Vascular Neurology/Neuro Critical Care

[IMGforNeuro]

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I wanted the views of med students considering neuro, residents and attendings on this forum on this issue.
A new Neurocritical care society was formed in 2002 by members of the AAN Section for Critical Care and Emergency Neurology. There is a new fellowship core curriculum in neurocritical care. They mention 'diagnostic and therapeutic procedures'. These include-
- continuous jugular bulb oximetric catheter
- lumbar drains
- placement of intracranial pressure monitors- fiberoptic, intraventricular, epidural
- General critical care procedures, Including but not limited to performance and analysis of blood gases, insertion of central venous or pulmonary arterial catheters, arterial lines, endotracheal intubation or ventilator management
The curriculum includes management of all neuro critical care problems including vascular and all critical care medicine as relevant to neuro. So neuro ICUs will not need internists with CCM specialisation.
http://www.aan.com/about/sections/fellowship/cri_car.pdf

I spoke to some people and they said that this is a way to increase the procedural domain of neurology. Many people do not want to practice the passive electrophysiology based neuro, so this opens another option.
Some vascular neuro fellowship directors are planning to combine it with neuro critical care. The fellows deal with all vascular dis and critical neuro and also manage neuro ICU including postoperative neurosurgical patients and neurotrauma. The AAN is also about to seek ACGME accreditation for this fellowship. Some people are of the view that there is a great shortage of neurointensivists, also because of shortage of neurosurgeons (because of malpractice liability issues). The vasc and neurocritical care experts will also share workload with neurosurgeons and take a lot of nonoperative work from neurosurgery. This subspeciality is intended to bridge EM, CCM, neurology and neurosurg.
Another view is that neurology is diversifying. Just like int med has subspecialities like cardio , GI ...nephro.. hemeonc...endocrine, rheumat ( in order of stress and procedural work) , similarly neurology is diversifying with vasc neuro, neurocritical care, epilepsy, movement disorders, MS...
What are your views on this subspeciality and its possible assimilation with vasc neurology?

 

[neurologist]

"Neurocritical care" = Being some neurosurgeon's scut monkey. No thanks. All ICU's should be run by CCM-trained internists with appropriate consultation as necessary. If I were an ICU patient I sure as hell wouldn't want some neurologist running the show when I went into sepsis/ARDS/multiorgan system failure; I don't care how much "neurocritical" training they may have.

 

[IMGforNeuro]

The fellowship focuses on critical aspect of neurologic disease which includes surgical as well as nonsurgical patients. Do you think that someone interested in vascular neurology fellowships should steer clear of neurocritical care?

 

[Mollaret]

"Neurocritical care" = Being some neurosurgeon's scut monkey. No thanks. All ICU's should be run by CCM-trained internists with appropriate consultation as necessary. If I were an ICU patient I sure as hell wouldn't want some neurologist running the show when I went into sepsis/ARDS/multiorgan system failure; I don't care how much "neurocritical" training they may have.

I think that you are misinformed our uninformed on this issue. Neurointensive care is a subspecialty of critical care. Intensivists not trained in neurocritical care just don't have the subspecialty knowledge to monitor and treat most patients with subarachnoid hemorrhage, malignant ischemic stroke syndromes, etc. If I had a difficult critical neurologic injury, I would want to be cared for in an institution with a neurointensive care unit.

 

[Mitogen79]

I'm all for the subspecialization of neurology. General neurology by itself is quite diverse; subspecialization will only add to the strength of the specialty as a whole. Neurological critical care with interventional procedures is the next logical step. As endovascular techniques are perfected, I see no reason why neurologists shouldn't be trained as interventionalists. Traditionally, neurology has always been thought of as a 'diagnostic' specialty that lacks few interventional options; this notion is slowly changing and I am looking forward to neurologists as being viewed as interventionalists.

Personally, another area I think neurology needs to expand further into is Neurological Oncology; though its a relatively new specialty, I see great potential for it as chemotherapy/radiation & immunotherapy are perfected. Ofcourse, wanting to go into Neuro-Oncology, has me a little biased, but to each his own.

vish~

 

[IMGforNeuro]

I agree with you Mitogen79.
With the expansion of medicine in neurologic disease, i think there is going to be reorganization of diseases treated by neurosurgeons and neurologists.
One contribution to neuro-oncology could be stereotaxy. I think stereotactic guided invasive procedures should be done by neurosurgeons, but non invasive procedures requiring stereotaxy could be added to the realm of neurologists. Like frameless stereotaxy and gamma knife for brain tumors. However stereotactic biopsies will be done by neurosurgeons. But i think this is still quite farfetched.There was a time when neurologists did invasive procedures as pneumoencephalography which is obsolete. They also did cerebral angiograms in those days, but lost this to radiologists. But may be things are moving on the same lines as cardiology.

