Intensive Care Med (2023) 49:987–990
https://doi.org/10.1007/s00134-023-07150-4
RECENT ADVANCES IN ICU
Neurological diseases in intensive care
Virginia Newcombe1,2,3* , Susanne Muehlschlegel4 and Romain Sonneville5,6
© 2023 Springer-Verlag GmbH Germany, part of Springer Nature
Acute neurological diseases represent a wide spectrum of performed a rigorous systematic review and meta-anal-
illnesses that frequently require care in the intensive care ysis of 26 studies and found a decreased risk of mortal-
unit (ICU). Their ICU management is highly complex, ity and poor functional outcomes in adults with brain
combining supportive care, and interventions to pre- injury when looked after by specialized neurocritical care
vent secondary brain injury and promote recovery. This staff [1]. It is unknown whether discrete interventions,
requires close collaboration between neurologists, neu- for example structured monitoring and prevention of
rosurgeons, critical care specialists, and other members delirium by trained nursing and other staff, or the over-
of the multi-disciplinary team to provide comprehensive all package of care, including advanced neuromonitoring,
and coordinated care to patients. are most important. The high volume of neurologically
Prognostication of patients with acute neurological dis- unwell patients may also lead to familiarity with their
eases remains challenging, especially regarding decisions needs, improved knowledge of current best evidence,
of withdrawal of life-sustaining therapy (WLST), because and/or higher accuracy at predicting good functional
of a perceived poor neurological prognosis with a high outcomes potentially providing less nihilistic care com-
degree of long-term disability. Given the significant long- pared with other physicians [2]. However, there are many
term consequences and costs of neurological diseases other potential causes of the differences in outcome
from many different aetiologies, continued optimisation between different models of care, and the optimum care
of care is of paramount importance to improve outcomes. model is not known.
Here, we explore five important recent articles in this An improved understanding of how to monitor, neuro-
area and their broader context that have been chosen protect, and manage brain health may help improve out-
not only as they may influence practice but also raise comes for all ICU survivors. Impairments in cognitive,
important issues to consider when caring for critically ill mental health, and physical domains (Post Intensive Care
patients with neurological diseases (Fig. 1). We discuss Syndrome) occur frequently after critical illness regard-
some of the challenges and controversies that surround less of the initial disease leading to admission. It is strik-
the management of these complex patients and highlight ing that the most complex organ in the body, the brain,
areas where further research is needed to improve care is often the least monitored in critical care. The increas-
pathways and outcomes. ing availability of non-invasive neuromonitoring options
offers great opportunity for the transfer of neurocritical
The black box of neurocritical care: is it effective? care concepts into general critical care. Better knowledge
There is considerable variation in the way services are of when to start, how, and the dose of rehabilitation may
structured to look after patients with neurocritical ill- be important to improve long-term cognitive impairment
nesses with dedicated neurocritical care units commonly in ICU survivors [3, 4].
existing throughout Europe and United States of America
but are less common elsewhere. Pham and colleagues Heterogeneity of care and what can we learn
from it
*Correspondence: [email protected]
Raised intracranial pressure (ICP) after acute brain injury
1
University Division of Anaesthesia, PACE Section, Department is associated with poorer outcomes, and ICP-guided
of Medicine, University of Cambridge, Addenbrooke’s Hospital, Hills Road, management is recommended to help guide manage-
Box 93, Cambridge CB2 OQQ, UK
Full author information is available at the end of the article
ment of severe traumatic brain injury (TBI) in many
guidelines [5]. A recent prospective cohort study of 146
988
Fig. 1 Schematic of where the discussed recent articles (themes in blue and red boxes) fit in the patient care pathway
intensive care units in 42 countries (SYNAPSE-ICU) of Impact of early interventions on long‑term
patients with an acute brain injury due to hemorrhagic outcomes
stroke or traumatic brain injury found that the use of Existing prognostication models for a variety of neu-
intracranial pressure (ICP) monitoring and management rological emergencies only include admission charac-
varies greatly [6]. The use of ICP monitoring was asso- teristics. Yet, an improved understanding of the acute
ciated with a more intensive therapeutic approach and trajectory, response to interventions, timing of reliable
with lower 6 months mortality in more severe patients. prognostication, and trajectory of recovery are key to
