In the 21st century, few, if any, therapeutic interventions have had as much impact in reducing mortality and morbidity from devastating neurologic disease as has the development of the modern intensive care unit (ICU). Pari passu with this change in venue for the treatment of life-threatening disorders has come scientific advancement in the understanding and management of critical medical and neurologic illness. Not unexpectedly, this has also resulted in the creation of the subspecialty of neurocritical care.
Today much of the care of the critically ill neurologic patient will be orchestrated by a neurointensivist. Often, however, such a highly trained subspecialist is unavailable, and critically ill neurologic patients may be treated in a medical or neurosurgical ICU. In such a situation, the expertise of the neurologist will be critical to the process of optimizing the outcome for these very sick patients. Even where a neurocritical care specialist is available, your role on the team caring for such patients remains highly important, and your knowledge about such illness and its management will be vital. For this issue of Continuum one of the country's foremost critical care neurologists, Dr Michael Diringer, has assembled an expert team of his colleagues to discuss some of the burning issues in this field.
Dr Alejandro Rabinstein kicks off the issue with a chapter entitled "Ethical Dilemmas in the Neurologic ICU: Withdrawing Life-Support Measures After Devastating Brain Injury," in which he makes the provocative observation that cessation of life support is the most common cause of death in the neurologic ICU. Dr J. Javier Provencio continues this theme in the subsequent chapter, "Evaluation and Prognosis of Coma: New Hope and Complicated Decisions." Being able to offer guidance to families about the prognosis of their loved one in coma is one of the most challenging tasks neurologists face. Dr Provencio thoughtfully presents the evidence to enable you to offer the most accurate assessment currently possible.
The hallmark of lifesaving care in the neurologic ICU has been the provision of modern and ever-improving respiratory care. In the next chapter, Dr Rajat Dhar discusses this matter in the context of several neurologic diseases that result in respiratory failure. Even though you are likely among the majority of neurologists who do not directly manage these complicated respiratory issues, you will surely benefit from a better understanding of such critical care. On the other hand, the management of acute ischemic stroke does regularly fall to the practicing neurologist, who will be updated by Dr Allyson Zazulia on a number of important matters such as the management of blood pressure, glucose, and cerebral edema, among others.
The course of a patient with a critical neurologic illness is often complicated by fever, which can worsen the situation. Dr Neeraj Badjatia will next discuss both the approach to the febrile patient and the management of fever. The following two chapters are devoted to specific, common, critical neurologic events. Although anoxic brain injury is addressed as part of the discussion of some of the earlier chapters, Drs Karen Hirsch, Matthew Koenig, and Romergryko Geocadin specifically tackle the very frequent problem of management of brain injury after cardiac arrest. Faculty chair Michael Diringer himself then provides an update on intracerebral hemorrhage. While brain hemorrhage accounts for only a minority of strokes, it is, nonetheless, still a frequent occurrence. This chapter will provide you with much new information on the management of this often life-threatening acute neurologic emergency. Anticoagulation is not only commonly employed to reduce the risk of stroke, but also may be the culprit in causing brain hemorrhage. In the final didactic chapter of this issue, Dr Venkatesh Aiyagari will bring you up to speed on the correction of coagulopathy secondary to oral and parenteral anticoagulants.
As usual, this issue also includes the important "Ethical Perspectives in Neurology" section in which Dr Agnieszka Ardelt addresses the challenging question of the management of a patient who has attempted suicide. With additional states now allowing the option of physician-assisted suicide under very specific circumstances, this is a particularly timely discussion. With the recent establishment of a new Continuum Editorial Board, this is a good time for me to acknowledge the continuing help and dedication of Dr Michael Williams, who thoughtfully and energetically serves as Associate Editor of Ethics.
You will not gain the maximum educational experience about critical care neurology from this issue of Continuum without engaging in the challenging question and answer sections. These include a patient management problem, crafted by Dr Andrew Naidech, that will help you work through a critical neurologic case from beginning to end. After that, you can tackle the multiple-choice questions-don't forget that they're easy to work through in the online version of Continuum available to all subscribers both at your computer (aan.com/go/elibrary/continuum) and now even on your mobile device (m.aan.com)-that feature clinical scenarios you will regularly encounter. Finally, this issue comes with the bonus-available only twice a year-of Quintessentials, which allows you to participate in a self-assessment program (either by faxing the forms included in the issue or online at aan.com/go/elibrary/continuum/quintessentials) by answering a series of questions about three commonly encountered clinical scenarios. Your responses will be linked back to the relevant sections in the Continuum text. A month after completion of this short exercise, you will have the opportunity to realize what you have learned by tackling three similar cases. Acquiring the habit now of regular self-assessment through the use of such tools as Quintessentials will serve you well when this practice is ultimately mandated as part of your maintenance of certification.
I know that you will share my appreciation for Dr Diringer and his faculty. Your understanding of critical care neurology and your ability to care for patients facing such urgent problems will be greatly enhanced by reading this issue.
- Aaron E. Miller, MD