In this age of subspecialization, neuro-intensive care is the latest area seeking certification by the United Council of Neurologic Subspecialties, which includes the American Academy of Neurology among its sponsors. Yet, general neurologists, or those with expertise in other subspecialties, cannot rely on the availability of those certified or trained in critical/intensive care neurology when emergency situations arise. For this issue of Continuum, Dr Kyra Becker has assembled a talented faculty to inform and guide us about these crucial matters.
While ischemic stroke occurs much more frequently than intracerebral hemorrhage, few conditions present more dramatically and with such potential neurological devastation as the latter. Drs Joshua N. Goldstein, Steven M. Greenberg, and Jonathan Rosand emphasize the tendency of these hemorrhages to enlarge while also informing us about the most current management strategies. While these authors address the issue of raised intracranial pressure in the context of intracerebral hemorrhage, Drs M. Sean Kincaid and Arthur Lam later discuss that general subject in greater depth. In recent years, increasing information about the pathophysiology and management of hypertensive emergencies, as well as the important, but slightly less critical, urgent hypertensive situations has become available. Dr Becker herself thoroughly reviews this subject, emphasizing the importance of the rise in blood pressure above an individual's normal levels in determining an escape from normal autoregulatory control. She points out this common denominator that marks such disparate clinical situations as eclampsia, posterior leukoencephalopathy associated with several immunosuppressive medications, and carotid reperfusion syndromes, in addition to more classical hypertensive encephalopathy.
Coma is one of the most common neurological situations that neurologists encounter in the hospital. Although the unconscious state has many potential etiologies, the neurologist most frequently will face a patient who has failed to awaken after a cardiac or respiratory arrest. Understanding the prognostic signals available at particular time points after an anoxic event not only will enable us to provide appropriate care for our patients, but also will allow us to deliver accurate information in the most empathic fashion to understandably anxious and concerned family members. Dr David L. Tirschwell carefully analyzes the complex literature on this subject and helps us avoid dependency on unreliable cues.
Our understanding of status epilepticus has evolved in recent years, as we have increasingly recognized the damage that can result from uncontrolled seizures. Drs Marek A. Mirski and Panayiotis N. Varelas emphasize that the modern definition of status epilepticus requires a much shorter period of continued seizure activity than we previously thought, and that a corresponding sense of urgency must be brought to terminating the condition rapidly in order to prevent irreversible damage. They review a variety of strategies for accomplishing that goal.
Dr Gene Y. Sung has prepared a patient management problem that tests our ability to synthesize and apply the information provided by the other authors in this issue. Finally, Drs D. Joanne Lynn and Douglas J. Gelb have assembled a series of multiple-choice questions that will simultaneously reinforce and assess your mastery of critical care neurology.
We are indebted to Dr Becker and the other faculty members for their practical, yet scholarly and informative, tutelage. We will undoubtedly be better prepared when we encounter critically ill neurological patients.
Aaron E. Miller, MD