Neurocritical Care Research Research Articles

Variations in the management of pediatric cerebral vasospasm.

Pediatric cerebral vasospasm (PCV) is associated with aneurysmal subarachnoid hemorrhage (aSAH), but aSAH is uncommon in children. No universal guidelines exist for PCV management. The authors sought to assess variations in practice patterns in pediatric aSAH and PCV management. A REDCap survey was circulated by the AANS/CNS Pediatric Section and the Pediatric Neurocritical Care Research Group assessing PCV management practices. A total of 58 responses were received. The proportion of responses received from each region ranged from 19% in the Northeast to 28% in the Midwest. Of all respondents, 88% reported practicing at academic institutions. Neurosurgeons constituted 79% of respondents, and intensivists 17%; 85% primarily managed children. Most providers treated 1-3 aSAHs annually and a minority (21%) reported protocolized aSAH management at their centers. PCV prevention used permissive hypertension (90%), chemoprophylaxis (86%), and strict fluid-volume management (83%). PCV was typically assessed using serial neurological examination (60%) and transcranial Doppler (TCD) studies (72%). Treatment of PCV included permissive hypertension (50%) and endovascular interventions (81% intraarterial verapamil, 35% nitroprusside, and 67% angioplasty). Balloon angioplasty was more common than stent retriever-plasty. Pediatric PCV is rare and primarily treated by specialists at academic institutions. Although some elements of management are commonly used, wide variability exists in the strategies used for PCV prevention, detection, and treatment. Management strategies for pediatric PCV may be extrapolations from adult paradigms, but standardized guidelines are lacking. Prioritization should be given to the development of such guidance to enable the development of more robust evidence-based practices in the future.

Transcranial volumetric imaging using a conformal ultrasound patch.

Accurate and continuous monitoring of cerebral blood flow is valuable for clinical neurocritical care and fundamental neurovascular research. Transcranial Doppler (TCD) ultrasonography is a widely used non-invasive method for evaluating cerebral blood flow1, but the conventional rigid design severely limits the measurement accuracy of the complex three-dimensional (3D) vascular networks and the practicality for prolonged recording2. Here we report a conformal ultrasound patch for hands-free volumetric imaging and continuous monitoring of cerebral blood flow. The 2 MHz ultrasound waves reduce the attenuation and phase aberration caused by the skull, and the copper mesh shielding layer provides conformal contact to the skin while improving the signal-to-noise ratio by 5 dB. Ultrafast ultrasound imaging based on diverging waves can accurately render the circle of Willis in 3D and minimize human errors during examinations. Focused ultrasound waves allow the recording of blood flow spectra at selected locations continuously. The high accuracy of the conformal ultrasound patch was confirmed in comparison with a conventional TCD probe on 36 participants, showing a mean difference and standard deviation of difference as -1.51 ± 4.34 cm s-1, -0.84 ± 3.06 cm s-1 and -0.50 ± 2.55 cm s-1 for peak systolic velocity, mean flow velocity, and end diastolic velocity, respectively. The measurement success rate was 70.6%, compared with 75.3% for a conventional TCD probe. Furthermore, we demonstrate continuous blood flow spectra during different interventions and identify cascades of intracranial B waves during drowsiness within 4 h of recording.

The Spectrum of Quantitative EEG Utilization Across North America: A Cross-Sectional Survey

BackgroundContinuous electroencephalography (cEEG) is commonly used for neuromonitoring in pediatric intensive care units (PICU); however, there are barriers to real-time interpretation of EEG data. Quantitative EEG (qEEG) transforms the EEG signal into time-compressed graphs, which can be displayed at the bedside. A survey was designed to understand current PICU qEEG use. MethodsAn electronic survey was sent to the Pediatric Neurocritical Care Research Group and Pediatric Status Epilepticus Research Group, and intensivists in 16 Canadian PICUs. Questions addressed demographics, qEEG acquisition and storage, clinical use, and education. ResultsFifty respondents from 39 institutions completed the survey (response rate 53% [39 of 74 institutions]), 76% (37 of 50) from the United States and 24% (12 of 50) from Canada. Over half of the institutions (22 of 39 [56%]) utilize qEEG in their ICUs. qEEG use was associated with having a neurocritical care (NCC) service, ≥200 NCC consults/year, ≥1500 ICU admissions/year, and ≥4 ICU EEGs/day (P < 0.05 for all). Nearly all users (92% [24 of 26]) endorsed that qEEG enhanced care of children with acute neurological injury. Lack of training in qEEG was identified as a common barrier [85% (22 of 26)]. Reviewing and reporting of qEEG was not standard at most institutions. Training was required by 14% (three of 22) of institutions, and 32% (seven of 22) had established curricula. ConclusionsICU qEEG was used at more than half of the institutions surveyed, but review, reporting, and application of this tool remained highly variable. Although providers identify qEEG as a useful tool in patient management, further studies are needed to define clinically meaningful pediatric trends, standardize reporting, and enhance educate bedside providers.