 

[neurologist]

I think that you are misinformed our uninformed on this issue. Neurointensive care is a subspecialty of critical care. Intensivists not trained in neurocritical care just don't have the subspecialty knowledge to monitor and treat most patients with subarachnoid hemorrhage, malignant ischemic stroke syndromes, etc. If I had a difficult critical neurologic injury, I would want to be cared for in an institution with a neurointensive care unit.

I think it is you who are somewhat confused. Look at the requirements for neurocritical care fellowships: completion of a NEUROLOGY or NEUROSURGERY residency. While I completely agree with you that most intensivists coming out of a medical residency are somewhat lacking in neurologic expertise, by the same token, don't imagine that that 70 year old with a big infarct is going to have "just" a stroke; there will be plenty of non-neurologic comorbidity, and after 3 years of neurology residency, how much about general medical ICU care are you going to remember? Sure, you can learn how to float a swan line during your NCC fellowship, but that doesn't make you an expert in its use. I still think the role of the neurologist in the ICU should be strictly consultative.

By the way, is that really a picture of Mollaret? It looks more like Descartes, or maybe Moliere.

 

[neurologist]

I'm all for the subspecialization of neurology. General neurology by itself is quite diverse; subspecialization will only add to the strength of the specialty as a whole.

Subspecialization may "add to the strength of the specialty" in terms of research and development (and perhaps $$$), but does it really benefit the patient? I see very few patients with a single isolated neurologic problem -- comorbidity is the rule, not the exception. Do you really think we should scrap general neurology and instead have the patient go to Neurologist A for their migraines, Neurologist B for their epilepsy, Neurologist C for their peripheral neuropathy and Neurologist D for their lumbar radiculopathy? Especially when the treatment for all of those conditions has massive overlap potential (i.e., gabapentin/topiramate)? I agree that a few things (interventional, for instance, where you really need to focus on a procedure skill set to get really good) make sense to break into subspecialties, but out in the community the general neurologist is the best way to pull together all the threads and address the whole gamut of patient problems.

 

[IMGforNeuro]

General neurology does have an important role too.
But certain subspecialities need greater expertise and time commitment to learn and practice. Neurocritical care is one. Just like cardiologists have diversified into intervention and cardiac electrophys. Neuro needs diversification. The entire neuro could be too much to handle for a three yr residency (pgy2 to 4) and also to practice. Many faculty members i spoke to now , seem to favor subspecialization.

 

[neurologist]

Many faculty members i spoke to now , seem to favor subspecialization.

Well, sure they do -- that's why they're in academic medicine. They have some relatively narrow, possibly even obscure, area of interest that they want to perpetuate. Not that this is wrong in and of itself, but generalizing that to say that all neurology should be subspecialized is sort of like missing the forest because you can only see all the trees.

Another problem I have with subspecialization is that in many cases I see subspecialists as basically skimming the cream off the pot both in terms of patient mix and financially. Neither of these particularly benefit the patient or the neurologic community in general. For example, I am tired of sending patients to "sleep specialists" whose only real interest is doing the $2500 polysomnogram and then sending a report that basically says "Patient has sleep apnea, follow up with referring physician," or the pain clinic that does the $1000 epidural injections but offers no comprehensive pain evaluation or management recommendations. The subspecialist gets the bucks and the general neurologist and patient are left no better off in terms of patient management. Now, maybe this is just an anomaly of where I practice, but overall, I'm getting sort of annoyed by subspecialists.

Also, patients referred to subspecialists tend to be more "interesting" or unusual patients. It is crucial that all neurologists have exposure to a wide variety of both common and rare illness. Packing off the patient to a subspecialist takes that person out of the general care population and reduces the ability and incentive of the neurologist to continue learning and growing intellectually. If the career choice in neurology becomes microspecialization vs general neurology where all that is left is headache and vague back pain, what kind of incentive is anyone going to have to go into the field to begin with?

 

[Bonobo]

This is an interesting discussion regarding neurocritical care and its future. In my discussions that I've had with intensive care specialists (trained via pulmonary and critical care or through anesthesiology) each intensivist has said that they would certainly defer care of a critically ill neurological patient to the neurointensivist. I should note these specialists include some who have written one of the standard texts in critical care.

