Impact of a Neurointensivist on Outcomes in Critically Ill Stroke Patients

Abstract

Introduction Current guidelines for management of critically ill stroke patients suggest that treatment in a neurocritical care unit (NCCU) and/or by a neurointensivist (NI) may be beneficial, but the contribution of each to outcome is unknown. The relative impact of a NCCU vs. NI on short- and long-term outcomes in patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) was assessed. Methods 2,096 stroke patients admitted to a NCCU or non-neuro ICU at a tertiary stroke center were analyzed before the appointment of a NI, during the NI’s tenure, and after the NI departed and was not replaced. Data included admission ICU type, availability of a NI, age, NIHSS, ICH score and 3 and 12 month outcome. Results For AIS, compared to the time interval with a NI, departure of the NI predicted a worse rate of return to pre-stroke function at 3 months. For ICH, NCCU treatment predicted shorter ICU and hospital LOS but had no effect on short or long term outcomes. No effect of a NI was seen. For SAH, availability of an NI (but not an NCCU) predicted improved outcomes but longer ICU LOS. Disposition and in-hospital mortality improved when a NI was present, but continued improvement did not occur after the NI’s departure. Conclusion Presence of an NI was associated with improved clinical outcomes. This effect was more evident in patients with SAH. Patients with ICH tend to have poor outcomes regardless of the presence of a NCCU or a NI.

What is Specialized Care in Status Epilepticus and in Which ICU?

“…Should one therefore conclude from this study that there is no benefit to be gained from specialist intensive care in the management of SE, in contrast to what has been demonstrated in other acute neurological pathologies [4,5]?…”

“…Regarding the management modalities, the only significant difference related to continuous EEG monitoring, performed in 85 % of cases in NICU compared to 30 % in MICU. The higher rate of intubation in MICU (72 %, compared to 48 % in NICU) was partially correlated with consciousness impairment.Should one therefore conclude from this study that there is no benefit to be gained from specialist intensive care in the management of SE, in contrast to what has been demonstrated in other acute neurological pathologies [4,5]?We are convinced that some SEs may benefit from a neurological ICU, even if the study of Varelas et al failed …”

Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

“…Knopf [2012] studied 2,096 AIS patients and found that those treated in an NICU or by a neurologic critical care specialist had lower in-hospital mortality, better discharge disposition, and shorter hospital LOS compared to controls. [17].…”

“…Knopf [2012] studied 2,096 AIS patients and found that those treated in an NICU or by a neurologic critical care specialist had lower in-hospital mortality, better discharge disposition, and shorter hospital LOS compared to controls. [17]. Similarly, Varelas [2008] performed a prospective analysis of 433 AIS patients, 259 of which were admitted after a NCC service had been put in place.…”

Residency Training: The role of neurocritical care in resident education

“…A growing body of literature supports that patients with traumatic brain injuries, 6 ischemic strokes, 7 intracerebral hemorrhages, 8 and subarachnoid hemorrhages 9 all have better outcomes and shorter hospital stay when treated by physicians with neurocritical care training. In an effort to disseminate the knowledge of basic neurocritical care competencies, the Neurocritical Care Society developed the Emergency Neurological Life Support course, with the same guiding principles of the Advanced Cardiac Life Support training.…”