An upcoming crossroad: should vascular neurologists become more intensivists?
by Barbara Casolla, Univ. Lille, Inserm U1171, Degenerative & vascular cognitive disorders, CHU Lille, Department of Neurology, F-59000 Lille, France
Clinical profile and therapeutic options for stroke patients have changed very fast during the last two decades and our practice has changed consequently, with more aggressive treatments for patients with severe neurological injury. Up to today, few data are available on clinical profile and outcomes of critically-ill stroke patients, but the proportion of these patients is likely to increase in the future.
Stroke units have long been recognized to save lives1. More recently, several studies evaluating neuro intensive care unit (neuroICU) in patients with ischemic stroke showed that presence of a neuro-intensivist was associated with shorter neuroICU and hospital length of stay, greater odds of home discharge and better functional outcome2–4. Another single-centre study also showed that mortality seemed to be decreased in neuroICU settings for intracerebral hemorrhages5. Possible explanations for better outcomes include more experienced clinicians because of higher patient volume, greater adherence to protocols, use of neuromonitoring data, and, last but not least, a more conservative approach to withdrawal of care6. This could be particularly true for some stroke subtypes, such as basilar artery occlusions, malignant middle cerebral artery strokes, intracerebral hemorrhages, and extensive cerebral venous thrombosis, where invasive hemodynamics, respiratory and neurological monitoring can be helpful when it comes to decision making
Indeed, a recent review from Dr Busl published in JAMA Neurol showed that Neurocritical Care (NCC) has evolved as an organized subspecialty7. In the setting of stroke, the authors mentioned that requirements for accreditation as a comprehensive stroke center by the Joint Commission also include the provision for dedicated Neurointensive Care Unit beds for patients with complex stroke and expert NCC staff 8.
Many organizational aspects and perspectives are in the pipeline. For instance, given the substantial differences between patients admitted to neuroICU vs. general ICU, specific quality metrics for neuroICUs still have to be developed. Clinical research in the area also needs to be developed. Some exciting fields of research include the role of multimodal monitoring, especially the use of brain hemodynamics, such as cerebral perfusion pressure and cerebral blood flow, all of which may become important tools to drive decision making in the acute phase of stroke. EEG monitoring is also another area of growing interest as EEG patterns may give important insights into the functional status of brain in stroke patients.
We are facing a crossroad concerning the implication of strokologists in the era of neuroICU: should we develop more intensive care-oriented stroke units? This would of course require teams, equipments and specific training in neurointensive care for vascular neurologists.
From my perspective, vascular neurologists should keep the leadership on research and clinical management of acute phase and severe complications of critically ill stroke patients. The discussion is open!
- Jørgensen HS, Nakayama H, Raaschou HO, Larsen K, Hübbe P, Olsen TS. The effect of a stroke unit: reductions in mortality, discharge rate to nursing home, length of hospital stay, and cost. A community-based study. Stroke. 1995;26(7):1178-1182.
- Bershad EM, Feen ES, Hernandez OH, Suri MFK, Suarez JI. Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients. Neurocrit Care. 2008;9(3):287-292. doi:10.1007/s12028-008-9051-5
- Knopf L, Staff I, Gomes J, McCullough L. Impact of a Neurointensivist on Outcomes in Critically Ill Stroke Patients. Neurocrit Care. 2012;16(1):63-71. doi:10.1007/s12028-011-9620-x
- Varelas PN, Schultz L, Conti M, Spanaki M, Genarrelli T, Hacein-Bey L. The impact of a neuro-intensivist on patients with stroke admitted to a neurosciences intensive care unit. Neurocrit Care. 2008;9(3):293-299. doi:10.1007/s12028-008-9050-6
- Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29(3):635-640. doi:10.1097/00003246-200103000-00031
- Kramer AH, Zygun DA. Neurocritical care: why does it make a difference? Curr Opin Crit Care. 2014;20(2):174-181. doi:10.1097/MCC.0000000000000076
- Busl KM, Bleck TP, Varelas PN. Neurocritical Care Outcomes, Research, and Technology: A Review. JAMA Neurology. 2019;76(5):612. doi:10.1001/jamaneurol.2018.4407
- Stroke. http://www.jointcommission.org/stroke/. Accessed July 21, 2019.