Admission to neurological intensive care: who, when, and why?

The majority of neurologists work in district general or teaching hospitals with large general intensive care units (ICUs). In this setting, ICUs require an increasing input from neurologists, especially with regard to the assessment of hypoxic brain damage and the neurological complications of organ failure, critical illness, and sepsis. In contrast, dedicated neurological intensive care units (NICUs) tend to deal largely with a different population of patients. Such units are primarily concerned with the management of primary encephalopathic patients, the control of raised intracranial pressure (ICP), the management of ventilatory, autonomic, and bulbar insufficiency, and the consequences of profound neuromuscular weakness. This role encompasses the treatment of mechanical ventilatory failure, specific treatments (both medical and surgical) and general medical complications of these disorders. In general, NICU patients with primary neurological diseases such as myasthenia gravis, Guillain-Barré syndrome, central nervous system infections, status epilepticus, and stroke have a better outcome than those patients with secondary neurological disease seen on general ICUs. However, such patients remain dependent on ICU support for very much longer periods of time. This results in very significant psychological demands on the patients, their carers, the nurses, physicians, and other health care professionals. In this review we will consider the rationale for managing acute neurological conditions in a dedicated NICU environment.