Neurocritical Care and Emergency Neurology

Kevin N. Sheth, MD, FAHA, FCCM, FNCS, FAAN, FANA

Just under 100 years ago, mechanical ventilators breathed to life and rescued from certain death patients who were stricken with a neurologic illness. Polio and myasthenia gravis, “grave weaknesses,” were founding illnesses that gave rise to an entire field of critical care medicine. Today, almost every neurology and neurosurgery department in major U.S. hospitals, including private hospitals, has assembled a critical care neurology team. A system of scholarly pursuit, formal fellowship training, and a dedicated journal represent only a few of the landmarks in this emerging field. The practice and art of critical care neurology resides professionally in the members of the Neurocritical Care Society, an international multidisciplinary body with lasting ties to sister organizations in the neurosciences.

A palpable energy chronicles the progress in this rapidly changing area of neurology, not simply because of improved organization, but because of the exciting scientific advances that are translated into improved health for patients. Inquiry does not recognize any arbitrary border. Critical care neurology is not the study of disease, it is a practice. Our patients' lives change when their illnesses first strike, whether at home or at work. The consequences endure long after they leave the intensive care unit. And so we clinicians and investigators who care about acute and devastating neurologic injury explore the basic underpinnings of brain swelling and discover ion channels, define what it means to be dead, and explore how and why we make the decisions we make. Strokes, seizures, brain tumors, paralysis, and spinal cord disorders are all critical care diseases, and because they are, research and clinical efforts facilitate collaboration across disciplines, whether in the emergency room, during recovery, or in the endovascular suite or operating room.

The resulting complexity, for practitioners, is fertile ground for those who wish to diagnose, treat, advance, and care for patients with often life-altering diseases. The resulting environment is one that is dynamic and facilitates change, both good and bad. The bond between and among caregivers and patients and families is one that is often sudden but intimate. It is not surprising that some of our best trainees are drawn to this exciting area of clinical neurology. Survival rates are increasing, there are increasing therapeutic options, and systems of care are increasingly consistent and ubiquitous. Yet challenges remain and suffering is too common. This is why humility is one of the most-required traits of the successful practitioner.

Many of these themes are reflected in this issue of Seminars. It has been a privilege for me to assemble a group of leading clinicians who are not only models for me, but who also push our existing limits. We are always hypothesis testing at the bedside, and in doing so, learning, teaching, and practicing neuroscience and medicine. In an already complex environment, every passing week requires interpretation of increasingly sophisticated technology; in the years to come, this trend is very likely to continue. This progress is juxtaposed with the requirement that we continue to ask the most essential questions in critical care neurology: Why is my patient not able to wake up? How do I make that assessment?

It used to be asked often of neurologists, and certainly of those treating acute neurologic injury: Why pursue a career in an area of medicine with so much morbidity and so little to offer? Indeed, I believe that where we have little to offer we have great opportunity for progress. At the same time, as neurology has been transformed by significant therapeutic advances, so has critical care neurology. Increasing numbers of device and pharmaceutical interventional trials occur in the neuroscience intensive care unit. This increased interest, even in the form of “negative” studies, is likely to be a prologue to interventions that will work in our lifetime. To be a participant often feels like a gift.

I personally am privileged, both in my own practice and in the assembly of this volume, to collaborate and learn from thoughtful colleagues who approach their writing and their service deliberately. I thank the contributors to this volume of Seminars for their participation and efforts for a magnificent series.