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Neurocritical Care and Emergency Neurology: Current Evidence and Consensus Practice.

Prior to this publication, Seminars in Respiratory and Critical Care Medicine has never had an entire issue dedicated to the topic of neurocritical care. While the past few decades have seen enormous growth in the number of dedicated neuroscience intensive care units (neuro-ICUs) staffed with fellowship-trained and board-certified neurointensivists, many intensivists care for patients with neurologic disease in general medical and surgical critical care settings. This issue, “Advancements in Neurocritical Care and Emergency Neurology,” is meant to summarize the scientific literature and practice consensus regarding management for several classic diseases found in neuro-ICUs, as well as to highlight several important unique considerations in the critical care management of brain-injured patients in general. The first three articles of this issue focus on issues in emergency neurology, as outcomes for brain-injured patients can often be profoundly influenced by management decisions even before ICU admission. A common mantra in acute ischemic stroke management is “time is brain.” With this mantra in mind, Bowry and Grotta summarize the recent rise of mobile stroke units—ambulances with the capability for computed tomography (CT) scanning, laboratory testing, telemedicine connections to hospitals, and medication administration. First, created in Germany, these units are now increasingly being tested in the U.S. cities for their impact on clinical outcomes. While blood pressure goals for ischemic stroke patients receiving intravenous tissue plasminogen activator (tPA) have been standard formany years, proper blood pressuremanagement for ischemic stroke patients receiving endovascular therapy and patients with acute intracerebral hemorrhage (ICH) are less well understood. Ko and Yoon review the current evidence on these topics in detail. Finally, again with the philosophy of “time is brain” in mind, Fuh et al summarize current practices for rapid reversal of anticoagulation for patients with ICH, including a discussion of four-factor prothrombin complex concentrates and evolving strategies for ICH patients receiving novel oral anticoagulants. The following three articles in this issue delve deeply intomajor neurovascular diseases cared for in neuro-ICUs: hemispheric ischemic stroke, spontaneous intraventricular hemorrhage (IVH), and aneurysmal subarachnoid hemorrhage (aSAH). Landreneau and Sheth discuss the state of the evidence for decompressive craniectomy for patients with large middle cerebral artery infarction. Decisions to pursue surgery for these patients aremade on a case-by-case basis, but recent data regarding outcomes in older patientsmay help inform these discussions. Similarly, relatively recent trial data may help guide clinicians who may be considering use of intraventricular fibrinolysis via external ventricular drain(s) to treat patients presenting with spontaneous IVH; Abdelmalik and Ziai discuss the general approach to the subset of ICH patients with IVH and the further subset who might benefit from a trial of intraventricular tPA. Admittedly, scientifically proven advancements in the prevention of delayed cerebral ischemia seen inpatientswith aSAHhavebeenhard to comeby, as enteral nimodipine remains the only provenmedical therapy to impact clinical outcome in these patients. However, Diringer and Zazulia summarize what has been tried to date and David Y. Hwang, MD, FNCS