Mortality and morbidity remain high from neurologic emergencies, such as acute stroke, traumatic brain injury, and hypoxic-ischemic encephalopathy after cardiac arrest. Decisions regarding initial aggressiveness of care must be made at the time of presentation, and perceived prognosis is often used as part of this decision-making process. These decisions are predicated on the accuracy of early outcome prediction, however. Decisions to limit treatment early after neuroemergencies must be balanced with avoidance of self-fulfilling prophecies of poor outcome attributable to clinical nihilism. This article examines the role of prognostication early after neuroemergencies, the potential impact of early treatment limitations, and how these may relate to communication with patients and surrogate decision makers in the context of these acute neurologic events.