A Virtual Community of Practice: An International Educational Series in Pediatric Neurocritical Care.

Pediatric neurocritical care (PNCC) is a rapidly growing field. Challenges posed by the COVID-19 pandemic on trainee exposure to educational opportunities involving direct patient care led to the creative solutions for virtual education supported by guiding organizations such as the Pediatric Neurocritical Care Research Group (PNCRG). Our objective is to describe the creation of an international, peer-reviewed, online PNCC educational series targeting medical trainees and faculty. More than 1600 members of departments such as pediatrics, pediatric critical care, and child neurology hailing from 75 countries across six continents have participated in this series over a 10-month period. We created an online educational channel in PNCC with over 2500 views to date and over 130 followers. This framework could serve as a roadmap for other institutions and specialties seeking to address the ongoing problems of textbook obsolescence relating to the rapid acceleration in knowledge acquisition, as well as those seeking to create new educational content that offers opportunities for an interactive, global audience. Through the creation of a virtual community of practice, we have created an international forum for pediatric healthcare providers to share and learn specialized expertise and best practices to advance global pediatric health.

A Survey of Neuromonitoring Practices in North American Pediatric Intensive Care Units

BackgroundNeuromonitoring is the use of continuous measures of brain physiology to detect clinically important events in real-time. Neuromonitoring devices can be invasive or non-invasive and are typically used on patients with acute brain injury or at high risk for brain injury. The goal of this study was to characterize neuromonitoring infrastructure and practices in North American pediatric intensive care units (PICUs). MethodsAn electronic, web-based survey was distributed to 70 North American institutions participating in the Pediatric Neurocritical Care Research Group. Questions related to the clinical use of neuromonitoring devices, integrative multimodality neuromonitoring capabilities, and neuromonitoring infrastructure were included. Survey results were presented using descriptive statistics. ResultsThe survey was completed by faculty at 74% (52 of 70) of institutions. All 52 institutions measure intracranial pressure and have electroencephalography capability, whereas 87% (45 of 52) use near-infrared spectroscopy and 40% (21/52) use transcranial Doppler. Individual patient monitoring decisions were driven by institutional protocols and collaboration between critical care, neurology, and neurosurgery attendings. Reported device utilization varied by brain injury etiology. Only 15% (eight of 52) of institutions utilized a multimodality neuromonitoring platform to integrate and synchronize data from multiple devices. A database of neuromonitoring patients was maintained at 35% (18 of 52) of institutions. Funding for neuromonitoring programs was variable with contributions from hospitals (19%, 10 of 52), private donations (12%, six of 52), and research funds (12%, six of 52), although 73% (40 of 52) have no dedicated funds. ConclusionsNeuromonitoring indications, devices, and infrastructure vary by institution in North American pediatric critical care units. Noninvasive modalities were utilized more liberally, although not uniformly, than invasive monitoring. Further studies are needed to standardize the acquisition, interpretation, and reporting of clinical neuromonitoring data, and to determine whether neuromonitoring systems impact neurological outcomes.

Unanswered questions in neonates with NE

This issue is the second of two volumes edited on behalf of the Newborn Brain Society, which discuss neonatal encephalopathy (NE), an area of significant importance for clinical practice and research in neonatal neurocritical care. This second issue discusses unanswered questions about NE. Birth asphyxia remains a significant global problem, accounting for almost one-quarter of all neonatal deaths [1]. While research is ongoing to improve the care of neonates with NE, many questions remained unanswered.

