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Prognostication is fundamental to determining the intensity of care offered for many critically ill patients with severe acute brain injury (SABI). Inherent uncertainties linked to predicting outcomes for patients with SABI primarily arise from a lack of complete data regarding the natural disease/injury progression that follows various forms of SABI, stemming from early withdrawal of life-sustaining treatment. This potential bias has led to limitations in using outcome data associated with clinical grading scales and a risk of perpetuating high mortality following SABI, leading to self-fulfilling prophecies. The aims of this article are to (1) review contemporary prognostication practices among clinicians for patients with SABI, (2) discuss inherent challenges in prognosticating outcomes following SABI, (3) summarize statements and guidelines from professional societies regarding SABI prognostication, and (4) identify directions for future research in prognostication after SABI., Competing Interests: Conflicts of interest: We confirm no conflicts of interest for all authors. DH does receive other grant funding from the National Institute of Neurological Disorders and Stroke (U24 NS135250-01) and the Neurocritical Care Foundation (INCLINE Award) and serves as Medical Director of Critical Care for New England Donor Services. Ethical Approval/Informed Consent: We confirm adherence to ethical guidelines and indicate ethical approvals (institutional review board) and use of informed consent, as appropriate., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care., Competing Interests: Disclosure The authors declare no conflicts of interest or financial disclosures relevant to this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: This retrospective study was aimed to develop a predictive model for assessing the necessity of tracheostomy (TT) in patients admitted to the neurosurgery intensive care unit (NSICU)., Method: We analyzed data from 1626 NSICU patients with severe acute brain injury (SABI) who were admitted to the Department of NSICU at the Affiliated People's Hospital of Jiangsu University between January 2021 and December 2022. Data of the patients were retrospectively obtained from the clinical research data platform. The patients were randomly divided into training (70%) and testing (30%) cohorts. The least absolute shrinkage and selection operator (LASSO) regression identified the optimal predictive features. A multivariate logistic regression model was then constructed and represented by a nomogram. The efficacy of the model was evaluated based on discrimination, calibration, and clinical utility., Results: The model highlighted six predictive variables, including the duration of NSICU stay, neurosurgery, orotracheal intubation time, Glasgow Coma Scale (GCS) score, systolic pressure, and respiration rate. Receiver operating characteristic (ROC) analysis of the nomogram yielded area under the curve (AUC) values of 0.854 (95% confidence interval [CI]: 0.822-0.886) for the training cohort and 0.865 (95% CI: 0.817-0.913) for the testing cohort, suggesting commendable differential performance. The predictions closely aligned with actual observations in both cohorts. Decision curve analysis demonstrated that the numerical model offered a favorable net clinical benefit., Conclusion: We developed a novel predictive model to identify risk factors for TT in SABI patients within the NSICU. This model holds the potential to assist clinicians in making timely surgical decisions concerning TT., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Purpose of Review: We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU)., Recent Findings: Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve., Competing Interests: Conflict of Interest Kristopher A. Hendershot declares that he has no conflict of interest. Maya N. Elias declares that she has no conflict of interest. Breana L. Taylor declares that she has no conflict of interest. Sarah Wahlster declares that she has no conflict of interest. Claire J. Creutzfeldt declares that she has no conflict of interest.

