Neurocritical Care

Contents

Preface: Neurocritical Care Past, Present, and Future xiii

Deepa Malaiyandi and Lori Shutter

The History of Neurocritical Care as a Subspecialty 1

Kristi Tempro and Cherylee W.J. Chang
The role of the neurointensivist as a subspecialist has been cemented in
modern medicine globally. It was forged through the collaboration of neu-
rologists, neurosurgeons, internists, anesthesiologists, general surgeons,
emergency medicine physicians, and pediatricians. As with all critical
care areas, it requires a multiprofessional environment. Neurocritical
care harnesses knowledge, technology, resources, and research opportu-
nities to embrace a multisystem approach to care for the neurologically
critically ill. Although recently formally recognized, its crucial role to serve
patients with acute, life-threatening neurologic insults has been well
established.

Quality Improvement in Neurocritical Care 17

Casey Olm-Shipman and Asma M. Moheet
Quality improvement is key to advancing outcomes for neurocritically ill
patients. Variation in neurocritical care practice can lead to differences
in health outcomes and contribute to health disparities. The implementa-
tion of evidence-based best practice standards represents a major oppor-
tunity to improve their care. Neurocritical care performance measures
have recently been developed and may be used to target high priority
areas for improvement. In addition, neurocritical care clinicians should
be aware of the heavily weighted pay-for-performance and publicly re-
ported performance measures that are directly relevant to neurocritical
care practice.

Neurocritical Care Education in the United States 29

Angela Hays Shapshak and Lori Shutter
Neurocritical care is a relatively young subspecialty that is rapidly coming
into its own. As the neurocritical care community has expanded, the pro-
cess of training and credentialing physicians in this growing field has un-
dergone a rapid evolution. This article will review the history and current
state of neurocritical care training and education, physician certification,
and program accreditation in the United States within the larger context
of critical care training across subspecialties.

Neurocritical Care Research: Collaborations for Curing Coma 47

Jose Javier Provencio
One of the most common questions asked by family members of patients
with brain injuries who are in a coma is “will my loved one wake up?”.
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Despite substantial improvements in the care of patients with neurological

diseases, the medical and scientific community struggles to answer this
simple question. More importantly, the technology and treatment strate-
gies to improve the trajectory of patients with impaired consciousness in
the acute setting are limited. The Curing Coma Campaign was developed
by the Neurocritical Care Society as a multispecialty, multi-interest com-
munity of researchers and caretakers who are focused on patients with
disorders of consciousness (DoC) in the acute phase of care. Over the first
few years of the group, several publications have focused on identifying
the gaps in our knowledge to encourage research in the area. In this re-
view, the current understanding of DoC is reviewed. The work of the Curing
Coma Campaign to identify gaps in our knowledge is highlighted.

Neurocritical Care Aspects of Ischemic Stroke Management 55

Dania Qaryouti and Diana Greene-Chandos
This article reviews the care of patients with ischemic stroke in the inten-
sive care unit, including early general critical care interventions for airway
control blood pressure goals according to the type of acute stroke treat-
ment, poststroke cerebral edema management, hemorrhagic conversion
in ischemic stroke, fibrinolytic reversal, and management of carotid endar-
terectomy and infective endocarditis. The importance of preventing com-
mon intensive care complications is discussed, including aspiration
pneumonia, deep venous thrombosis, urinary tract infections, cardiac ar-
rhythmias, and hyperglycemia.

Advances in Intracranial Hemorrhage: Subarachnoid Hemorrhage and Intracerebral

Hemorrhage 71
Salvatore A. D’Amato and Tiffany R. Chang
Aneurysmal subarachnoid hemorrhage and intracerebral hemorrhage are
devastating injuries causing significant morbidity and mortality. However,
advancements made over decades have improved outcomes. This review
summarizes a systematic approach to stabilize and treat these patient
populations.

Status Epilepticus: A Neurologic Emergency 87

Patrick J. Coppler and Jonathan Elmer
In this review, we discuss treatment and considerations for status epilep-
ticus in general intensive care unit patients, acquired brain injury, autoim-
mune conditions, toxidromes, pediatrics, and pregnancy.

Neurotrauma and Intracranial Pressure Management 103

Francis Bernard
Video content accompanies this article at http://www.criticalcare.
theclinics.com.

