Aarti Sarwal, MD, FAAN, FNCS, FCCM, professor of neurology at Virginia Commonwealth University Health System, explores the nuanced intersection of neurology and critical care, offering practical insights for clinicians across disciplines.
Dr. Sarwal shares her perspective on the unique challenges of managing neurocritically ill patients, particularly when impairment presents challenges in administering a neurologic examination. She emphasizes that “the brain is the barometer of critical illness,” urging clinicians to prioritize daily neurologic evaluations and integrate neuromonitoring even in non-neurologic ICU populations. Listeners will gain an overview of tools such as continuous EEG, transcranial Doppler, emboli monitoring, and multimodal neuromonitoring platforms, including the role of neuro-ultrasound in expanding point-of-care capabilities.
This episode also highlights the need for multidisciplinary collaboration and a shared decision-making model that extends across the continuum of care—from early ICU admission to post-discharge recovery.
Listeners will appreciate Dr. Sarwal’s reflections on neuroprognostication and the ethical dimensions of care withdrawal, particularly the danger of therapeutic nihilism in patients whose outcomes are uncertain. Referencing a 2023 review she coauthored (Crit Care Med. 2023;51:525-542), Dr. Sarwal outlines a practical framework for neuromonitoring that integrates structural, electrical, vascular, and metabolic insights.
This conversation provides a timely and inclusive look at the future of neurocritical care—where technology, teamwork, and training converge to support better patient outcomes.
Transcript:
Dr. McLaughlin: Hello, and welcome to the 2024 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Diane McLaughlin. Today I'm joined by Arti Sarwal to discuss neurologic monitoring in the intersection of neurology and critical care.
Dr. Sarwal is a professor of neurology at Wake Forest School of Medicine in Winston-Salem, North Carolina. She is a neurocritical care physician with significant experience in program development, education, and quality improvement. Welcome, Dr. Sarwal.
Before we start, do you have any disclosures to report? Diane, thank you for having me here.
Dr. Sarwal: I'm honored to be a part of this podcast and really humbled to be talking to you about my favorite topic, neurological monitoring at the intersection of neurology and critical care. I have a few disclosures. I am the director of neurovascular ultrasound courses at Wake Forest School of Medicine.
I have a loan of ultrasound devices from two vendors, Butterfly, as well as image monitoring via Sonix Dolphin robotic system, essentially for some investigator-initiated projects related to use of ultrasound in critical care. And I'm a consultant for the RE-INVIGRATE trial that is being sponsored by StemDia regarding phrenic nerve stimulation and diaphragmatic weakness in the mechanically ventilated critically ill patients.
Dr. McLaughlin: Those all sound like fun disclosures. Thank you. It's fun working on them.
I should disclose that we have known each other for a long time now, so it's exciting to be able to let other people listen in on things that we would probably be normally talking about. I think I call it like the sisterhood of NeuroICU. Oh, it's definitely here at Congress for sure.
So we'll get everybody else excited about some of our favorite topics here. And so a good place to start is what is different in monitoring a neurocritically ill patient versus a critically ill patient?
Dr. Sarwal: Well, great question, Diane. And you and I have known how this is one of the biggest mysteries in critical care. In another critically ill patient that has an intact brain, we have the most precious neuromonitoring tool, the patient's exam itself.
And the patient's ability to be able to interact with us and allow us an assessment of their brain, their brain stem, different parts of how the brain functions, their peripheral neurological system is a very precious tool in being able to know and evaluate that the brain's functioning fine. There are many diseases across the spectrum of critical care that pose a risk to brain. Neurocritically ill patients by themselves inherently present with acute brain injury that takes away this precious resource.
So the very resource that allows us to evaluate the brain functions, that is the neurological exam, gets impaired in these patients. And from my perspective, I think that's the biggest challenge in monitoring of these patients compared to regularly another critically ill patient.
Dr. McLaughlin: So I have my own mantra, which is that the brain is the barometer of critical illness because it seems as though no matter what you present with, one of your symptoms are going to be that you're altered in some way. What would you suggest to critically ill patients that are not neuroprimary and don't have an exam, whether it's due to sedation or a severe metabolic encephalopathy?
Dr. Sarwal: Well, Diane, I love your simile. Brain is the barometer of critical illness. Again, even in patients that are critically ill without an acute brain injury, where sedation or neuromuscular paralysis impedes the exam, we have seen extensive literature, especially with ICU liberation, on trying to get sedation-free holidays.
And I think it is imperative that we at least allow the patient sedation-free holiday to the point of being able to evaluate the neurological exam every day. In our practice, I encourage my colleagues in critical care across medical and surgical populations to do that at least twice a day, more if possible. When that is not possible, there is a whole realm of neuromonitoring devices available that are very context-specific.
