RESIDENT & FELLOW SECTION Emerging Subspecialties in Neurology: Section Editor Neurocritical care Mitchell S.V. Elkind, MD, MS Asma Zakaria, MD Historically, neurology has been a primarily out- the competing interests of neurointensivists with J. Javier Provencio, patient specialty.1 The advent of modern neuro- neurosurgeons, neurologists, and other intensive MD surgical techniques, as well as more elegant care physicians. This has resulted in several dif- George A. Lopez, MD, means of artificial ventilation in the 1960s, ferent institution-dependent types of NICU PhD brought increasing numbers of neurologic pa- practices. tients to the intensive care units (ICU). Although The NICU consult service involves a team of these patients were primarily managed by medical neurointensivists who provide consultation ser- Address correspondence and and surgical–anesthesiologist intensivists, occa- vices to neurosurgical and medical ICU patients. reprint requests to Dr. Asma sional consults for neurophysiologic testing, man- Zakaria, Baylor College of The primary anesthetist/medical intensivist han- Medicine, Department of agement of neuromuscular failure, and, more dles ventilator management and invasive moni- Neurology, 6501 Fannin Street, commonly, prognostication, would bring neurol- NB 302, Houston, TX 77030 toring procedures. [email protected] ogists to the ICU. In the 1980s and 1990s, the The open NICU is probably the commonest surge in new neurosurgical procedures and ad- arrangement. This involves a neurointensivist vances in cardiovascular disease spurred on the who has admitting privileges in a NICU but is not development of a newer, different subset of neu- responsible for all patients in the NICU. Neuro- rologist. Some developed an interest in cerebro- surgeons may admit directly to the NICU and vascular diseases, while others ventured into the consult other medical intensivists to care for ven- ICUs and carved a niche for a new subspecialty: tilated patients. neurocritical care. The closed NICU is the model in which all pa- A small number of neurologists, anesthesiolo- tients admitted to the NICU are primarily man- gists, neurosurgeons, and medical intensivists aged by the neurointensivist. Upon discharge aimed to identify and correct the factors that were from the NICU, they are attended to by the neu- contributing to the high mortality rates in neuro- rology or neurosurgical ward teams. Some units logic intensive care units (NICUs). Through the also take care of non-neurologic ICU spillover pa- 1980s and 1990s, four major centers of NICU tients. Most procedures are handled by the NICU training emerged. These centers were headed by team. Dr. Allan Ropper at Massachusetts General Hos- The closed-cooperative NICU model is one in pital, Dr. Matthew Fink at Columbia University, which the neurology/neurosurgery service contin- Dr. Thomas Bleck at University of Virginia at ues to have an active role in the management of Charlottesville, and Dr. Dan Hanley at Johns patients in the NICU (particularly in regard to Hopkins.2 These “Four fathers”3 of neurocritical family discussions and longer-term management care in the United States have trained numerous decisions). The NICU team handles day to day fellows who then went on to run their own ICUs issues, however, and is responsible for most across the country. procedures. THE PRACTICE OF NEUROCRITICAL CARE Neurology residency programs are required to TODAY Today, neurocritical care is a more estab- have “discrete rotations in critical care”4 where lished subspecialty and fellowships are awaiting residents learn to manage patients with neuro- United Council for Neurologic Subspecialties logic complications of medical diseases, intracere- (UCNS) accreditation within the next year. How- bral hemorrhages, malignant cerebral infarctions, ever, this has not been an easy course. Many neu- status epilepticus, and neuromuscular respiratory rointensivists have faced challenges in part due to failure. With the advent of modern neurosurgical From the Department of Neurology (A.Z., G.A.L.), Baylor College of Medicine, Houston, TX; and Cleveland Clinic Foundation (J.J.P.), Cleveland, OH. Disclosure: The authors report no conflicts of interest. e68 Copyright © 2008 by AAN Enterprises, Inc. and neurointerventional radiology procedures, a who enjoy procedures, there are ample opportu- newer face of neurology is emerging. Many resi- nities to insert arterial and central venous cathe- dents graduating from training programs today ters, ventriculostomies, endotracheal tubes, and are not exposed to this subspecialty because of the invasive and noninvasive monitoring devices.5 apparent nationwide dearth of NICUs. According The proposed curriculum for neurocritical to the “Neurologists 2004”1 