The European Academy of Neurology COVID-19 registry (ENERGY): an international instrument for surveillance of neurological complications in patients with COVID-19.

The COVID‐19 pandemic is a global public health issue. Neurological complications have been reported in up to one‐third of affected cases, but their distribution varies significantly in terms of prevalence, incidence and phenotypical characteristics. Variability can be mostly explained by the differing sources of cases (hospital vs. community‐based), the accuracy of the diagnostic approach and the interpretation of the patients’ complaints. Moreover, after recovering, patients can still experience neurological symptoms. To obtain a more precise picture of the neurological manifestations and outcome of the COVID‐19 infection, an international registry (ENERGY) has been created by the European Academy of Neurology in collaboration with European national neurological societies and the Neurocritical Care Society and Research Network. ENERGY can be implemented as a stand‐alone instrument for patients with suspected or confirmed COVID‐19 and neurological findings or as an addendum to an existing registry not targeting neurological symptoms. Data are also collected to study the impact of neurological symptoms and neurological complications on outcomes. The variables included in the registry have been selected in the interests of most countries, to favour pooling with data from other sources and to facilitate data collection even in resource‐poor countries. Included are adults with suspected or confirmed COVID‐19 infection, ascertained through neurological consultation, and providing informed consent. Key demographic and clinical findings are collected at registration. Patients are followed up to 12 months in search of incident neurological manifestations. As of 19 August, 254 centres from 69 countries and four continents have made requests to join the study.

Genetic Variation and Response to Neurocritical Illness: a Powerful Approach to Identify Novel Pathophysiological Mechanisms and Therapeutic Targets.

Disease-specific therapeutic options for critically ill neurological patients are limited. The identification of new preventive, therapeutic, and rehabilitation strategies is of the utmost importance in the field of neurocritical care research. Population genetics offers powerful tools to identify and prioritize biological pathways to be targeted by novel interventions. New treatments with supportive genetic evidence have twice the chances of obtaining final FDA approval compared to those without this support. Large collaborations, public access to data, reproducible science, and innovative analytical methods have exponentially increased the pace of discoveries related to neurocritical care genetics.

Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers.

The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. Electronic-mail recruitment with survey of expert centers using web-based questionnaire. Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. None. None. A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.

The Future of Neurocritical Care Research: Proceedings and Recommendations from the Fifth Neurocritical Care Research Network Conference.

The Fifth Neurocritical Care Research Network (NCRN) Conference held in Boca Raton, Florida, in September of 2018 was devoted to challenging the current status quo and examining the role of the Neurocritical Care Society (NCS) in driving the science and research of neurocritical care. The aim of this in-person meeting was to set the agenda for the NCS's Neurocritical Care Research Central, which is the overall research arm of the society. Prior to the meeting, all 103 participants received educational content (book and seminar) on the 'Blue Ocean Strategy®,' a concept from the business world which aims to identify undiscovered and uncontested market space, and to brainstorm innovative ideas and methods with which to address current challenges in neurocritical care research. Three five-member working groups met at least four times by teleconference prior to the in-person meeting to prepare answers to a set of questions using the Blue Ocean Strategy concept as a platform. At the Fifth NCRN Conference, these groups presented to a five-member jury and all attendees for open discussion. The jury then developed a set of recommendations for NCS to consider in order to move neurocritical care research forward. We have summarized the topics discussed at the conference and put forward recommendations for the future direction of the NCRN and neurocritical care research in general.

PICU-Based Rehabilitation and Outcomes Assessment: A Survey of Pediatric Critical Care Physicians.

