Neuroprognostication in the First Six hours

Abstract

Early neuroprognostication following cardiac arrest or acute brain injury remains a complex and high-stakes clinical challenge. Accurate prediction of neurological outcomes is limited during the initial hours due to biological instability, confounding factors such as sedation, temperature management, and systemic derangements, and the dynamic evolution of cerebral injury. Multimodal assessment, integrating clinical examination, electrophysiology, biomarkers, brain-directed physiologic monitoring, and early neuroimaging, provides a structured framework to evaluate injury severity and guide acute management. While ultra-early prognostic indicators exist, their reliability is constrained, and premature interpretation risks self-fulfilling errors, particularly through early withdrawal of life-sustaining therapy. This review synthesizes current evidence on early neurological assessment within the first six hours post-cardiac arrest, highlighting the role of sequential evaluation, confounder management, and multimodal integration. By contextualizing physiological data with imaging, biomarkers, and continuous monitoring, clinicians can optimize acute care, stabilize patients, and defer definitive prognostication until biological signals regain interpretability.