Continuum, Critical Care Neurology, June 2009, Volume 15, Issue 3

Withholding aggressive treatments and withdrawing life-support measures are common in patients with devastating acute brain injury. Yet, guiding families who make these decisions is often very challenging. Ethical questions arise when the level of care requested by the family does not agree with the prognosis estimated by the clinician. There is also concern that communicating a pessimistic prognosis to families might produce a self-fulfilling prophecy by leading to restriction of intensive care. Understanding the limitations of our prognostic information and the factors that influence the decision to withhold or withdraw care in the neurologic intensive care unit is crucial to ensure honest and effective communication with families.(C) 2009 American Academy of Neurology

A wide variety of neurologic disorders cause acute generalized weakness precipitating hospital admission and neurologic evaluation; serious dysfunction of the neuromuscular system also occurs in critically ill patients in the intensive care unit. Respiratory muscles are commonly affected in either case, leading to hypoventilation, hypercapnic respiratory failure, and the need for (or prolongation of) mechanical ventilation (MV). Closely monitoring patients with neuromuscular weakness is critical in recognizing early signs of respiratory failure and guiding the need for prompt ventilatory support; patients may also need to be intubated for airway protection. While intubated, these patients are at high risk for complications such as pneumonia that contribute to mortality. The proper recognition of the underlying neuromuscular disorder allows appropriate management and discussion of prognosis, including weaning from MV. Selective use of ancillary testing, such as EMG and nerve/muscle biopsy, may help when the clinical diagnosis is unclear and further assist with estimating recovery.(C) 2009 American Academy of Neurology

Fever in the neurocritical care setting is very common and has a negative impact on outcome of all disease types. Meta-analyses have demonstrated that fever at onset and in the acute setting after ischemic brain injury, intracerebral hemorrhage, and cardiac arrest has a negative impact on morbidity and mortality. Data support that the impact of fever is sustained for longer durations after subarachnoid hemorrhage and traumatic brain injury. Recent advances have made eliminating fever and maintaining normothermia feasible. However, currently no prospective randomized trials demonstrate the benefit of fever control in these patient populations, and important questions regarding indications and timing remain. The purpose of this chapter is to analyze the data surrounding the impact of fever across a range of neurologic injuries to better understand the optimal timing and duration of fever control. Prospective randomized trials are needed to determine whether the beneficial impact of secondary injury prevention is outweighed by the potential risks of prolonged fever control.(C) 2009 American Academy of Neurology

Compared to ischemic stroke, intracerebral hemorrhage (ICH) has higher mortality and worse morbidity. Unfortunately, we still lack a primary treatment for ICH. Promising trials using recombinant activated factor VII (rFVIIa) to prevent hematoma expansion have not yielded consistent improvement in outcome, and a large multicenter surgical trial failed to show benefit. Thus, management focuses on supportive care, including management of blood pressure, intraventricular hemorrhage, glucose, and fever.This chapter summarizes the trials of rFVIIa and surgery and provides an update on the issues surrounding the management of hypertension, intraventricular hemorrhage, glucose, and fever. Recent work on the impact of antiplatelet agents and statins on the incidence and severity of ICH is reviewed, and some new considerations regarding defining prognosis and limiting care are discussed.(C) 2009 American Academy of Neurology