Clinicians and researchers are calling for a paradigm shift.
In a typical day, a neurocritical care team will see a dozen patients: older patients who have suffered strokes, people with subarachnoid hemorrhages, younger patients with traumatic brain injuries as well as post-operative brain tumor patients of any age. Routine care involves bedside procedures such as inserting central venous catheter lines and arterial lines, endotracheal intubation, intracranial pressure monitoring and critical care ultrasounds.
In the best-case scenario, these neurocritical care patients, who are at risk for irreversible neurological injury or brain death, will be out of the neurological intensive care unit (Neuro ICU) in a matter of days.
Yet in more severe cases, critical care patients will stay in the Neuro ICU for an extended period, and each additional day brings new challenges to neurosurgeons and neurointensivists charged with their care.
“Taking care of patients in the neurological intensive care unit is hard enough on its own but becomes more challenging if they are there for longer periods of time,” says Dr. Stephan Mayer, director of neurocritical care and emergency neurological services at Westchester Medical Center. “Long-term Neuro ICU stays present a unique set of problems with a higher risk of complications.”
Admission to the Neuro ICU can range from a few days to multiple weeks depending on the patient’s progress and disease state. For example, a 2013 study by Witiw et al. found that patients with aneurysmal subarachnoid hemorrhage had a mean length of stay in the Neuro ICU of 12.6 days for which they required neurocritical care.
A 2021 study by Loggini et al. showed that critical care patients with spontaneous intracerebral hemorrhage typically stayed in the Neuro ICU for 8 days.
In a study by Lazaridis et al., the mean ICU length of stay for 438 severe traumatic brain injury patients was 19 days, and those with lower Glasgow Coma scores and mass lesions upon admission stayed upwards of 30 days.
“With long-term patients in the Neuro ICU, you are trying to address multiple problems at the same time,” says Dr. Jefferson W. Chen, director of neurotrauma in neurological surgery at the University of California, Irvine. “Resolving their brain issues is made trickier by other potential problems, such as failing pulmonary function, infectious diseases, nutrition and hydration concerns and deep vein thrombosis.”
According to Dr. Mayer and Dr. Chen, the length of stay in the Neuro ICU is generally dictated by disease state and progression, types of injuries, intensity of treatments, required therapies, management of comorbidities and complications, secondary traumas, and other factors influencing how long a patient needs neurocritical care services.
One of the biggest contributing factors to longer Neuro ICU stays is a patient’s characteristics at the time of admission. Factors such as multiple traumas and the critical care patient’s response to treatment can extend the length of time a patient spends in the Neuro ICU. A 2006 study by Gruenberg et al. found that other important factors include advanced age, illness severity and prior substance abuse history.
Dr. Chen and Dr. Mayer point out that specific disease states often contribute to longer stays in the Neuro ICU.
Neurocritical Care for Traumatic Brain Injury (TBI)
“By day five in the ICU for a TBI, you are still dealing with increased intracranial pressure, so you are focused on treating it while potentially dealing with other problems like nutrition,” says Dr. Chen. A patient with TBI may stay in the Neuro ICU for a week or longer because of the risk of secondary brain injury, hypoxia and hypotension.
Dr. Mayer shares that acute stroke usually requires resuscitation and close monitoring to prevent secondary injuries and clinical deterioration, with most stays in the Neuro ICU lasting 7 to 20 days. A longer stay in the Neuro ICU allows for physiological monitoring and treatment of complications. Ongoing assessments in neurocritical care include airway management such as endotracheal intubation, maintaining arterial blood pressure and cerebral perfusion pressure, intracranial pressure monitoring, nutrition, intravenous fluid management and other therapies.
An aneurysmal subarachnoid hemorrhage has an average Neuro ICU stay of 12.6 days.
Subarachnoid hemorrhage requires a longer neurocritical care for monitoring, management of complications, prevention of clinical deterioration and treatment.
Managing the condition also includes maintaining adequate arterial blood pressure, controlling seizures and preventing secondary brain damage.
Intracerebral Hemorrhage (ICH)
In a cross-sectional, single-center, retrospective analysis of spontaneous ICH patients over an 8-year period, almost a third of the patients were in the Neuro ICU for longer than 8 days.2 Intracerebral hemorrhage requires ongoing monitoring as part of neurocritical care to determine if aggressive treatment is necessary, such as when elevated intracranial pressure occurs. As acute deterioration can happen in 30% to 60% of ICH patients, monitoring is important.
Read our special report to learn how other neurosurgeons view the unique set of challenges of these long-term patients as well as opportunities to optimize how these patients are managed.