Characterize current practices for PICU-based rehabilitation, and physician perceptions and attitudes, barriers, resources, and outcome assessment in contemporary PICU settings. International, self-administered, quantitative, cross-sectional survey. Online survey distributed from March 2017 to April 2017. Pediatric critical care physicians who subscribed to email distribution lists of the Pediatric Acute Lung Injury and Sepsis Investigators, the Pediatric Neurocritical Care Research Group, or the Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment study group, and visitors to the World Federation of Pediatric Intensive and Critical Care Societies website. None. Of the 170 subjects who began the survey, 148 completed it. Of those who completed the optional respondent information, most reported working in an academic medical setting and were located in the United States. The main findings were 1) a large majority of PICU physicians reported working in institutions with no guidelines for PICU-based rehabilitation, but expressed interest in developing and implementing such guidelines; 2) despite this lack of guidelines, an overwhelming majority of respondents reported that their current practices would involve consultation of multiple rehabilitation services for each case example provided; 3) PICU physicians believed that additional research evidence is needed to determine efficacy and optimal implementation of PICU-based rehabilitation; 4) PICU physicians reported significant barriers to implementation of PICU-based rehabilitation across centers; and 5) low routine assessment of long-term functional outcomes of PICU patients, although some centers have developed multidisciplinary follow-up programs. Physicians lack PICU-based rehabilitation guidelines despite great interest and current practices involving a high degree of PICU-based rehabilitation consultation. Data are needed to identify best practices and necessary resources in the delivery of ICU-based multidisciplinary rehabilitation and long-term functional outcomes assessment to optimize recovery of children and families affected by critical illness.

A Bibliometric Analysis of the Most Cited Articles in Neurocritical Care Research.

Bibliometric analyses may indicate the most active journals, authors, countries, institutions and specialties by evaluating the most cited articles in a given research field. To the authors' knowledge, there is no bibliometric analysis regarding neurocritical care research. Thus, the aim of this study is to analyze and to provide a scope of the current scientific production in this area. The 100 most cited articles in the neurocritical care research were retrieved from the research "(neurocritical) AND (care)" in the Scopus database. The variables collected and included in this analysis were: number of citations, article title, first author's name, year and journal of publication and its impact factor (IF), specialty, affiliation and country of the corresponding author at the time of publication, and category of the article. Also, these variables were assessed for primary research only. The articles were published in 34 different journals from 1995 to 2017, with a mean citation number of 109.36, ranging from 44 to 540. Neurocritical Care (23 articles in top 100 and 2190 citations, IF = 3.163) and Critical Care Medicine (20 articles and 2896 citations in top 100, IF = 6.630) were the journals with the greatest number of articles and citations, respectively. Neurocritical Care also had the highest number of primary research papers (15 articles, accounting for 850 citations). Excepting one article from Asia (Singapore) and one from Oceania (Australia), all the other 98 papers were from North America (67) or Europe (31). United States was the country with most articles (60, 35 primary research) and citations (6115) among the top 100. Columbia University (11 articles, being 7 primary research, and 915 citations) was the institution with the highest number of articles and primary research articles in top 100, whereas University of Heidelberg (6 articles and 1220 citations) was the most cited institution. Neurology was the specialty with the greatest number of publications in top 100 and the most cited one (57 articles and 5983 citations). The first author with the greatest number of publications as well as primary research articles was A. I. Qureshi (5 articles, being 4 primary research, and 660 citations), while the most cited was K. H. Polderman (2 articles and 749 citations). Fifty-nine publications were primary and 41 secondary research. Among primary research, treatment/management was the most frequent and most cited topics (33 articles and 4172 citations). To the authors' knowledge, this is the first bibliometric analysis regarding neurocritical care research. Our findings suggest that the neurocritical care research field is more prominent in North America and Europe, more frequently published in specific critical care journals and after 1994. The most discussed topic was related to treatment and/or management within neurocritical care.

Medical Device Connectivity Challenges Outline the Technical Requirements and Standards For Promoting Big Data Research and Personalized Medicine in Neurocritical Care.

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.

Imaging in Neurocritical Care Practice.

The use of neuroimaging in conjunction with serial neurological examinations is a core component of modern neurocritical care practice. Although there is a growing role for other neuromonitoring techniques, the ability to quickly and accurately interpret images in the context of a patient's clinical status arguably remains the indispensable skill for neurocritical care practitioners. Due to its rapid acquisition time and excellent ability to detect intracerebral hemorrhage (ICH), cerebral edema, and signs of elevated intracranial pressure, computed tomography (CT) remains the most useful neuroimaging technique for intensive care unit (ICU) patients. An emergent head CT is obtained to inform most time-sensitive decisions that arise in the neurological ICU (NICU). CT features also figure prominently in prognostic scores for common NICU conditions such as traumatic brain injury (TBI), ICH, and subarachnoid hemorrhage (SAH). Among patients who are sufficiently stable to leave the ICU and lie flat for an extended period, magnetic resonance imaging provides much more detailed, high-contrast images which can aid in the detection of ischemia, diffuse axonal injury, and neuroprognostication. Though primarily used in neurocritical care research, nuclear medicine imaging techniques have some clinical applications, particularly in ancillary testing for brain death. Finally, as in the field of critical care as a whole, formal and point-of-care ultrasound studies are increasingly utilized in the NICU, and are an important tool in the neurointensivist's armamentarium. We review here the common applications of imaging in the neurocritical care setting. As ICU patients are frequently unstable and their risk of clinical decompensation increases substantially during transport away from the ICU, guidelines and recommendations for maximizing patient safety during transport to radiology studies are also explored.

