Future of neurocritical care:Integrating neurophysics,multimodal monitoring,and machine learning

Multimodal monitoring(MMM)in the intensive care unit(ICU)has become increasingly sophisticated with the integration of neurophysical principles.However,the challenge remains to select and interpret the most appropriate combination of neuromonitoring modalities to optimize patient outcomes.This manuscript reviewed current neuromonitoring tools,focusing on intracranial pressure,cerebral electrical activity,metabolism,and invasive and noninvasive autoregulation moni-toring.In addition,the integration of advanced machine learning and data science tools within the ICU were discussed.Invasive monitoring includes analysis of intracranial pressure waveforms,jugular venous oximetry,monitoring of brain tissue oxygenation,thermal diffusion flowmetry,electrocorticography,depth electroencephalography,and cerebral microdialysis.Noninvasive measures include transcranial Doppler,tympanic membrane displacement,near-infrared spectroscopy,optic nerve sheath diameter,positron emission tomography,and systemic hemodynamic monitoring including heart rate variability analysis.The neurophysical basis and clinical relevance of each method within the ICU setting were examined.Machine learning algorithms have shown promise by helping to analyze and interpret data in real time from continuous MMM tools,helping clinicians make more accurate and timely decisions.These algorithms can integrate diverse data streams to generate predictive models for patient outcomes and optimize treatment strategies.MMM,grounded in neurophysics,offers a more nuanced understanding of cerebral physiology and disease in the ICU.Although each modality has its strengths and limitations,its integrated use,especially in combination with machine learning algorithms,can offer invaluable information for individualized patient care.

Approaches to neuroprotection in pediatric neurocritical care

Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit.After primary neurologic insults,there may be cerebral brain tissue that remains at risk of secondary insults,which can lead to worsening neurologic injury and unfavorable outcomes.A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children.This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes.Here,we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.

Neurocritical Care Training for the Neurosurgery Resident

Introduction: Recent data has associated favorable outcomes in patients who were treated in a “semi-closed” intensive care unit and attended to by a devoted team of neurointensivists as opposed to the neurosurgeons. This has led many to question the need for dedicated critical care education in the neurosurgical residency training program. Our aim was to determine what current neurosurgery residents and program directors/chairman thoughts were on NCC education in neurosurgical resident training, and to discuss possible methods to allow for collaboration between the NCC team and the neurosurgeons. Methods: Surveys were sent out electronically to all residency programs. Thirty-nine responses from junior residents, 36 responses from senior/chief residents, and eight responses from program directors/chairman were obtained. Results: No statistical difference between the majority responses of the different level residents, and between program directors/chairman and combined resident responses. Conclusions: Clearly, neurosurgery residents of all levels and program directors/chairman value NCC education and see a valuable role for this knowledge in their future. Most residents however do not want to spend an additional year of fellowship training to become certified neurointensivists. We discuss the role of NCC education in residency training and possible solutions to allow collaboration between the NCC team and the neurosurgical team.

Stroke:Evolution of newer treatment modalities for acute ischemic stroke

Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide.Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes.However,there has been a paradigm shift in the management approach over the last decade,and with the emphasis currently directed toward including newer modalities such as neuroprotection,stem cell treatment,magnetic stimulation,anti-apoptotic drugs,delayed recanali-zation,and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.

An overview of neurocritical care in China： a nationwide survey

Background Little quantitative evidence was available regarding the development of NICUs in China. The purpose of this survey was to evaluate the current situation of neurointensive care units （NICUs） across China. Methods The directors of NICUs from 100 tertiary care hospitals across China were contacted and asked to complete a closed response questionnaire regarding their NICUs. Basic information, equipment, and technology information available in the units, as well as staffing information were investigated. Results Seventy-six questionnaires were returned （a 68% response rate）. Of 76 NICUs, 43 units constituted the majority. The number of each NICU bed varied from 4 to 45, occupying 2%-30% of the total department beds. Over 70% of NICUs were equipped with many emergency treatment equipments as well as physiological and biochemical monitoring equipments, while 34%-70% of NICUs still lacked some kinds of equipments such as defibrillators. Some specialist equipments were still partially lacking in 62%-95% of NICUs. A vast majority of the NICUs were equipped with neurocritical care directors, full-time attending physicians, and head nurses, but full-time NICU residents and neurocritical care nurses were still lacking in nearly half （53%） and one-third （33%-37%） of NICUs, respectively. In 76 NICUs, full-time neurointensivists and nurses added up to 359 and 852, respectively. In addition, 78%-97% of all the surveyed NICUs were severely short of non-neurological professional staffs. Conclusion In China, neurocritical care has developed rapidly, but there is still a shortage of well-equipped and well- staffed NICUs across the nation currently.

Recommendations for Electroencephalography Monitoring in Neurocritical Care Units

INTRODUCTION Since the 1950s, electroencephalography （EEG） has been used extensively in Neurocritical Care Units （NCUs）. At the beginning of this century, China＇s NCUs underwent rapid development. According to an incomplete statistical report, 76 NCUs had achieved the construction standard in 2010.

Pulmonary complications and respiratory management in neurocritical care:a narrative review

Neurocritical care(NCC)is not only generally guided by principles of general intensive care,but also directed by specific goals and methods.This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC.This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases,including the catecholamine pathway,systemic inflammatory reactions,adrenergic hypersensitivity,and dopaminergic signaling.Pulmonary complications of neurocritical patients include pneumonia,neurological pulmonary edema,and respiratory distress.Specific aspects of respiratory management include prioritizing the protection of the brain,and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension.Compared with the traditional mode of protective mechanical ventilation with low tidal volume(V_(t)),high positive end-expiratory pressure(PEEP),and recruitment maneuvers,low PEEP might yield a potential benefit in closing and protecting the lung tissue.Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice.Future studies are required to develop guidelines for respiratory management in NCC.

Research progress in core body temperature measurement during target temperature management

Core body temperature(CBT)is increasingly attracting attention as crucial data during target temperature management(TTM).Accurate and continuous measurement of human CBT can effectively identify and monitor central high fever,and provide a basis for the effective implementation during TTM,which is therefore of great significance for human health care and disease monitoring.The reliable core measurement sites are nasopharynx,esophagus,bladder,rectum,pulmonary artery,etc.,but the measurement methods in these sites are all invasive.At present,the medical field is more inclined to noninvasive data collection methods through monitoring an appropriate site(such as forehead,mouth,or axilla)depending on clinical circumstances,so as to ensure the comfort and security of patients to the greatest extent.This review will provide reference choosing more safe and accurate temperature measurement methods for patients during TTM by reviewing the sites and accuracy of invasive and noninvasive CBT measurements.