Neurointensive care

Abstract

© Cambridge University Press 2011. Introduction Critical care medicine has evolved rapidly over the last two decades, with therapeutic and technological advances leading to improved outcome in a wide variety of life-threatening conditions. This is particularly the case for neurological disorders where improved understanding of the pathophysiology of neurological injury, in association with advances in monitoring and imaging techniques, has led to the introduction of more effective and individualized treatment strategies that have translated into improved outcomes. In parallel, neurointensive care has developed as a subspecialty of intensive care medicine dedicated to the treatment of critically ill patients with primary and secondary neurological disease. This chapter will review the history, evolution and organization of neurointensive care units and emphasize the key role that neurointensive care teams play in delivering improved outcomes for patients. The origins of neurointensive care date back to the poliomyelitis epidemics of the 1940s and 1950s when specialized teams established the principles of prolonged mechanical ventilation and high-intensity nursing support in dedicated wards. In the 1970s and 1980s, advances in neurosurgery and neuroanaesthesia allowed more complex interventions that brought the need for close monitoring and management in the post-operative period. Areas of neurosurgical wards, staffed by neurosurgical teams, became the early neurosurgical intensive care units (ICUs). Thereafter, neurointensive care expanded to include the management of patients with a broader range of neurological disorders such as traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), intracranial haemorrhage, elevated intracranial pressure (ICP), neuromuscular respiratory failure, status epilepticus and the medical complications of brain injury. The management of critically ill patients with neurosurgical and neurological disease were thus combined into a single specialist unit where neurointensivists, neurologists, neurosurgeons and their teams provide comprehensive management for complex and life-threatening disorders of the central nervous system (CNS). More recently, neurointensive care has embraced the management of conditions, such as acute ischaemic stroke, that were not traditionally seen as part of its role. Its primary challenge now is the resuscitation and treatment of patients with massive traumatic and vascular brain injuries that were previously assumed to be unsalvageable.