Management of External Ventricular Drains After Subarachnoid Hemorrhage: A Multi-Institutional Survey.

Patients with aneurysmal subarachnoid hemorrhage (SAH) often develop hydrocephalus requiring an external ventricular drain (EVD). The best available evidence suggests that a rapid EVD wean and intermittent CSF drainage is safe, reduces complications, and shortens ICU and hospital length of stay as compared to a gradual wean and continuous drainage. However, optimal EVD management remains controversial and the baseline practice among neurological ICUs is unclear. Therefore, we sought to determine current institutional practices of EVD management for patients with aneurysmal SAH. An e-mail survey was sent to attending intensivists and neurosurgeons from 72 neurocritical care units that are registered with the Neurocritical Care Research Network or have been previously associated with the existing literature on the management of EVDs in critically ill patients. Only one response was counted per institution. There were 45 out of 72 institutional responses (63%). The majority of responding institutions (80%) had a single predominant EVD management approach. Of these, 78% favored a gradual EVD weaning strategy. For unsecured aneurysms, 81% kept the EVD continuously open and 19% used intermittent drainage. For secured aneurysms, 94% kept the EVD continuously open and 6% used intermittent drainage. Among continuously drained patients, the EVD was leveled at 18 (unsecured) and 11cm H2O (secured) (p<0.0001). When accounting for whether the EVD strategy was to enhance or minimize CSF drainage, there was a significant difference in the management of unsecured versus secured aneurysms with 42% using an enhance drainage approach in unsecured patients and 92% using an enhance drainage approach in secured patients (p<0.0001). Most institutions utilize a single predominant EVD management approach, with a consensus toward a continuously open EVD to enhance CSF drainage in secured aneurysm patients coupled with a gradual weaning strategy. This finding is surprising given that the best available evidence suggests that the opposite approach is safe and can reduce ICU and hospital length of stay. We recommend a critical reassessment of the approach to the management of EVDs. Given the potential impact on patient outcomes and length of stay, more research needs to be done to reach a threshold for practice change, ideally via multicenter and randomized trials.

Global monitoring in the neurocritical care unit.

Effective methods of monitoring the status of patients with neurological injuries began with non-invasive observations and evolved during the past several decades to include more invasive monitoring tools and physiologic measures. The monitoring paradigm continues to evolve, this time back toward the use of less invasive tools. In parallel, the science of monitoring began with the global assessment of the patient's neurological condition, evolved to focus on regional monitoring techniques, and with the advent of enhanced computing capabilities is now moving back to focus on global monitoring. The purpose of this session of the Second Neurocritical Care Research Conference was to collaboratively develop a comprehensive understanding of the state of the science for global brain monitoring and to identify research priorities for intracranial pressure monitoring, neuroimaging, and neuro-electrophysiology monitoring.

Regional brain monitoring in the neurocritical care unit.

Regional multimodality monitoring has evolved over the last several years as a tool to understand the mechanisms of brain injury and brain function at the cellular level. Multimodality monitoring offers an important augmentation to the clinical exam and is especially useful in comatose neurocritical care patients. Cerebral microdialysis, brain tissue oxygen monitoring, and cerebral blood flow monitoring all offer insight into permutations in brain chemistry and function that occur in the context of brain injury. These tools may allow for development of individual therapeutic strategies that are mechanistically driven and goal-directed. We present a summary of the discussions that took place during the Second Neurocritical Care Research Conference regarding regional brain monitoring.

Multi-modality neuro-monitoring: conventional clinical trial design.

