. The fatwās differ when it comes to what conditions justify withdrawing or withholding life- sustaining care. Our analyses suggest that while notions of futility greatly impact the bioethical discourse regarding with holding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. Therefore, clinicians, Islamic jurists, and bioethicists need to come together in order to unify a conception of medical futility and relate it to the ethics of withholding and/or withdrawal of treatment.

Neural Stem Cell Extracellular Vesicles Disrupt Midline Shift Predictive Outcomes in Porcine Ischemic Stroke Model

Magnetic resonance imaging (MRI) is a clinically relevant non-invasive imaging tool commonly utilized to assess stroke progression in real time. This study investigated the utility of MRI as a predictive measure of clinical and functional outcomes when a stroke intervention is withheld or provided, in order to identify biomarkers for stroke functional outcome under these conditions. Fifteen MRI and ninety functional parameters were measured in a middle cerebral artery occlusion (MCAO) porcine ischemic stroke model. Multiparametric analysis of correlations between MRI measurements and functional outcome was conducted. Acute axial and coronal midline shift (MLS) at 24 h post-stroke were associated with decreased survival and recovery measured by modified Rankin scale (mRS) and were significantly correlated with 52 measured acute (day 1 post) and chronic (day 84 post) gait and behavior impairments in non-treated stroked animals. These results suggest that MLS may be an important non-invasive biomarker that can be used to predict patient outcomes and prognosis as well as guide therapeutic intervention and rehabilitation in non-treated animals and potentially human patients that do not receive interventional treatments. Neural stem cell–derived extracellular vesicle (NSC EV) was a disruptive therapy because NSC EV administration post-stroke disrupted MLS correlations observed in non-treated stroked animals. MLS was not associated with survival and functional outcomes in NSC EV–treated animals. In contrast to untreated animals, NSC EVs improved stroked animal outcomes regardless of MLS severity.

Incidence of the initiation of comfort care immediately following emergent neurosurgical and endovascular procedures

OBJECTIVE

It is unknown what proportion of patients who undergo emergent neurosurgical procedures initiate comfort care (CC) measures shortly after the operation. The purpose of the present study was to analyze the proportion and predictive factors of patients who initiated CC measures within the same hospital admission after undergoing emergent neurosurgery.

METHODS

This retrospective cohort study included all adult patients who underwent emergent neurosurgical and endovascular procedures at a single center between 2009 and 2014. Primary and secondary outcomes were initiation of CC measures during the initial hospitalization and determination of predictive factors, respectively.

RESULTS

Of the 1295 operations, comfort care was initiated in 111 (8.6%) during the initial admission. On average, CC was initiated 9.3 ± 10.0 days postoperatively. One-third of the patients switched to CC within 3 days. In multivariate analysis, patients > 70 years of age were significantly more likely to undergo CC than those < 50 years (70-79 years, p = 0.004; > 80 years, p = 0.0001). Two-thirds of CC patients had been admitted with a cerebrovascular pathology (p < 0.001). Admission diagnosis of cerebrovascular pathology was a significant predictor of initiating CC (p < 0.0001). A high Hunt and Hess grade of IV or V in patients with subarachnoid hemorrhage was significantly associated with initiation of CC compared to a low grade (27.1% vs 2.9%, p < 0.001). Surgery starting between 15:01 and 06:59 hours had a 1.70 times greater odds of initiating CC compared to surgery between 07:00 and 15:00.

CONCLUSIONS

Initiation of CC after emergent neurosurgical and endovascular procedures is relatively common, particularly when an elderly patient presents with a cerebrovascular pathology after typical operating hours.