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Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients., (Copyright © 2023. Published by Elsevier España, S.L.U.)

Background: We sought to characterize the specialty classification of US physicians who provide critical care for neurological/neurosurgical disease.Methods: Using inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries, we selected hospitalizations for neurological/neurosurgical diseases with potential to result in life-threatening manifestations requiring critical care. Using Current Procedural Terminology® codes, we determined the medical specialty of providers submitting critical care claims, and, using National Provider Identifier numbers, we merged in data from the United Council for Neurologic Subspecialties (UCNS) to determine whether the provider was a UCNS diplomate in neurocritical care. We defined providers with a clinical neuroscience background as neurologists, neurosurgeons, and/or UCNS diplomates in neurocritical care. We defined neurocritical care service as a critical care claim with a qualifying neurological/neurosurgical diagnosis in patients with a relevant primary hospital discharge diagnosis and ≥ 3 total critical care claims, excluding claims from the first day of hospitalization since these were mostly emergency-department claims. Our findings were reported using descriptive statistics with exact confidence intervals (CI).Results: Among 1,952,305 Medicare beneficiaries, we identified 99,937 hospitalizations with at least one claim for neurocritical care. In our primary analysis, neurologists accounted for 28.0% (95% CI, 27.5-28.5%) of claims, neurosurgeons for 3.7% (95% CI, 3.5-3.9%), UCNS-certified neurointensivists for 25.8% (95% CI, 25.3-26.3%), and providers with any clinical neuroscience background for 42.8% (95% CI, 42.2-43.3%). The likelihood of management by physicians with a clinical neuroscience background increased proportionally with patients' county-level socioeconomic status and such providers were 3 times more likely to be based at an academic medical center than other physicians who billed for critical care in our sample (odds ratio, 2.9; 95% CI, 1.1-8.1).Conclusions: Physicians with a dedicated clinical neuroscience background accounted for less than half of neurocritical care service in US Medicare beneficiaries. [ABSTRACT FROM AUTHOR]

Brain injuries are complicated medical problems and their management requires data from disparate sources to extract actionable information. In neurocritical care, interoperability is lacking despite the perceived benefits. Several efforts have been underway, but none have been widely adopted, underscoring the difficulty of achieving this goal. We have identified the current pain points of data collection and integration based on the experience with two large multi-site clinical studies: Transforming Research And Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) in the United States and Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) in Europe. The variability of measurements across sites remains a barrier to uniform data collection. We found a need for annotation standards and for a standardized archive format for high-resolution data. Overall, the hidden cost for successful data collection was initially underestimated.Although the use of bedside data integration solutions, such as the Moberg's Component Neuromonitoring System (Moberg Research, Inc., Ambler, PA, USA) or ICM+ software (Cambridge Enterprise, Cambridge, UK), facilitated the homogenous collection of synchronized data, there remain issues that need to be addressed by the neurocritical care community. To this end, we have organized a Working Group on Neurocritical Care Informatics, whose next step is to create an overarching informatics framework that takes advantage of the collected information to answer scientific questions and to accelerate the translation of trial results to actions benefitting military medicine. [ABSTRACT FROM AUTHOR]

Objective: This manuscript describes the state of neurocritical care fellowship training, compares its written standards to those of other critical care fellowship programs, and discusses how programmatic oversight by the United Council for Neurological Subspecialties should evolve to meet American College of Graduate Medical Education standards. This review is a work product of the Society of Critical Care Medicine Neuroscience section and was reviewed and approved by the Council of the Society of Critical Care Medicine.Data Sources: We evaluated the published training criteria and requirements of American College of Graduate Medical Education Critical Care subspecialty fellowships programs of Internal Medicine, Surgery, and Anesthesia and compared them with the training criteria and required competencies for neurocritical care.Study Selection: We have reviewed the published training standards from American College of Graduate Medical Education as well as the United Council for Neurologic Subspecialties subspecialty training documents and clarified the definition and responsibilities of an intensivist with reference to the Leapfrog Group, the National Quality Forum, and the Joint Commission.Data Extraction: No data at present exist to test the concept of similarity across specialty fellowship critical care training programs.Data Synthesis: Neurocritical care training differs in its exposure to clinical entities that are directly associated to other critical care subspecialties. However, the core critical care knowledge, procedural skills, and competencies standards for neurocritical care appears to be similar with some important differences compared with American College of Graduate Medical Education critical care training programs.Conclusions: The United Council for Neurologic Subspecialties has developed a directed program development strategy to emulate American College of Graduate Medical Education standards with the goal to have standards that are similar or identical to American College of Graduate Medical Education standards. [ABSTRACT FROM AUTHOR]