report by the Ameri- care training programs submitted to UCNS is a can Academy of Neurology (AAN), only 11.6% comprehensive mix of neurologic, medical, and of neurologists participate in some capacity in surgical ICU training. The defined fellowship will critical care and 42% in stroke management. be 2 years in duration6 and include at least 1 year There was no clarification of the type or extent of of ICU rotations and approximately 6 months of critical care exposure. The vast majority of neu- research. The first set of board certification ex- rologists (80%) continue to pursue primarily out- aminations was administered in December 2007. patient careers. The steady growth in the number Additional information regarding job and fel- of adequately staffed NICUs has not matched the lowship opportunities, and the Neurocritical overwhelming demand for specialists in this field Care Society, can be obtained at www.neurocriti- across the country. Similarly, new fellowship pro- calcare.org and www.aan.com/students/awards/ grams emerge every year, and although the num- fel_res.cfm. ber of neurology applicants increases with each Neurocritical care serves as a meeting ground academic year, this is not enough to fill all posi- for neurosurgery, neurointerventional radiology, tions and is far from fulfilling the national de- neurology, stroke, and airway management and mand. Although no statistics exist to support this the intensivist is a crucial mediator in patient care contention, it appears that several neurointensiv- by all of these services. There remains a shortage ist positions remain unfilled every year. While of well-staffed NICUs across the nation and fur- some of this may be attributed to the type of ap- ther efforts should be made by residency pro- plicants neurology residencies attract (most, per- grams, the AAN, and the Neurocritical Care haps, being interested in outpatient careers), this Society to encourage trainees to consider this as trend may also reflect the curricula of training an attractive professional choice. programs in general. It is essential that program directors and the Accreditation Council for Grad- ACKNOWLEDGMENT uate Medical Education (ACGME) incorporate The authors thank Irfan Lalani, MD, for assistance with this article. rotations such as critical care into neurology resi- dency requirements in order to provide a more REFERENCES rounded training experience as well as to increase 1. Henry K, et al. Neurologists 2004: AAN Member De- mographic and Practice Characteristics. In: AAN Pub- exposure and interest in this field. lications. Available at: www.aan.com/publications/ other/index.cfm. Accessed November 25, 2006. FELLOWSHIP TRAINING IN NEUROCRITICAL 2. Rowland Lewis P. A new book evokes memories of the CARE Neurocritical care as a fellowship and a early days of the Neuro-ICU. Neurology Today No- career has much to offer clinicians as well as sci- vember 2005;5:37. entists. We are still learning the mechanisms of 3. Chang C. Society keynote address 1. Past, Present and cerebral perfusion and how they are disrupted in Future: Perspectives of Neurocritical Care. Synchronic- the setting of hemorrhages, ischemic strokes, and ity Meeting in Baltimore, MD. Neurocritical Care revascularization therapies. We have several 2006. 4. AAN Core Curricula. Residency Core Curriculum: monitoring devices available, but we are still Critical Care and Emergency Neurology. Available at: learning their application in clinical medicine. In www.aan.com. Accessed March 6, 2007. addition, we are still looking for new therapies, 5. Core Curriculum and Core Competencies in Neurolog- reviving old ones (e.g., decompressive craniec- ical Intensive Care. UCNS Documents: Appendix A. tomy, induced hypothermia), and refining them Available at: www.neurocriticalcare.org. Accessed No- to improve patient outcomes. This brings forth a vember 25, 2006. 6. Mayer SA. UCNS Update: Setting New Standards for large uncharted territory for both clinical and Neurocritical Care Training and Certification. Cur- bench research as well as for clinicians who are rents. Newsletter of the Neurocritical Care Society interested in developing guidelines and practice Vol. 1:2. Available at: www.neurocriticalcare.org. Ac- parameters for future application. For physicians cessed: November 25, 2006. Neurology 70 April 29, 2008 e69 Emerging Subspecialties in Neurology: Neurocritical care Asma Zakaria, J. Javier Provencio and George A. Lopez Neurology 2008;70;e68-e69 DOI 10.1212/01.wnl.0000310991.31184.c9 This information is current as of April 28, 2008 Updated Information & including high resolution figures, can be found at: Services http://n.neurology.org/content/70/18/e68.full References This article cites 1 articles, 0 of which you can access