Background: Caregivers of patients with severe acute brain injuries (SABI) that lead to coma and require intensive care unit (ICU) treatment often experience chronic emotional distress. To address this need, we developed the Coma Family (COMA-F) program, a mindfulness-based resiliency intervention for these caregivers., Objective: We will conduct an open pilot trial of COMA-F (National Institutes of Health Stage IA). Here we describe our study protocol and proposed intervention content., Methods: We will enroll 15 caregivers of patients with SABIs during their loved one's hospital course from 3 enrollment centers. A clinical psychologist will deliver the COMA-F intervention (6 sessions) over Zoom (Zoom Video Communications, Inc) or in person. We will iterate COMA-F after each caregiver completes the intervention and an exit interview. English-speaking adults who have emotional distress confirmed by the clinical team and are the primary caregivers of a patient with SABI are eligible. The adult patient must have been admitted to the neuro-ICU for SABI and (1) have had a Glasgow Coma Scale score below 9 while not intubated or an inability to follow meaningful commands while intubated at any point during their hospitalization for >24 hours due to SABI; (2) will be undergoing either tracheostomy or percutaneous endoscopic or surgical gastrostomy tube placement or have already received one or both; and (3) have a prognosis of survival >3 months. We will identify eligible caregivers through screening patients' medical records and through direct referrals from clinicians in the neuro-ICU. During the intervention we will teach caregivers mind-body and resilience skills, including deep breathing, mindfulness, meditation, dialectical thinking, acceptance, cognitive restructuring, effective communication, behavioral activation, and meaning-making. Caregivers will complete self-report assessments (measures of emotional distress and resilience) before and after the intervention. Primary outcomes are feasibility (recruitment, quantitative measures, adherence, and therapist fidelity) and acceptability (treatment satisfaction, credibility, and expectancy). We will conduct brief qualitative exit interviews to gather feedback on refining the program and study procedures. We will examine frequencies and proportions to determine feasibility and acceptability and will analyze qualitative exit interview data using thematic analysis. We will also conduct 2-tailed t tests to explore signals of improvement in emotional distress and treatment targets. We will then conduct an explanatory-sequential mixed methods analysis to integrate quantitative and qualitative data to refine the COMA-F manual and study procedures., Results: This study has been approved by the institutional review board at 1 of the 3 enrollment centers (2023P000536), with approvals at the other 2 centers pending. We anticipate that the study will be completed by late 2024., Conclusions: We will use our findings to refine the COMA-F intervention and prepare for a feasibility randomized controlled trial., Trial Registration: ClinicalTrials.gov NCT05761925; https://clinicaltrials.gov/study/NCT05761925., International Registered Report Identifier (irrid): PRR1-10.2196/50860., (©Alexander Mattia Presciutti, Emily Woodworth, Elizabeth Rochon, Molly Neale, Melissa Motta, Joseph Piazza, Ana-Maria Vranceanu, David Yi-Gin Hwang. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 25.10.2023.)

To investigate the pandemic's impact on critically ill patients with neurological emergencies, we compared care metrics and outcomes of patients with severe acute brain injury (SABI) before and during the initial COVID-19 surge at our institution. We included adult patients with SABI during two separate three-month time periods: 'pre-COVID vs COVID'. We further stratified the COVID cohort to characterize outcomes in patients requiring COVID-19 precautions (Patient Under Investigation, 'PUI'). The primary endpoint was in-hospital mortality; secondary endpoints included length of stay (LOS), diagnostic studies performed, time to emergent decompressive craniectomies (DCHC), ventilator management, and end-of-life care. We included 394 patients and found the overall number of admissions for SABI declined by 29 % during COVID (pre-COVID n = 231 vs COVID, n = 163). Our primary outcome of mortality and most secondary outcomes were similar between study periods. There were more frequent extubation attempts (72.1 % vs 76 %) and the mean time to extubation was shorter during COVID (55.5 h vs 38.2 h). The ICU LOS (6.10 days vs 4.69 days) and hospital LOS (15.32 days vs 11.74 days) was shorter during COVID. More PUIs died than non-PUIs (51.7 % vs 11.2 %), but when adjusted for markers of illness severity, this was not significant. We demonstrate the ability to maintain a consistent care delivery for patients with SABI during the pandemic at our institution. PUIs represent a population with higher illness severity at risk for delays in care. Multicenter, longitudinal studies are needed to explore the impact of the pandemic on patients with acute neurological emergencies., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Claire Creutzfeldt has received research support from the NINDS (K23 NS099421). Abhijit Lele receives ongoing salary support from LifeCenter Northwest. Sarah Livesay receives consulting fees via Stroke Challenges through Lombardi Hill. Sherry Chou has received research support from the NIH (UL1 TR001857, R21NS113037) and University of Pittsburgh Dean’s Faculty Achievement Award as well as has a leadership role in the Neurocritical Care Society. Robert Bonow received in-kind research support from Butterfly Network. The remaining authors have no relevant financial disclosures or conflicts of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Context: Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty., Objectives: To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV)., Methods: We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons., Results: Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2-6.0)., Conclusion: Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS)., Recent Findings: ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (P a O 2 ) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80-120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered., Summary: The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population., Competing Interests: Conflict of InterestWe report no conflicts of interests, and none of the authors has received direct funding for this study. Abhijit Lele receives ongoing salary support from LifeCenter Northwest. Vasisht Srinivasan receives grant support from the Centers for Disease Control and Prevention via the Influenza and Other Viruses in the Acute Ill (IVY) network. Nicholas Johnson receives funding from the National Institutes of Health, from the Centers for Disease Control and Prevention, the Department of Defense, and the UW Royalty Research Fund for unrelated work. The remaining authors report no financial disclosures., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022.)