I should also note that the skills and training of a neurointensivist far extend beyond that of a traditional intensivist. One of the primary roles of a neurointensivist is to manage intracranial pressure--this is something that intensivists have admitted not having nearly enough experience with.

Though neurosurgery residency trains for neurocritical care, neurosurgeons that I have spoke with tell me that neurosurgeons will have to spend more time doing surgery and less neurocritical care. Thus, neurologists specializing in neurocritical care are actually in high demand right now--not by neurology departments but by neurosurgery departments! Of course, as for all of critical care, studies are now showing that dedicated neurointensivists are better for patient care than those who practice both neurosurgery and critical care.

Finally, regarding patient care, in situations of stroke, status epilepticus, or other dire neurological situations, I would prefer to have a specialist specifically trained to deal with these illness in my treatment than a general neurologist consulting with a general intensivist.

 

[neurologist]

neurosurgeons that I have spoke with tell me that neurosurgeons will have to spend more time doing surgery and less neurocritical care. Thus, neurologists specializing in neurocritical care are actually in high demand right now--not by neurology departments but by neurosurgery departments!

. . . . which brings us back full circle to what I said at the very start of this thread: neurocritical care = being some neurosurgeon's scut monkey. So now I will bow out of this one and let you all fight it out.

 

[IMGforNeuro]

I don't want to offend anyone, but trying to belittle a subspeciality because it takes away $$$ from general neurology is not a very good thing in my opinion.
According to experts neurocritical care will take care of many issues not dealt by neurosurgeons as ischemic stroke, epilepsy(acute), ICH (non surgical), coma ,GB syn, encephalopathy, etc apart from traumatic brain injury, SAH, acute hydrocephalus etc,etc. I read an article in pubmed which stated that most experts including current residents favor subspecialization, the only ones who don't are currently practicing gen neurologists. Having worked as a nsurg resident before, i don't see any reason why neurointensivists cannot handle this work. In this age of advancing medicine there is definitely going to be redistribution of turf. If you look in the past it has always happened. Neurosurgeons gave up lobotomy for schizophrenia because of good medical treatment. Functional neurosurgery has come up for intractable movement disorders. Stereotactic surgery for mesial temporal lobe surgery is said to be the best for intractable seizures and makes it more amenable to drug treatment. Neurology has become too big to be handled by general neurologists. This is after the 'decade of the brain'. Advances in medicine always lead to changes.

 

[IMGforNeuro]

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=pubmed&dopt=Abstract&list_uids=10668718
This is the article i mentioned in pubmed.

 

[Bonobo]

According to experts neurocritical care will take care of many issues not dealt by neurosurgeons as ischemic stroke, epilepsy(acute), ICH (non surgical), coma ,GB syn, encephalopathy, etc apart from traumatic brain injury, SAH, acute hydrocephalus etc,etc.

Thank you IMGforNeuro--I thought that this would be obvious, but I am glad it has been stated. I should note for those that are reading this forum that just like everywhere else, there is a high propensity for misinformation. The best information comes from those in the know: neurology, intensive care, and neurosurgery attendings.

 

[ashtraveler]

How competitive are these programs? What do they look at? Do you need to have a backup plan?

Someone told me that there are positions as a neurointensivist that do shift work. Any comments.

And if applying to a neuro residency what are good electives to take. I have one elective my 3rd year. 6 or so my 4th year.

thanks

 

[IMGforNeuro]

I don't know how competitive these fellowships are. But there are certain generalizations about vasc neuro/neurocritical care. These things are also common to neurosurgery (mainly cranial).
There is significant mortality/morbidity in this field (more than other fields with the possible exception of hemeonc), so it could have an emotional toll on the physician. It is stressful which also makes it challenging.
I feel if the physician loves this challenge and also loves the fact that he/she is involved in managing the most dangerous and critical diseases, then he will be motivated to carry on.
It is not like most fields in which the patient comes sick and leaves happily. Bad outcomes are common so managing 'end of life' issues is also an aspect. I personally feel that 'saving' these patients can be very gratifying.
However, it is adrenaline stimulating because of the acute nature of the neurologic illness and challenging and can be satisfying in a very different way.

 

[charcot]

I have been following the neurocritical care story for a while. As a resident having just completed my month of unit I can share some thoughts;

1. neurocritical care plays an important part in major academic centers and will generate enough internal funding to maintain subdivision status within larger neurology departments. In fact it may be one of the few remaining profitable areas in clinical neurology. this seems to be a growth period for the field but total number of spots in the country may be limited given the resources and patient load needed to fill such a unit.