This heterogeneity was also seen in the Global Neuro- improving outcomes after neurocritical illness. A post
trauma Outcomes Study (57 countries) [7]. Fewer than hoc analysis of two trials of patients with high-severity
1 in 5 patients with severe TBI had intracranial pres- intracerebral hemorrhage (ICH) found that hospital
sure monitoring, and only ~ 25% were admitted to criti- events including ICH and intraventricular hemorrhage
cal care indicating significant mismatch between severity volume reduction, prevention of systemic complications,
of illness and critical care availability. ICP monitoring and cerebral ischemic injury were significantly associ-
enables the burden of intracranial hypertension to be ated with long-term functional recovery [9]. The results
assessed and treated, the maintenance of adequate cer- suggest that prevention of hypoperfusion is more critical
ebral perfusion pressure, and assessment of cerebral than presence of intracranial hypertension, which raises
autoregulation. These are important to understand the two important questions. First, how fast and aggressive to
pathophysiology and to guide and optimise individual be with blood pressure reduction to prevent haematoma
patient management [8]. Understanding the variation via progression, and second, could invasive or non-invasive
comparative effectiveness research is important to iden- brain oxygenation monitoring guided management help
tify and encourage best practices that could improve care to prevent secondary ischemia. Additionally, this paper
in different contexts. shows that too early outcome prognostication using only
989
validated admission predictors is less accurate compared recently published guidelines on neuroprognostication
to prognostication at a later time point incorporating after cardiac arrest examining in detail the reliability of
events or complications that arise within the first 30 days individual factors and prognostication scales influence
of intracerebral hemorrhage, in addition to the known clinical practice [16]. Machine learning/artificial intel-
admission predictors of outcome. ligence algorithms, potentially taking into account the
temporal progress of a patient and large amounts of data,
Side effects of medical treatments/unexpected trial may offer improved ways to prognosticate in the future.
results Further research in this area, including validation and
Medical interventions in neurocritical care can be both how best to implement such algorithms in clinical path-
beneficial and harmful. Steroids are commonly used in ways, is required.
many acute neurological conditions to reduce oedema
and inflammation at the acute phase. However, their Author details
impact on functional recovery and long-term outcomes is 1
University Division of Anaesthesia, PACE Section, Department of Medicine,
unknown. A recent randomized placebo-controlled trial University of Cambridge, Addenbrooke’s Hospital, Hills Road, Box 93, Cam-
bridge CB2 OQQ, UK. 2 Neurosciences and Trauma Critical Care Unit (NCCU),
conducted in patients with symptomatic chronic sub- Addenbrooke’s Hospital, Cambridge, UK. 3 Emergency Department, Adden-
dural haematoma found that treatment with dexametha- brooke’s Hospital, Cambridge, UK. 4 Departments of Neurology, Anesthesiol-
sone resulted in fewer favourable outcomes and more ogy/Critical Care and Surgery, University of Massachusetts Chan Medical
School, Worcester, MA, USA. 5 Université Paris Cité, INSERM UMR1148, Team 6,
adverse events than placebo at 6 months, despite fewer 75018 Paris, France. 6 Department of Intensive Care Medicine, AP-HP, Hôpital
repeat operations were performed in the dexamethasone Bichat-Claude Bernard, 75018 Paris, France.
group [10]. Of note, the risk of any site infection was six-
Funding
fold higher in the intervention group as compared to the VFJN is supported by a National Institute for Health and Care Research (NIHR)
placebo group. Other adverse events associated with dex- Advanced Fellowship and holds grants with NIHR, Brain Research UK and
amethasone included endocrine disorders and psychiat- Roche Pharmaceuticals. SM is supported by the National Institutes of Health
grants R21NR020231, U01NS099046, and U01NS119647. RS received grants
ric disorders up to day 30 after randomization. Careful from the French Ministry of Health, and LFB.
patient stratification and selection for future trials will be
important avenues of research to improve outcomes and Data availability
There is no data to make available.
avoid with unacceptable side-effects.
Publisher’s Note
Neurological prognostication Springer Nature remains neutral with regard to jurisdictional claims in pub-
Prognostication of the long-term outcome of neurocriti- lished maps and institutional affiliations.
cally ill patients remains challenging, especially regard-
Received: 8 May 2023 Accepted: 22 June 2023
ing decisions of WLST, because of a perceived poor Published: 10 July 2023
neurologic prognosis. However, three important recent
studies, in intracerebral haemorrhage [9] and traumatic
brain injury [11, 12], demonstrate that recovery may take References
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