Although intracranial pressure (ICP) monitoring has been the mainstay of

traumatic brain injury (TBI) management for decades, new understanding
of TBI physiopathology calls for paradigm shifts. The complexity of TBI
management precludes ICP being taken as an isolated value with a
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specific threshold. Multimodality monitoring is crucial to expanding our

comprehension of individualized pathophysiology, allowing for a precise
and tailored treatment approach. This article will review keys concepts
to interpret and apply published ICP management guidelines and
statements.

Neuromuscular Weakness in Intensive Care 123

Deepa Malaiyandi and Elysia James
Diseases of the peripheral nervous system create an additional diagnostic
conundrum within the intensive care setting. Causes are vast, presenta-
tions are myriad, and symptoms are often ill-defined or misidentified.
Care benefits from a multidisciplinary approach including a neuromuscular
specialist, rehabilitation services, and a specialty pharmacist in addition to
the neurocritical care team. In general, survivors achieve a good functional
recovery relative to their preintensive care unit baseline.

Neuroprognostication 139
Victoria Fleming and Susanne Muehlschlegel
Patients with severe acute brain injury are left incapacitated, critically ill,
and unable to make their own medical decisions. Surrogate decision-
makers must make life-or-death decisions for patients and rely on clini-
cians’ prognostication for guidance. No guidelines currently exist to guide
clinicians in how to prognosticate; hence, neuroprognostication is still
considered an “art” leaving room for high variability. This review examines
the current literature on prognostication in neurocritical care, identifies
ongoing challenges that exist in the field, and provides suggestions for
future research with the goal to ameliorate variability and focus on scien-
tific and patient-centered, rather than artistic approaches to
prognostication.

Neurocritical Care in the General Intensive Care Unit 153

Firas Abdulmajeed, Mohanad Hamandi, Deepa Malaiyandi, and Lori Shutter
Neurologic conditions are often encountered in the general intensive care
unit. This article will discuss some of the more common neurologic issues
encountered and provide guidance in the assessment and management of
these conditions.

Neuropharmacology in the Intensive Care Unit 171

Abdalla Ammar, Mahmoud A. Ammar, and Eljim P. Tesoro
Clinicians must individualize pharmacotherapy for patients with acute
neurological injury based on multiple factors, including age, comorbidities,
and chronic medication use. Many pharmacokinetic and pharmacody-
namic properties are altered during acute illness, particularly absorption,
distribution, metabolism, and elimination, which may result in loss of
drug effect or toxicity. This article provides clinicians with general pharma-
cologic knowledge of the following drug regimens commonly prescribed to
neurocritically ill adults: sedatives, analgesics, osmotherapy, antiseizure
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medications, antishivering agents, vasoactive agents, and antithrombotic

reversal agents.

Brain Death/Death by Neurological Criteria: International Standardization and the

World Brain Death Project 215
Gene Sung
This article reviews the criteria for determination of brain death, discusses
the importance of protocol development, and reviews the international ef-
forts to standardize clinical testing.

Physiological Monitoring in Patients with Acute Brain Injury: A Multimodal

Approach 221
Tracey H. Fan and Eric S. Rosenthal
Neurocritical care management of acute brain injury (ABI) is focused on
identification, prevention, and management of secondary brain injury
(SBI). Physiologic monitoring of the brain and other organ systems has a
role to predict patient recovery or deterioration, guide individualized ther-
apeutic interventions, and measure response to treatment, with the goal of
improving patient outcomes. In this review, we detail how specific physio-
logic markers of brain injury and neuromonitoring tools are integrated and
used in ABI patients to develop therapeutic approaches to prevent SBI.

Artificial Intelligence and Big Data Science in Neurocritical Care 235

Shraddha Mainali and Soojin Park
In recent years, the volume of digitalized web-based information utilizing
modern computer-based technology for data storage, processing, and
analysis has grown rapidly. Humans can process a limited number of vari-
ables at any given time. Thus, the deluge of clinically useful information in
the intensive care unit environment remains untapped. Innovations in ma-
chine learning technology with the development of deep neural networks
and efficient, cost-effective data archival systems have provided the infra-
structure to apply artificial intelligence on big data for determination of clin-
ical events and outcomes. Here, we introduce a few computer-based
technologies that have been tested across these domains.