Multi-modal monitoring has become an integral part of neurointensive care. However, our approach is at this time neither standardized nor backed by data from randomized controlled trials. The goal of the second Neurocritical Care Research Conference was to discuss research priorities in multi-modal monitoring, what research tools are available, as well as the latest advances in clinical trial design. This section of the meeting was focused on how such a trial should be designed so as to maximize yield and avoid mistakes of the past.

Authors’ Response to Letter Neurocritical Care Research Networks—Pediatric Considerations

We thank Drs. Bell et al. for their thoughtful comments regarding the contributions of pediatrics to the formation of specialized research networks to advance and promote clinical investigations in important critical care disorders affecting children. We acknowledge the outstanding efforts that the pediatric critical care community has undertaken and the significant salutary effects they have had on patients. The First Neurocritical Care Research Conference was the initial step of the Neurocritical Care Society (NCS) to begin to address objectives and goals for research endeavors in neurocritical care. One of the main goals of the conference was the creation of the Neurocritical Care Research Network (NCRN) and this conference was attended largely by NCS members, who are specialists in adult neurocritical care. The fact that no pediatric research networks were mentioned in the manuscripts reflects the composition of the conference attendees and our expertise toward adult neurocritical care practice rather than a deliberate omission on our part. The summary statements presented in the Journal reflect the material presented and discussed at the symposium. We admire the organized pediatric research infrastructure. In addition, we realize that NCRN is a recent effort and at a very early organizational stage but aspire to rise to a similar standard achieved by PECARN, PALISI, and PNCRG. As we acknowledge the comments of Bell et al. regarding the lack of pediatric research focus in the first Neurocritical Care Research Conference, we also like to indicate that the NCS is committed to pediatric patients with the formation of a pediatric neurocritical care committee and the initiatives to train and certify pediatricians in the field of neurocritical care. We agree with Bell et al. that investigators caring for adults and children can and should work together to address mutual goals and achieve them in a more efficient manner. In fact, we invite them to become active members of NCS and NCRN. This study was conducted on behalf of the First Neurocritical Care Research Conference Participants.

Neurocritical Care Research Networks—Pediatric Considerations

To The Editor: We read the series of articles in the most recent edition of Neurocritical Care with great interest [1–3] regarding the utility of research networks for critical illnesses. We appreciate that specialized research networks for patients with critical neurological conditions are needed to advance the field, and we share the author’s view that collaborative efforts of a large number of individuals and institutions are essential to muster the forces necessary to carry out truly groundbreaking studies. We also believe that such studies must be properly designed, conducted, supported, and reported within the literature. However, we were disappointed that the contribution of pediatrics to the history of such networks, both funded through traditional sources and formed on an ad hoc basis, was omitted from the series of articles. One of the earliest examples of collaborative efforts in life-threatening diseases stems from the Children’s Oncology Group (COG). Founded in 1955, this group (now including 200 institutions and 7,500 collaborating investigators) has made major advances in decreasing the mortality rates from cancers of childhood [4, 5]. In 1986, the Eunice Kennedy Shriver National Institute of Child Health and Human Development initiated the Neonatal Research Network to conduct studies that would improve the health of newborn infants. Among other studies, this network has successfully determined that hypothermia is neuroprotective for children who suffer from perinatal asphyxia—leading to a global change in standards of care across the country [6–8]. In 2001, the Emergency Medical Services for Children Program awarded cooperative agreements to fund the Pediatric Emergency Care Applied Research Network (PECARN) to conduct multi-institutional research in the management of acute illnesses of children. One of their most influential studies to date involved the determination of a decision-rule for obtaining neurological imaging in children after traumatic brain injury (TBI) [9], and they continue to investigate the utility of progesterone after TBI and hypothermia after cardiac arrest. Most recently, the Collaborative Pediatric Critical Care Research Network (CPCCRN) was formed in 2005. This network, consisting of seven clinical sites, has established new outcome assessment tools for children after critical illness (the Functional Status Score) [10] and is actively working with PECARN to complete the therapeutic hypothermia after pediatric cardiac arrest (THAPCA) trials among other initiatives. In addition to these federally funded networks, several investigator-initiated networks have made significant contributions. As mentioned in the current report, the Canadian M. J. Bell (&) PNCRG, University of Pittsburgh, Pittsburgh, PA, USA e-mail: bellmj4@upmc.edu