Miller, Aaron E. MD
In a medical universe of burgeoning technology and increasing subspecialization, much of the care of critically ill neurologic patients has devolved to neurointensivists. Nonetheless, recognizing critical situations and understanding their management is crucial for neurologists who are not critical care specialists. Conditions seen in hospitalized patients today are often extremely complex, and patients survive circumstances that might have been lethal in earlier years. Thus, it is incumbent upon neurologists to recognize critical illness and master the basics of care. This issue of Continuum: Lifelong Learning in Neurology, organized by Guest Editor Matthew Fink, provides a valuable tool to help you achieve that goal.
One of the most frequent in-patient consultations required of neurologists is to offer a prognosis after cardiac arrest. Families devastated by an often sudden coma in their loved one who has survived an initial cardiac address want to know what outcome can be predicted and how soon. Answering these questions remains challenging, and the utility of certain physical signs and laboratory investigation has changed with the expanding use of therapeutic hypothermia, a treatment modality that has increased the likelihood of quality survival after cardiac arrest. Drs Michael De Georgia and Bassel Raad kick off this issue with a discussion of this subject.
Care of the patient with a severe brain injury is often primarily provided by neurosurgeons and neurointensivists. However, general neurologists are often involved in the care of these patients, and it is therefore vital that we understand the principles of management and its complications. Dr Halinder Mangat addresses the treatment of patients with major traumatic brain injury, much of which involves the control of raised intracranial pressure. Later in the issue, Guest Editor Fink broadens the discussion of the treatment of intracranial hypertension by addressing the subject of osmotherapy, specifically comparing the use of mannitol to that of hypertonic saline.
Acute ischemic stroke remains perhaps the most frequent type of neurologic hospital admission and poses complex management issues. Dr William Coplin does not address issues of therapeutic revascularization (see Dr Allyson R. Zazulia’s article, “Critical Care Management of Acute Ischemic Stroke,” in the CONTINUUM Critical Care Neurology issue from June 2009, Volume 13, Number 3), but rather discusses such matters as hemorrhagic transformation, seizures, cardiopulmonary complications, glycemic control, and temperature regulation.
Status epilepticus (SE) is another frequently encountered critical neurologic situation. The definition of SE has changed with the increasing recognition of how quickly the brain can be damaged and how important it is to stop generalized epileptic discharges rapidly. Dr Thomas Bleck updates our knowledge in this area, emphasizing not only convulsive SE, but also the very important and challenging dilemmas of nonconvulsive status epilepticus.
Few circumstances present such acutely critical manifestations as the presence of blood in the cranium. Ruptured cerebral aneurysm with the production of subarachnoid hemorrhage is a dramatic and often rapidly devastating event. One of the most feared complications in patients who survive the initial insult is the development of delayed cerebral ischemia. Recognition and management of this consequence of cerebral vasospasm is the subject of an article by Dr Matthew Koenig. Even more common and often equally serious is intracerebral hemorrhage (ICH). Hypertension was formerly identified as the cause of spontaneous ICH in an overwhelming majority of cases. Recently, however, and perhaps because of increasing recognition of the importance of quickly and aggressively addressing elevated blood pressure, a substantial percentage of patients with ICH have alternative etiologies. Irrespective of the cause, effective strategies to minimize damage as a result of hematoma expansion, cerebral edema, and secondary complications are crucial to optimizing outcome of these events. Dr Edward Manno brings us up-to-date on this frequently encountered problem.
Metabolic encephalopathy, the topic of the remaining review article for this issue, is another exceedingly familiar source of neurologic consultation, not only in the intensive care unit—the venue on which Dr Jennifer Frontera focuses—but also throughout the hospital. Although often considered reversible, metabolic encephalopathy and, particularly, its more dramatic manifestation as delirium are now recognized to carry an ominous prognosis. Dr Frontera concentrates her discussion on the most common etiologies for this syndrome, including hepatic and renal failure, sepsis, electrolyte derangements, and Wernicke’s encephalopathy.
Critical illness in neurology is perhaps the arena in which ethical dilemmas arise most often and add immeasurably to the emotional turmoil with which the patient’s loved ones must wrestle. In the Ethical Perspectives section of this issue, Drs Eric Adelman and Darin Zahuranec address the matter of surrogate decision making. Inevitably, despite the knowledge and skill of those with expertise in critical care, many patients will succumb to their illness. In our modern age, frequently death occurs first by cessation of brain function rather than of cardiac function. In order to minimize emotional suffering of families, reduce economic burden, and, importantly, maximize the opportunity to salvage organs, it is crucial to be able to accurately diagnose brain death as early as possible. Drs Adam Webb and Owen Samuels discuss this problem, emphasizing the appropriate use of ancillary testing in specific situations.
As usual, opportunities to achieve continuing medical education credits are abundant in this issue of CONTINUUM. Dr Mangat extends his discussion of severe brain injury in collaboration with Dr Alan Velander in the Patient Management Problem. The Multiple-Choice Questions, which will help you solidify your understanding of critical care neurology, have been crafted for this issue by Drs Douglas Gelb and Joanne Lynn. Finally, to make sure you get paid properly for your work, Dr Laura Powers demystifies coding, especially in the troublesome area of encephalopathy.
Critical illness. Critical information. Continuum: Lifelong Learning in Neurology to the rescue!
—Aaron E. Miller, MD