Objective: To examine racial and ethnic differences in the utilization of 3 interventions (tracheostomy placement, gastrostomy tube placement, and hospice utilization) among patients with severe acute brain injury (SABI)., Design: Retrospective cohort study., Setting: Data from the National Inpatient Sample, from 2002 to 2012., Patients: Adult patients with SABI defined as a primary diagnosis of stroke, traumatic brain injury, or post-cardiac arrest who received greater than 96 hours of mechanical ventilation., Exposure: Race/ethnicity, stratified into 5 categories (white, black, Hispanic, Asian, and other)., Measurements and Main Results: Data from 86 246 patients were included in the cohort, with a mean (standard deviation) age of 60 (18) years. In multivariable analysis, compared to white patients, black patients had an 20% increased risk of tracheostomy utilization (relative risk [RR]: 1.20, 95% CI: 1.16-1.24, P < .001), Hispanic patients had a 10% increased risk (RR: 1.10, 95% CI: 1.06-1.14, P < .001), Asian patients had an 8% increased risk (RR: 1.08, 95% CI: 1.01-1.16, P = .02), and other race patients had an 10% increased risk (RR: 1.10, 95% CI: 1.04-1.16, P < .001). A similar relationship was observed for gastrostomy utilization. In multivariable analysis, compared to white patients, black patients had a 25% decreased risk of hospice discharge (RR: 0.75, 95% CI: 0.67-0.85, P < .001), Hispanic patients had a 20% decreased risk (RR: 0.80, 95% CI: 0.69-0.94, P < .01), and Asian patients had a 47% decreased risk (RR: 0.53, 95% CI: 0.39-0.73, P < .001). There was no observed relationship between race/ethnicity and in-hospital mortality., Conclusions: Minority race was associated with increased utilization of tracheostomy and gastrostomy, as well as decreased hospice utilization among patients with SABI. Further research is needed to better understand the mechanisms underlying these race-based differences in critical care.

