Seminars in Neurology最新文献

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Highly educated and skilled nursing care is critical to improving patient outcomes in general and in specialties like neurocritical care. Nursing interventions reflect nursing knowledge, critical thinking, and decision-making and is generally rooted in the nursing process. Nursing interventions are also a key focus of research to better understand how nursing care influences patient outcomes. This review describes the literature regarding nursing interventions in key neurocritical diagnoses and contextualizes it within the broader discussion about the nursing process and nursing interventions research. Publications about nursing interventions in neurocritical care emphasize key themes, including managing neurophysiologic parameters, providing psychosocial support, managing the environmental milieu, and interventions to prevent complications. Further study of how to best support nurses in collecting and interpreting data to form nursing interventions is needed, as is understanding the benefits and limitations of the nursing process in low- and middle-income countries.

Spontaneous intracerebral hemorrhage (ICH) is the most morbid of all stroke types with a high early mortality and significant early disability burden. Traditionally, outcome assessments after ICH have mirrored those of acute ischemic stroke, with 3 months post-ICH being considered a standard time point in most clinical trials, observational studies, and clinical practice. At this time point, the majority of ICH survivors remain with moderate to severe functional disability. However, emerging data suggest that recovery after ICH occurs over a more protracted course and requires longer periods of follow-up, with more than 40% of ICH survivors with initial severe disability improving to partial or complete functional independence over 1 year. Multiple other domains of recovery impact ICH survivors including cognition, mood, and health-related quality of life, all of which remain under studied in ICH. To further complicate the picture, the most important driver of mortality after ICH is early withdrawal of life-sustaining therapies, before initiation of treatment and evaluating effects of prolonged supportive care, influenced by early pessimistic prognostication based on baseline severity factors and prognostication biases. Thus, our understanding of the true natural history of ICH recovery remains limited. This review summarizes the existing literature on outcome trajectories in functional and nonfunctional domains, describes limitations in current prognostication practices, and highlights areas of uncertainty that warrant further research.

When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.

This review delves into updates in management of large hemispheric infarction (LHI), a condition affecting up to 10% of patients with supratentorial strokes. While traditional management paradigms have endured, recent strides in research have revolutionized the approach to acute therapies, monitoring, and treatment. Notably, advancements in triage methodologies and the application of both pharmacological and mechanical abortive procedures have reshaped the acute care trajectory for patients with LHI. Moreover, ongoing endeavors have sought to refine strategies for the optimal surveillance and mitigation of complications, notably space-occupying mass effect, which can ensue in the aftermath of LHI. By amalgamating contemporary guidelines with cutting-edge clinical trial findings, this review offers a comprehensive exploration of the current landscape of acute and ongoing patient care for LHI, illuminating the evolving strategies that underpin effective management in this critical clinical domain.

The burden of neurological disease disproportionately affects low- and middle-income countries, where the lowest number of neurologists are located. Building local training opportunities in resource-limited settings is a foundational step to enhancing the neurological workforce and improving access to neurological care in these regions. In this article, we describe the development and growth of the first neurology residency program in East Africa, which was established in 2006 at Zewditu Memorial Hospital and the Tikur Anbessa Specialized Hospital, Addis Ababa University, Ethiopia. We highlight the impact of the program on clinical care, research, collaborations between neurologists across Ethiopia, and ways to build educational opportunities and mentorship while faced with limited resources. The main challenges in starting the residency program included lack of faculty with neurological expertise, lack of a precedent for subspecialty training in our setting, as well as limited resources and space. The formation of sustainable international collaborations with clinicians at established institutions in high-income countries and neurological societies has been a major source of support in developing the initial infrastructure, curriculum and educational content, knowledge assessments, and mentored research projects. Local partnerships with related medical specialties, including internal medicine, critical care, neurological surgery, and psychiatry, were also instrumental in creating training opportunities. As the program continues to evolve, many challenges remain, including limited diagnostics, lack of access to advanced treatment modalities, lack of fellowship training opportunities in various neurological subspecialties, and insufficient training and experience in scientific writing. Despite these challenges, the residency program has persevered and its creation resulted in many positive changes: since its inception in 2006, we graduated 80 neurologists and the number of practicing neurologists in Ethiopia has increased from 5 to 78, our institution has evolved into a national referral center for neurology, graduates have published 61 articles in the past 3 years and contributed to international neurology research, and alumni of the program have grown the Association of Ethiopian Neurologists. Future directions include development of fellowship opportunities, creation of international rotations, and implementation of teleneurology to further strengthen neurological care across Ethiopia.

The Curing Coma Campaign (CCC) and its contributing collaborators identified multiple key areas of knowledge and research gaps in coma and disorders of consciousness (DoC). This step was a crucial effort and essential to prioritize future educational and research efforts. These key areas include defining categories of DoC, assessing DoC using multimodal approach (e.g., behavioral assessment tools, advanced neuroimaging studies), discussing optimal clinical trials' design and exploring computational models to conduct clinical trials in patients with DoC, and establishing common data elements to standardize data collection. Other key areas focused on creating coma care registry and educating clinicians and patients and promoting awareness of DoC to improve care in patients with DoC. The ongoing efforts in these key areas are discussed.

Posttraumatic epilepsy (PTE) is a complication of traumatic brain injury that can increase morbidity, but predicting which patients may develop PTE remains a challenge. Much work has been done to identify a variety of risk factors and biomarkers, or a combination thereof, for patients at highest risk of PTE. However, several issues have hampered progress toward fully adapted PTE models. Such issues include the need for models that are well-validated, cost-effective, and account for competing outcomes like death. Additionally, while an accurate PTE prediction model can provide quantitative prognostic information, how such information is communicated to inform shared decision-making and treatment strategies requires consideration of an individual patient's clinical trajectory and unique values, especially given the current absence of direct anti-epileptogenic treatments. Future work exploring approaches integrating individualized communication of prediction model results are needed.