Neurocritical Care at Sanford Health
Sep 18, 2013 12:01PM ● Published by MED Editor
In mid-October 2012, South Dakota Highway Patrol Trooper Andrew Steen suffered a traumatic brain injury after being run down by a drunk driver in a Sioux Falls parking lot. It was the kind of injury after which many people do not survive, let alone recover. But after eight weeks in the care of Sanford’s Neurocritical Care team, who treated him using some of the most cutting edge techniques and technologies available, Steen walked out of the hospital 10 days before Christmas.
The high-profile case and Steen’s remarkable recovery shone a media spotlight on a branch of medicine that has evolved in recent years from a segment of Intensive Care to its own subspecialty, with its own society, journal, research studies, and growing number of practitioners. Simply put, Neurocritical Care is the critical care of patients with injuries or acute conditions of the brain or spinal cord. Brain trauma like Steen’s, as well as stroke, subarachnoid hemorrhage, intracranial hemorrhage, subdural hematomas, seizures, spinal cord trauma, status epilepticus, and encephalitis all fall under the auspices of Neurocritical Care.
“If it is something in your head, we will take care of it,” says Larry Burris, DO. Originally trained as an internist and nephrologist, Dr. Burris, along with his partner Charles Miller, MD, is now one of the 400 or so board certified Neurocritical Intensivists in the country.
“When we first started focusing in this area in the early 1990s, EEG monitoring was archaic,” recalls Dr. Burris. “As far as invasive procedures, about all we could do was take off the skull and put in an external ventricular drain (EVD). We would hang out in the ICU and try to do what we could. But we both remember people being wheeled from the ICU into the Neuro Unit just staring into space. It was very disheartening.”
“It is a specialty that has developed out of a need,” agrees Dr. Miller, who comes to Neurocritical Care by way of neurosurgery. Miller says the declining number of neurosurgeons performing procedures on ER patients and the growing use of the ICU have both contributed to that need. “There has been a core of true believers who are trying innovative therapies and renewing interest and energy in Neurocritical Care as a separate and distinct specialty,” he says.
Neurocritical Care could not have emerged as its own specialty area without certain important technological advances. Drs. Miller and Burris say chief among those is the improved ability to monitor certain parameters in the injured or diseased brain, such as intracranial swelling, brain blood pressure and neurooxygenation. This ability to monitor, which Sanford uses in almost every Neurocritical case, has revolutionized the field and dramatically improved outcomes.
“In many ways, the evolution of Neurocritical Care can be compared to the progress seen in cardiac care,” says Dr. Burris. “Once, if you came in with a heart attack, they put you in a room and took your pulse. Now, they give you a clot busting drug. We give tPA (tissue plasminogen activator) for stroke. They can put in central lines and perform echocardiograms. We can do the same thing with Doppler and improved imaging studies. They measure oxygen in your finger; we can measure oxygen in the brain. They put in stents; we put in stents.”
Just as cardiac care is focused on minimizing heart damage, Neurocritical Care is largely focused on reducing organ damage which, in turn, has opened the door to other types of more goal-directed therapy. This is especially critical for traumatic brain injury patients for whom the mortality rate has hovered around 50 percent. Today, with aggressive monitoring and timely intervention, Dr. Burris says that figure can be reduced by half.
Monitoring and Protection
One of the life-saving interventions made possible by improved monitoring is decompressive craniectomy, a neurosurgical procedure Dr. Miller calls one of the “coolest” he performs. The procedure is used most often in patients with traumatic brain injuries or ischemic stroke to reduce the damaging effects of intracranial pressure. A portion of the skull – sometimes as large as a hand – is removed and carefully preserved at -60° C while the patient’s potentially brain-damaging inflammation diminishes. Pressure and oxygenation continue to be monitored. When it is safe to do so (which could be weeks later), Dr. Miller closes the hole with the patient’s own bone.
“Novel application of acceptable techniques allows us to go beyond standard therapies and give our patients a better fighting chance when it comes to these really terrible injuries,” he says.
Another one of those acceptable but not highly-publicized techniques is therapeutic hypothermia, a method of lowering a patient’s body to a therapeutic temperature of 91° F in an effort to prevent ischemic injury to already-damaged tissues. Using a cooling pad placed on the skin or an endovascular cooling device that goes in the groin, the patient’s body temperature can be dropped for days or even weeks.
“Unfortunately, it’s not just the injury itself which creates problems for the patient,” says Dr. Miller. “It’s the inflammatory cascade that occurs after the injury. In those inflammatory injuries, the cooling literally turns off the metabolic activity in neural tissue and blunts the inflammatory response, so that you can just deal with the injury and you don’t also have the body’s response to contend with. It effectively protects the tissue.”
Therapeutic hypothermia (also called protective hypothermia), which has now been performed on more than 150 patients at Sanford, has been shown to reduce secondary neurological damage from strokes, spinal cord injuries and traumatic brain injuries. A 2002 study found that patients who had suffered cardiac arrest were less likely to also have neurological damage if therapeutic hypothermia was part of their treatment.
Advances in EEG monitoring have also been pivotal in the development of Neurocritical Care as a specialty. With 24/7 EEG monitoring, which can be continued for days, it is now possible to accurately track and measure ischemia and seizures over time. Sanford’s Neurocritical Care team is researching the use of a small intracranial EEG monitor to track microshiver (subclinical muscle tone) in patients undergoing therapeutic hypothermia. Improved EEG monitoring supports more accurate diagnoses and highly targeted interventions which, in turn, result in better outcomes.
The Team Approach
While the Neurocritical Care techniques offered at Sanford are advanced, Drs. Miller and Burris say their greatest asset is their small but comprehensive team. In addition to neurosurgeon Dr. Miller and Dr. Burris with his background in general medicine, the team includes board-certified vascular neurologist Kathryn Florio, DO, and the state’s only interventional neurologist, Jitendra Sharma, MD.
“Dr. Sharma provides the endovascular part, which is really the only thing that our program was missing,” says Dr. Burris. “There are pure neurological things, so you need someone like Dr. Florio who is well-trained in pure neurology. Then there are surgical issues, such as aneurysms that need to be fixed, etc. and we have Dr. Miller for that. Then you have the whole range of medical issues or things that may crop up in the hospital and that’s where I come in. So we have all the bases covered and that is really what makes us great.”
“One type of patient that brings us Neurocritical Intensivists together with the rest of the team is a subarachnoid hemorrhage,” says Dr. Miller. “When these patients come in, they immediately need the Neurocritical Care aspect. We start putting in lines and managing blood pressure. I may call Dr. Sharma to do an angiogram to identify the aneurysm. I may go in and put in a drain. Postoperatively, Dr. Burris would manage them in the ICU. If the person seizes or is not waking up well, Dr. Florio might be pulled in on that.”
The team not only works in collaboration (Drs. Florio and Burris are married to each other), but they also round together, a fact which Dr. Miller says sometimes sparks “lively discussion”. In the end, he says, patients benefit from getting multiple perspectives on their neurocritical hospital care from physicians with a single passion.
“This is the beauty of medicine: You can find your passion and follow it,” says Dr. Miller, who says few providers embrace trauma the way he and Dr. Burris do. “They don’t want to deal with the accidents and the gunshot wounds and the drunk people who fell. But these are my people. I really do thrive on this, even though there is also a lot of heartache. Overall I think we do a very good job.”
 “Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest”, New England Journal of Medicine, Feb. 21,, 2002.