Severe traumatic brain injury (TBI) causes substantial morbidity and mortality, and is a leading cause of death in both the developed and developing world. The need for a systematic evidence-based approach to the care of severe TBI patients within the emergency setting has led to its inclusion as an Emergency Neurological Life Support topic. This protocol was designed to enumerate the practice steps that should be considered within the first critical hours of neurological injury from severe TBI. [ABSTRACT FROM AUTHOR]

This proceedings article presents the scope of pediatric coma and disorders of consciousness based on presentations and discussions at the First Pediatric Disorders of Consciousness Care and Research symposium held on September 14th, 2021. Herein we review the current state of pediatric coma care and research opportunities as well as shared experiences from seasoned researchers and clinicians. Salient current challenges and opportunities in pediatric and neonatal coma care and research were identified through the contributions of the presenters, who were Jose I. Suarez, MD, Nina F. Schor, MD, PhD, Beth S. Slomine, PhD Erika Molteni, PhD, and Jan-Marino Ramirez, PhD, and moderated by Varina L. Boerwinkle, MD, with overview by Mark Wainwright, MD, and subsequent audience discussion. The program, executively planned by Varina L. Boerwinkle, MD, Mark Wainwright, MD, and Michelle Elena Schober, MD, drove the identification and development of priorities for the pediatric neurocritical care community., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Objective: Concussions are a form of mild traumatic brain injury (mTBI) that most commonly occur after blunt trauma to the head and may result in temporary loss of consciousness. These patients are typically comanaged by neurocritical care specialists, neurologists, and neurosurgeons depending on the severity of disease. The purpose of this study was twofold: 1) evaluate how patient demographic characteristics impact the development of novel psychiatric disorders (NPDs) after mTBI; and 2) develop screening recommendations to identify patients with NPDs., Methods: The authors used data from the 2010-2019 National Readmissions Database of the Healthcare Cost and Utilization Project. Patients who were readmitted for mTBI within a year of their first admission between 2010 and 2019 were identified (n = 206,070). The association between patient demographic characteristics and the emergence of NPDs after mTBI was examined using multivariable binomial regression analysis. Density plots were used to examine diagnostic patterns for NPDs., Results: The mean ± SD age of all patients was 50.9 ± 26.2 years, and 43.9% of patients were female. Overall, an additional 818 (0.40%) patients were reported to have novel suicidal ideation (SI), 3866 (1.9%) novel depression, 3449 (1.7%) novel anxiety, and 88 (0.043%) novel homicidal ideation (HI) after mTBI. Younger age (OR 0.9775, 95% CI 0.9705-0.9848, p < 0.0001) and reduced Charlson Comorbidity Index (CCI) score (OR 0.9155, 95% CI 0.8539-0.9774, p = 0.010) may predict novel SI, and female sex (OR 0.7464, 95% CI 0.6026-0.9214, p = 0.0069) may be inversely related to novel SI after mTBI. Also, multivariable analysis found that female sex (OR 1.1774, 95% CI 1.0654-1.3016, p = 0.0014) and Medicare/Medicaid insurance type (OR 0.9381, 95% CI 0.8983-0.9797, p = 0.0039) may predict novel anxiety after mTBI. Similarly, younger age (OR 0.9956, 95% CI 0.9923-0.9989, p = 0.0096), higher CCI score (OR 1.0363, 95% CI 1.0099-1.0629, p = 0.0062), and Medicare/Medicaid insurance type (OR 0.9386, 95% CI 0.8998-0.9789, p = 0.0032) may predict novel depression. Lastly, female sex (OR 0.3271, 95% CI 0.1467-0.6567, p = 0.0031) and increased median income (OR 0.8829, 95% CI 0.7930-0.9944, p = 0.049) were inversely proportional to novel HI after mTBI. The median time to diagnosis of NPD was 69.5 days for depression, 66.5 days for anxiety, 70.0 days for SI, and 66.5 days for HI., Conclusions: Numerous patient demographic factors are significant predictors of the development of NPDs after mTBI and concussion. Screening for NPDs within 3 weeks and 3 months after mTBI may identify most patients at risk for developing novel postconcussive psychiatric conditions, including anxiety, depression, HI, and SI. Further studies are warranted to understand how patient demographic characteristics should dictate medical management and screening after mTBI and concussion.

