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Jose I. Suarez

recommended. 1 , 3 Neurocritical care is the newest subspecialty of critical care. The development of neurocritical care units stemmed from the notion that neurological and neurosurgical critically ill patients were better served in ICUs staffed by health-care personnel trained to recognize and treat intracranial processes as well as the systemic factors affecting them. Evidence from two recent studies supports the idea that the admission of patients to a neurocritical care unit staffed by a neurocritical care team is associated with reduced mortality rates and resource

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Robert H. Bonow, Christopher C. Young, David I. Bass, Anne Moore, and Michael R. Levitt

ultrasonography may demonstrate reverberant flow, with equal antegrade systolic and retrograde diastolic velocities indicating the absence of net forward flow; narrow low-velocity systolic spikes, consistent with flow cessation at the carotid siphon; and/or absence of intracranial flow in a patient where Doppler signals had previously been detected. 18 Two examinations separated by 30 minutes should be performed to confirm the diagnosis. 18 Conclusions The indications for TCD ultrasonography in neurological surgery and neurocritical care have expanded significantly since this

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Samon Tavakoli, Geoffrey Peitz, William Ares, Shaheryar Hafeez, and Ramesh Grandhi

patients treated for suspected VAI. 49 Furthermore, Harrop et al. described a prospective cohort study in which the introduction of AI-EVDs decreased the VAI rate from 8.2% to 1%. 28 Interestingly, the VAI rate increased to 7.6% when the institution reverted to standard catheters due to technical problems with the AI-EVDs; however, when the AI-EVDs were reintroduced, the VAI rate decreased to 0.9%. 28 Based on the available evidence and selected studies above, there seems to be a trend toward decreased rates of VAI with AI-EVDs. To this end, the 2016 Neurocritical Care

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Ariana S. Barkley, Laura J. Spece, Lia M. Barros, Robert H. Bonow, Ali Ravanpay, Richard Ellenbogen, Phearum Huoy, Try Thy, Seang Sothea, Sopheak Pak, James LoGerfo, and Abhijit V. Lele

with neuro-specialization. 13 The Neurocritical Care Society (NCS) has recently established standards for neurocritical care units (NCCUs). 10 However, these standards are based on HIC resources. LMIC health systems experience unique barriers to fulfilling these requirements based on their neurosurgical and neurocritical care capacity. 17 Evaluation of critical care capacity is not reflected in current instruments developed to assess surgical capacity, such as the World Health Organization Personnel, Infrastructure, Procedures, Equipment, Supplies (WHO PIPES

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Jian Guan, Michael Karsy, Andrea A. Brock, Ilyas M. Eli, Holly K. Ledyard, Gregory W. J. Hawryluk, and Min S. Park

vitamin D supplementation. 1 Vitamin D deficiency has also been shown to have an effect on immune, inflammatory, cardiac, and vascular functions, 17 including various neurological diseases such as stroke 8 , 34 and dementia. 23 Despite the important role of vitamin D, there have been no studies examining the impact of hypovitaminosis D in patients in specialized neurocritical care units (NCCUs). Given the significant differences in management of patients between NCCUs and more generalized ICUs, 20 there is a need for further inquiries into the impact of low vitamin

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Michael Karsy, Jian Guan, Ilyas Eli, Andrea A. Brock, Sarah T. Menacho, and Min S. Park

prevalence rates of low vitamin D as high as 80%–100% in select populations. 11 Work from our group previously suggested a potential for hypovitaminosis D to predict worse outcomes in neurocritical care patients. 6–8 To date, no randomized clinical trial specifically aimed at vitamin D replacement in this population has been performed. We hypothesized that vitamin D supplementation would result in a clinically meaningful, 2-day reduction in hospital length of stay (LOS) in the neurocritical care population. Methods Study Sample Institutional review board approval and a US

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Thomas P. Bleck

types of critical care units, but also must master many components of the neurological examination to a much greater degree of sophistication and precision. Despite all of our imaging and electrophysiological technologies, the neurocritical care nurse at the bedside is the most important monitor. Furthermore, he or she is the chemical engineer who manages most of the therapy as well as the psychologist and spiritual advisor for patients and families who often find themselves in the most dire straits of their lives. The nurse can also make sure that everyone in the

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Jian Guan, Michael Karsy, Andrea A. Brock, Ilyas M. Eli, Gabrielle M. Manton, Holly K. Ledyard, Gregory W. J. Hawryluk, and Min S. Park

-hospital mortality rate in a specialized neurocritical care unit (NCCU) suggest an association between vitamin D deficiency on admission and worse outcomes within this unique population. 8 Although the results of several studies also suggest that the effects of hypovitaminosis D on patient outcome extend beyond the hospitalization itself, 3 , 12 a paucity of data on the relationship between vitamin D status on admission and postdischarge outcomes in neurocritical care patients exists. We prospectively studied the association between hypovitaminosis D on admission and 3-month

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Michael F. Stiefel, Joshua D. Udoetuk, Alejandro M. Spiotta, Vicente H. Gracias, Aaron Goldberg, Eileen Maloney-Wilensky, Stephanie Bloom, and Peter D. Le Roux


Control of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is the foundation of traumatic brain injury (TBI) management. In this study, the authors examined whether conventional ICP- and CPP-guided neurocritical care ensures adequate brain tissue O2 in the first 6 hours after resuscitation.


Resuscitated patients with severe TBI (Glasgow Coma Scale score ≤ 8 and Injury Severity Scale score ≥ 16) who were admitted to a Level I trauma center and who underwent brain tissue O2 monitoring within 6 hours of injury were evaluated as part of a prospective observational database. Therapy was directed to maintain an ICP of 25 mm Hg or less and a CPP of 60 mm Hg or higher.

Data from a group of 25 patients that included 19 men and six women (mean age 39 ± 20 years) were examined. After resuscitation, ICP was 25 mm Hg or less in 84% and CPP was 60 mm Hg or greater in 88% of the patients. Brain O2 probes were allowed to stabilize; the initial brain tissue O2 level was 25 mm Hg or less in 68% of the patients, 20 mm Hg or less in 56%, and 10 mm Hg or less in 36%. Nearly one third (29%) of patients with ICP readings of 25 mm Hg or less and 27% with CPP levels of 60 mm Hg or greater had severe cerebral hypoxia (brain tissue O2 ≤10 mm Hg). Nineteen patients had both optimal ICP (≤25 mm Hg) and CPP (> 60 mm Hg); brain tissue O2 was 20 mm Hg or less in 47% and 10 mm Hg or less in 21% of these patients. The mortality rate was higher in patients with reduced brain tissue O2.


Brain resuscitation based on current neurocritical care standards (that is, control of ICP and CPP) does not prevent cerebral hypoxia in some patients. This finding may help explain why secondary neuronal injury occurs in some patients with adequate CPP and suggests that the definition of adequate brain resuscitation after TBI may need to be reconsidered.

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Aditya Vedantam, Claudia S. Robertson, and Shankar P. Gopinath

H ypernatremia has been shown to increase mortality in critically ill patients, independent of comorbidities. 5 , 13 , 14 , 17 Although the negative impact of hypernatremia is well described for patients treated in medical or surgical ICUs, 5 , 14 , 17 there is increased interest in the effects of hypernatremia in patients treated in neurocritical care units. 2 , 18 In particular, few studies have evaluated the independent effect of hypernatremia on mortality after severe traumatic brain injury (TBI). 6 , 15 The relationship between hypernatremia and TBI is