The call to the bedside and the prognostication of a comatose patient—telling family members what to expect—commonly falls to neurologists. The assessment is often confounded by the treatment paradigms of modern intensive care (ie, drugs, drug interactions and targeted temperature management). Patients may be too unstable to leave the intensive care unit for neuroimaging; thus, repeated clinical examinations are decisive. Despite diverse causes, certain principles do apply: (1) Many patients can improve, although with significant abnormalities; (2) Neuroimaging and electrodiagnostic tests can help but are rarely definitive; (3) Secondary involvement of the upper brainstem marks a tipping point with much lower probability for an independent outcome; (4) We rarely predict mortality or diagnose brain death; usually the major concern is anticipated neurological deficits; and (5) Prior comorbidity and permanent organ dysfunction are critical factors in making decisions about de-escalation or escalation of care. This review provides a practical approach to evaluating outcome of a comatose patient. Prognostication is difficult, and we should only attempt it when the diagnosis is confirmed and appropriate (often aggressive) medical or surgical treatment has been tried.
- cerebral oedema
- persistent vegetative state
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Contributors EFMW is the sole author of this manuscript. He completed all literature review associated with this article and wrote the first version and the current revision.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests EFMW receives book royalties from Oxford University Press and Elsevier Publishing for authored books on coma, brain death and other issues of critical care neurology.
Patient consent for publication Not required.
Provenance and peer review Commissioned. Externally peer reviewed by Robin Howard, London, UK.
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