Neurocritical care is a relatively young subspecialty that is rapidly coming into its own. As the neurocritical care community has expanded, the process of training and credentialing physicians in this growing field has undergone a rapid evolution. This article will review the history and current state of neurocritical care training and education, physician certification, and program accreditation in the United States within the larger context of critical care training across subspecialties., Competing Interests: Disclosure Drs A.H. Shapshak and L. Shutter have no financial conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The primary objective of this study was to determine the effectiveness of a lower dose of levetiracetam (500 mg every 12 hours) to prevent early seizures after traumatic brain injury (TBI). It was hypothesized that the seizure rate would be low and comparable to previous studies using phenytoin. Methods: This was a retrospective cohort study conducted in a tertiary care, academic institution that is designated as a level 1 trauma centre in the US. Consecutive patients with TBI were evaluated. Patients who were given a levetiracetam dose of 500 mg every 12 hours were included. The primary outcome was the occurrence of a seizure within 7 days of TBI. Results: There were a total of 169 patients included in the study, who were treated with levetiracetam 500 mg every 12 hours. The median time to first dose of levetiracetam was 3.5 hours after injury (interquartile range = 1–13 hours). After initiation of levetiracetam, there were four (2.4%) patients who had a seizure within 7 days. This was not significantly different than the hypothesized population value of 3.6% (p= 0.390). Conclusions: A lower dose of levetiracetam 500 mg every 12 hours after TBI may be effective for early seizure prevention after TBI. [ABSTRACT FROM AUTHOR]

Background: Several recent studies across the field of medicine have indicated gender disparity in the reception of prestigious awards and research grants, placing women in medicine at a distinct disadvantage. Gender disparity has been observed in neurology, critical care medicine and within various professional societies. In this study, we have examined the longitudinal trends of gender parity in awards and grants within the Neurocritical Care Society (NCS)., Methods: A retrospective analysis was conducted of all available data longitudinally from 2004, when NCS first granted awards through 2019. We used self-identified gender in the membership roster to record gender for each individual. For individuals without recorded gender, we used a previously validated double verification method using a systematic web-based search. We collected data on six awards distributed by the NCS and divided these awards into two main categories: (1) scientific category: (a) Christine Wijman Young Investigator Award; (b) Best Scientific Abstract Award; (c) Fellowship Grant; (d) INCLINE Grant; and (2) non-scientific category: (a) Travel Grant; and (b) Presidential Citation. Available data were analyzed to evaluate longitudinal trends in awards using descriptive statistics and simple or multiple linear regression analyses, as appropriate., Results: A total of 445 awards were granted between the years 2004 and 2019. Thirty-six awards were in the scientific category, while 409 awards were in the non-scientific category. Only 8% of women received NCS awards in the scientific awards category, whereas 44% of women received an award in the non-scientific category. Most notable in the scientific category are the Best Scientific Abstract Award and the Fellowship Grant, in which no woman has ever received an award to date, compared to 18 men between both awards. In contrast, women are well represented in the non-scientific awards category with an average of 5% increase per year in the number of women awardees., Conclusions: Our data reveal gender disparity, mainly for scientific or research awards. Prompt evaluation of the cause and further actions to address gender disparity in NCS grants and recognition awards is needed to establish gender equity in this area., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

The article focuses on the consequences of prolonged immobility in patients at neurological intensive care unit (Neuro ICU). Topics discussed include ICU-acquired weakness which is common in critically ill patients with no acute brain injury, impact of ICU-acquired weakness in long-term outcomes, such as quality of life and functional status at 12 months, and early mobility program for patients in U.S.

Acute ischemic stroke is a major cause of mortality and morbidity in the United States and worldwide. Despite the development of specialized stroke centers, mortality and morbidity as a result of acute ischemic strokes can and do happen anywhere. These strokes are emergency situations requiring immediate intervention. This article covers the fundamentals of care involved in treating patients with acute ischemic stroke, including essentials for the initial evaluation, basic neuroimaging, reperfusion therapies, critical care management, and palliative care, as well as current controversies. National guidelines and current research are presented, along with recommendations for implementation., (©2018 American Association of Critical-Care Nurses.)

In this article the author discusses the implication of President Barack Obama's administration with regards to stroke care in the U.S. He states that the need of all Americans to have access to more comprehensive and integrated medical services is essential in order to prevent and cure stroke. He mentions that President Obama must allocate enough resources when it comes to stroke care because treatment and preventive measures for stroke is expensive.

Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Although neurocritical care as a subspecialty is a relatively young field of medicine, its origins can be traced back to ancient times. This article focuses on the progression of neurocritical care from prehistoric trepanation procedures, through the development of mechanical ventilation, management of increased intracranial pressure, and traumatic brain injury, to the establishment of the first "real" intensive care units, and finally to modern monitoring in neurocritical care, management of post-cardiac arrest patients, and the diagnosis of brain death. This article also focuses on the future direction of neurocritical care., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy (ET) cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison with late tracheostomy (LT)., Methods: We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Independent samples t tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures., Results: In total, 13,165 stroke cases were included in the study (5591 in the ET group and 7574 in the LT group). Patients receiving an ET had a significant reduction in the odds of ventilator-associated pneumonia in comparison with the LT group (OR: .688, P = .026). The length of stay for patients receiving an ET was significantly lower in comparison with the LT group (P < .001) and was associated with an 18% reduction in total hospital costs (P < .001)., Conclusions: Early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial., (Copyright © 2014 National Stroke Association. Published by Elsevier Inc. All rights reserved.)