We had a virtual coffee with Laura Llull, who is a neurologist in Barcelona. Laura is an expert in running neurocritical care of stroke patient and is the co-principal investigator of the Catalan SAH registry.
Let’s hear what she thinks about the role of neurologists in neurocritical care and their ongoing work on management of SAH.
- Why should stroke neurologists be involved in neurocritical care? What specific training do we need in order to do that?
My opinion is that neurologists should be part of a multidisciplinary team that gives attention to the neurocritical patient. And not only solving critical consults, but participating as an active part of their care. To this end, we should receive specific training from doctors who are experts in the management of critical patients in an ICU. If we stroke neurologists did all those work our stroke units could become semi-intensive care units and offer a better care to patients.
- How does the neurocritical care unit currently work at your hospital? Have you been well accepted by intensivists and anesthesiologists?
We have a very good relationship with the specialists in the intensive care areas of our center. As neurologists, we visit patients admitted to the ICU under our care and participate in making decisions that affect these patients. We hold joint sessions and formed a coordinated working group with common research projects.
- As I understand, you’ve been helping with critical care of Covid-19 patients. What was your role during the worst moments of the pandemic?
That’s right. For five weeks I worked in a semi-intensive care unit for patients affected by Covid-19. It was a professional challenge that I was lucky enough to face alongside a team of specialists from other areas that I had never worked with before. The connection with them and with the rest of the people in the unit was immediate. I learned how to handle non-invasive mechanical ventilation and vasoactive drugs. I believe this experience and the evidence that hospitals need more semi-intensive care units has reinforced my belief in the importance of neurologist training in critical care.
- Which patients with SAH should be admitted to an intensive care unit (ICU) and which to a stroke unit (an intermediate care unit)?
We have written a paper on this subject which is under review, we have made a retrospective review of a series of consecutive patients collected prospectively over 7 years. In our experience, the stroke unit may be an appropriate admission area for SAH patients with a WFNS grade I and II. According to data from our centre, SAH patients with WFNS grade I-II who were admitted to the stroke unit did not develop more complications nor had a worse prognosis than patients with WFNS grade I-II who were admitted to the ICU. The area of hospitalization where SAH patients with WFNS grade III should be admitted should be decided on an individual basis. SAH is a multisystemic disease; patients can suffer lung, myocardial and kidney damage. Therefore, the medical team that attends to these patients must be multi-disciplinary and composed of expert personnel who offer comprehensive care.
I would also like to highlight the role that the stroke unit can play as an “ICU de-escalation” area for patients with SAH, as a preliminary step to being in a conventional hospital ward. In the stroke unit, patients are continuously monitored by expert staff and it would be appropriate for them to remain in the stroke unit throughout the period in which they may develop neurological complications.
- How should a patient with SAH be monitored? What can a stroke neurologist contribute in this case?
Patients with SAH may have multiple neurological complications during admission. Therefore, I believe that a neurologist with experience in this pathology can be a good practitioner for this type of patient. Clinical changes in SAH patients must be monitored constantly. The neurologist can also detect vasospasm with transcranial doppler and intensify clinical monitoring to identify clinical changes secondary to vasospasm as early as possible.
The electroencephalogram is also a very useful tool in SAH patients, especially in those where physical examination is not possible (patients under sedation). This is another point that emphasizes the importance of the neurologist in the care of these patients. Epileptic seizures and epileptic status are complications that we must also quickly identify to adequate therapeutic management in each case.
Interviewed by Daniel Guisado Alonso
Unidad de Enfermedades Vasculares Cerebrales, Servicio de Neurología
Unitat de Malalties Vasculars Cerebrals, Servei de Neurologia
Stroke Unit, Department of Neurology
Hospital de la Santa Creu i Sant Pau. Barcelona.
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