Background: Patients with severe acute brain injury (SABI) lack decision-making capacity, calling on families and clinicians to make goal-concordant decisions, aligning treatment with patient's presumed goals-of-care. Using the family perspective, this study aimed to (1) compare patient's goals-of-care with the care they were receiving in the acute setting, (2) identify patient and family characteristics associated with goal-concordant care, and (3) assess goals-of-care 6 months after SABI. Methods: Our cohort included patients with SABI in our Neuro-ICU and a Glasgow Coma Scale Score <12 after day 2. Socio-demographic and clinical characteristics were collected through surveys and chart review. At enrollment and again at 6 months, each family was asked if the patient would prefer medical care focused on extending life vs. care focused on comfort and quality of life, and what care the patient is currently receiving. We used multivariate regression to examine the characteristics associated with (a) prioritized goals (comfort/extending life/unsure) and (b) goal concordance. Results: Among 214 patients, families reported patients' goals-of-care to be extending life in 118 cases (55%), comfort in 71 (33%), and unsure for 25 (12%), while care received focused on extending life in 165 cases (77%), on comfort in 23 (11%) and families were unsure in 16 (7%). In a nominal regression model, prioritizing comfort over extending life was significantly associated with being non-Hispanic White and having worse clinical severity. Most patients who prioritized extending life were receiving family-reported goal-concordant care (88%, 104/118), while most of those who prioritized comfort were receiving goal-discordant care (73%, 52/71). The only independent association for goal concordance was having a presumed goal of extending life at enrollment (OR 23.62, 95% CI 10.19-54.77). Among survivors at 6 months, 1 in 4 family members were unsure about the patient's goals-of-care. Conclusion: A substantial proportion of patients are receiving unwanted aggressive care in the acute setting after SABI. In the first days, such aggressive care might be justified by prognostic uncertainty. The high rate of families unsure of patient's goals-of-care at 6 months suggests an important need for periodic re-evaluation of prognosis and goals-of-care in the post-acute setting., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer, KD, declared a shared affiliation, though no collaboration, with three of the authors, RR, GB, and RJ to the handling editor., (Copyright © 2021 Rutz Voumard, Dugger, Kiker, Barber, Borasio, Curtis, Jox and Creutzfeldt.)

Objective: To synthesize reported long-term outcomes in patients undergoing tracheostomy after severe acute brain injury (SABI)., Methods: We systematically searched PubMed, EMBASE, and Cochrane Library for studies in English, German, and Spanish between 1990 and 2019, reporting outcomes in patients with SABI who underwent tracheostomy. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the meta-analyses of observational studies in epidemiology guidelines. We excluded studies reporting on less than 10 patients, mixed populations with other neurological diseases, or studies assessing highly select subgroups defined by age or procedures. Data were extracted independently by two investigators. Results were pooled using random effects modeling. The primary outcome was long-term functional outcome (mRS or GOS) at 6-12 months. Secondary outcomes included hospital and long-term mortality, decannulation rates, and discharge home rates., Results: Of 1405 studies identified, 61 underwent full manuscript review and 19 studies comprising 35,362 patients from 10 countries were included in the meta-analysis. The primary outcome was available from five studies with 451 patients. At 6-12 months, about one-third of patients (30%; 95% confidence interval [CI] 17-48) achieved independence, and about one-third survived in a dependent state (36%, 95% CI 28-46%). The pooled short-term mortality for 19,048 patients was 12%, (95% CI 9-17%) with no significant difference between stroke (10%) and TBI patients (13%), and the pooled long-term mortality was 21% (95% CI 11-36). Decannulation occurred in 79% (95% CI 51-93%) of survivors. Heterogeneity was high for most outcome assessments (I 2  > 75%)., Conclusions: Our findings suggest that about one in three patients with SABI who undergo tracheostomy may eventually achieve independence. Future research is needed to understand the reasons for the heterogeneity between studies and to identify those patients with promising outcomes as well as factors influencing outcome.

Objectives: The global COVID-19 pandemic made strict visitation policies necessary. We explored the experiences of family members of patients with severe acute brain injury focusing on the impact of family presence in the hospital. Methods: Semistructured interviews (February 2018-April 2020) were audiotaped, transcribed, and analyzed using thematic analysis. Results: We interviewed family members of 19 patients with stroke, traumatic brain injury, or cardiac arrest; five interviews occurred after initiation of restrictive visitation policies. Four key themes highlight the role of visitation on family's ability to (1) cope by being at the bedside, (2) protect and advocate for the patient, (3) build trust with clinicians, and (4) receive emotional support in the intensive care unit. After visitation restrictions, families found ways to communicate and support virtually and wished for proactive communication from clinicians. Conclusions: Family presence at patient's bedside fulfills important needs. Visitation restrictions require hospitals to be creative and inclusive to help maintain these connections.