2. neurocritical care seems to involve, to some extent, post-op, PACU type of work. The neurosurgeons will have quick turnover patients going through and the question is if they are willing to split some of the pie to have someone watch their sicker patients. About 25 percent of cases will be purely neurology diagnoses.

3. if you are interested in intubating, vent management, central line placement, and ICU concepts including ventilator associated pneumonia, elevated ICPs, sepsis, CHF, rapid Afib, and coma this may be the field for you. the hours are pretty involved, even at the attending level, but hte peopel who do it are action oriented and consider themselves more critical care docs than neurologists.

 

[Aspalgarry]

About 25 percent of cases will be purely neurology diagnoses ?

Why do a neurology training to later become a neurointensivist if most of the patients you will taking care off will be neurosurgical cases (75%) and pt's with medical complications. In that case you better do neurosurgery or critical care after internal medicine?

In that sense I agree with "Neurologist" you will be a neurosurgeon scut monkey because when things get out of hands Who is going to do the ventriculostomy?

I definitively agree with some specialization on neurology however neurointensive care does not make a lot of sense to me. At my institution the neurointesivist is a guy who started his tranining in neuroradiology but did not finished. Don't take me wrong but if your interest is to manage ventilators, treat ICU infections, and follow pt's after neurosurgery (75% of the cases) you are better on IM critical care or neurosurgery.

 

[Bonobo]

I am going to try to answer the question of why one should do neurology instead of neurosurgery or IM if one is interested in neurointensive care--primarily because this is precisely a decision that I have tried to make.

Regardingly neurosurgery, I think this is my answer: there will be a shortage of neurosurgeons in the future simply because neurosurgery departments cannot train enough residents to keep up with the demand. In this case, any department that hires you to their neurosurgery department will expect you to do enough surgical cases that you probably wouldn't have the time, energy, or desire to continue with neurointensive care. Tell me how many neurointensivists you know that are neurosurgery trained? Furthermore, you will need to acquire training in order to deal with the neurology cases in the neuro ICU. Neurosurgeons are not trained, for example, to deal with epilepsy or myasthenia gravis. Using neurosurgery to train to be a neurointensivist is not unlike going through cardiac surgery to become cardiac intesivist--it just isn't practical.

I think IM is good for learning to deal with the intensive care issues, but certainly does not provide as much training as neurology would in dealing with stroke patients--clearly the m.o. of neurointensive care. Again, every IM trained intensivists that I have spoken to agree that they would defer to neurointensivists for care of critical ill neurological patients.

The final point I would like to make is that in the future, the percentage of "purely neurological cases" will increase. As medical and interventional treatment of stroke improves, neurosurgery will become less involved--much like the case for MIs in cardiology. And finally, if one thinks that dealing with critical care issues is "scut", then you must be quite the physician; in many instances, I have seen surgeons hold the critical care physician with very high respect (including the neurosurgeons at my school who highly praise our neurointensivists here).

I think that it would be okay to choose IM, neurosurgery, anesthesiology or neurology if one were interested in neurointensive care. If you are interested in neurointensive care, then I would recommend choosing that path that best suits you.

 

[Yoyomama88]

Do NCC trained neurologists perform ventriculostomies?

 

[TUGM]

There are some programs that do train their fellows to do ventriculostomies... MUSC for example. In real life, I think it just depends on the individual attending's relationship with neurosurgery and their technical ability. I will do some research and try to find some additional examples of NCC programs that train fellows in performing ventriculostomies and placing the EVDs.

 

[typhoonegator]

Re: EVD training, some do it on an informal basis, fewer on a formal basis. You're essentially never going to do as many as the surgeons do, and it's one of those things that you want to have a lot of experience with to do well. Regardless of whether you train to do it, as an attending you won't find too many places willing to credential you to do it, as the neurosurgery department will probably need to sign off on it, and why would they want you taking their procedures away from them and leaving them to clean up your morbidities?

Sure, there are probably some places in the boonies that would love for you to do them, but when you royally screw one up and they need operative exploration to stop the cortical bleeder you can't reach, what are you going to do then?

 

[danielmd06]

For example, I am tired of sending patients to "sleep specialists" whose only real interest is doing the $2500 polysomnogram and then sending a report that basically says "Patient has sleep apnea, follow up with referring physician," or the pain clinic that does the $1000 epidural injections but offers no comprehensive pain evaluation or management recommendations.

