An intraparenchymal monitor is emergently placed uneventfully. Initial ICP is 28mmHg. You recommend restarting and bolusing propofol. Her ICP responds to this. You admit her to the NCCU. On your way upstairs, though, the ED team tracks you down. They’re confused that these aggressive measures are being taken, as they’re concerned that she has DAI on her scan and has a poor motor exam. They ask you if providing all this aggressive care is futile.
One of the biggest problems in managing acute neurologic injury is early transitions to comfort measures (documented in the literature as early Withdrawal of Life-Sustaining Treatment), which typically stems from prognostic pessimism. However, we know that neurologic recovery can take a long time, and that even patients with severe injuries can significantly recover function.
In terms of the expressed concern about prognosis as a function of her DAI and poor motor exam, based on the available evidence, the most recent 2024 NCS guidelines on neuroprognostication of moderate and severe TBI suggest “that the GCS score or the motor subscore of the GCS alone, assessed on admission after adequate resuscitation, not be considered a reliable predictor of hospital mortality or disease-related mortality beyond discharge” (Muehlschlegel et al. 2024). Historically, the presence of DAI (which may be discovered on MRI if not obvious on HCT) has been considered to be another poor prognostic indicator. However, this is an unreliable predictor, and is unlikely to correlate with post-hospital morbidity or mortality (Humble et al. 2018).
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