The sleep people near you don't follow the patients, and get them PAP compliant? What do they do all day? Sit around and read sleep studies and go home? That's terrible.

 

[danielmd06]

Though neurosurgery residency trains for neurocritical care, neurosurgeons that I have spoke with tell me that neurosurgeons will have to spend more time doing surgery and less neurocritical care. Thus, neurologists specializing in neurocritical care are actually in high demand right now--not by neurology departments but by neurosurgery departments! Of course, as for all of critical care, studies are now showing that dedicated neurointensivists are better for patient care than those who practice both neurosurgery and critical care.

That's what the neurosurgeons where I trained actually wanted. It's easier for them and more financially efficient for them. They don't want to admit the patient to their service and do the paperwork or social work. They want to operate, make money, and as they say "cut and run." At least where I trained. Not trying to sound too cynical. Neurocritical care is an interesting subspecialty, I think.

 

[typhoonegator]

The idea that a neurosurgery residency "trains for neurocritical care" is extremely outdated. Aside from simple post-operative complications, most neurosurgeons outside of the dedicated few who have made NCC a priority can't manage much of anything, although that doesn't seem to stop them from trying at times. After their first year or two, they spend essentially all their time in the OR. And this is all fine with me -- surgeons should be trained to operate, and if they want to be intensivists, they should go to more school for it. It's not like a general surgery residency graduates attending level SICU providers, so the notion that NSG residencies somehow poop out serviceable intensivists is hubris. The body of literature required to perform evidence-based management in the neuroICU has gotten much larger since senior neurosurgeons trained, and while HHH therapy and neurotrauma management used to be in their purview, times have definitely changed. How the hell would a neurosurgeon know how to manage SE? They have no reason to.

NCC is RVU-dense, but not nearly as much as operating. Neurosurgeons may want to practice NCC for a lot of reasons, but financially it makes no sense. Many neurointensivists are being recruited by neurosurgery groups these days, and yes, they are in high demand to manage big post-op services so the patients can have good outcomes and the surgeons can keep operating.

 

[bustbones26]

The sleep people near you don't follow the patients, and get them PAP compliant? What do they do all day? Sit around and read sleep studies and go home? That's terrible.

Unfortunately, I have been in some environments where this is what the sleep specialist does. Fortunately, it has not been in most environments where I have worked.

 

[neurodoc]

Maybe this is a bit off-topic, but I think there is a good reason to have good general neurology training as a prerequisite for going into "neurocritical care." A general neurology residency or NS residency ought to qualify. In theory, a good IM residency ought also to qualify, but often doesn't...because of the way diagnosis is taught in general medicine. I'm thinking about the "neurologic method" of diagnosis, which depends on a thorough understanding functional neuroanatomy and being able to perform a good neurological H&P that allows one to answer two diagnostic questions: 1) Where is [are] the lesion; and, What is [are] the lesion?

In certain "neurocritical" situations, an accurate diagnosis is urgently essential. A good example is the management of acute ischemic stroke. We now have the ability to effectively intervene in acute ischemic stroke (using IV thrombolytics and more directed radiologically guided thrombolysis and angioplasty). These interventions have no become part of ACLS protocols, that are described, "cook-book" fashion in the AHA ACLS Guidelines.

One way that neurologists can contribute to the effective treatment of acute ischemic stroke is to clarify whether or not a patient is actually suffering from an ischemic stroke and determining "where" that stroke is coming from. This is quite important, mainly because thrombolysis is not without risk. You don't want to unnecessarily expose patients to that risk.

I can tell you that I have been asked to see patients for suspected stroke who I determined, after careful examination, to have had symptoms that were due to such things as Bell's Palsy, migraine, epilepsy, radiculopathy, vestibulopathy, and even Carpal Tunnel Syndrome... It would have been a mistake to expose these patients to the risks of thrombolysis. The ACLS protocols really don't eliminate the risk of misdiagnosis and potentially hazardous treatment. For example, these protocols require a "negative" CT scan of the brain...the rationale being that a "positive" CT (showing blood or an obvious infarct) would raise the risk of hemorrhage if thrombolytics were given. I've got no qualms with that, but the fact is that a "negative CT" (which we would expect in patients whose symptoms were due to the six "non-stroke" things I mentioned, could allow physicians to expose patients with those conditions to the considerable risks of thrombolysis, which would not be at all justifiable. This is where evaluation by an expert neurologist is needed.