So if you have patients that are at the risk of seizures but have to be sedated or paralyzed for, say, ARDS, we have continuous CEG. If there are patients at the risk of vasospasm or other cerebrovascular complications, say a cardiothoracic patient at the risk of emboli from a central source, we have transcranial Doppler with emboli monitoring. If you have patients at the risk of vasospasm, say from RCVS, chemotherapeutic agents, we have transcranial Doppler again.
So a myriad of neuromonitoring devices are available, but you have to take into context the patient's clinical evaluation, the clinical picture, what's keeping them in the ICU, and what particular neurological risk they are at while they're at critical yield in the ICU.
Dr. McLaughlin: So I love that you mentioned TCD multiple times because, you know, we're three days into Congress. We have the two days of pre-courses and then today. And I've been hearing TCD, TCD, TCD from a lot of people that I've interacted with as a tool to keep in mind outside of the neuroICU.
Can you speak to any more about how do you get those skills if you're a general intensivist?
Dr. Sarwal: A great question, Deanne, and I should have probably disclosed that in my conflicts that the topic of neuroultrasound gives me butterflies in the brain. And my hope is that any focus enthusiasts out there like yourself incorporate neuroultrasound as a part of their focus toolbox. Because at the end of the day, the brain is the eventual target of all resuscitation.
And like you said, brain is the barometer of critical illness. My hope is neuroultrasound becomes an important tool for it. Thankfully, Society of Critical Care Medicine has been a pioneer in incorporating neuroultrasound as a part of their advanced critical care ultrasound courses.
My hope is over time these skills come to the basic ultrasound course. We have lots of focus enthusiasts that have spent a lot of their voluntary time and effort in learning neuroultrasound skills like yourself and a couple of others. And my hope is that they continue to take these skills to a next level where they can become trainers and champions in their own units.
There are other educational resources available through Neurocritical Care Society, American Society of Neuroimaging. There are a couple of educational CME courses available both on the East Coast and the West Coast if you can search them on the internet. Many critical care societies, including European Society of Intensive Care Medicine, Indian Society of Critical Care Medicine, have kind of followed suit.
And my hope is that with increasing awareness of value of point-of-care ultrasound in critically ill patients' evaluation, neuroultrasound just becomes one other thing in the toolbox because without evaluating the brain, your evaluation is incomplete.
Dr. McLaughlin: So I'm going to really put you right on the spot now. Would you say that every person working in the ICU, every provider working in the ICU, should know how to perform neuroultrasound as a diagnostic tool?
Dr. Sarwal: That would be a utopian dream, and the bias in me would say yes. Ultrasound has become the stethoscope in medicine, especially in acute care and critical care. I can't even imagine managing a shock patient without point-of-care echocardiography these days.
The neurologist in me says all your resuscitation strategies and perfusion-targeted strategies also need to incorporate the brain because perfusion to the brain is as important as perfusion to the rest of the body. So with increasing emphasis on creating evidence-based clinical paradigms that show value of neuroultrasound in critical care, I think that's a big research gap at this point. My real hope is that people like you and other pioneers who have great focus skills in other modalities incorporate neuroultrasound in their toolbox, challenge themselves to create these clinical paradigms where we can show management-changing incorporation, and I think that would be the threshold where I would say, yes, neuroultrasound needs to be a part of it.
At this point, I am excited at all the potential neuroultrasound has to bring, especially in patients who we traditionally don't consider at risk of brain injury. Sepsis, ARDS, kidney failure, it's an uncharted territory, but having a noninvasive tool that is so convenient to point-of-care assessment can be a great tool to perform such bedside research, create clinical paradigms, and I think that's the need for the next decade at this point.
Dr. McLaughlin: So aside from the need of high-quality research to drive future care, what are other challenges that currently exist in providing excellent neurocritical care to both the neurospecialty and the general ICU?
Dr. Sarwal: I think from my side, from an educational hat, the biggest challenge is brain seems like a mystery to everybody, and there is a mental inertia in taking on brain disorders or taking care of brain-injured patients. We all are very capable intensive care physicians and professionals, and we work in a great multidisciplinary format where we bring the best of each professional that is a part of this team, and somehow brain seems to be this up-there, man-in-a-high-castle kind of organ to conquer. I would just encourage everybody to endorse it, just like you've endorsed other challenges, like learning point-of-care ultrasound and management of shock and resuscitation.
So I think that mental inertia about neurological disorders, what we also call as neurophobia, from my perspective, is number one. And the second, I think, is with increasing collaboration in an interdisciplinary format that SCCM offers, neurocritical care, cardiac critical care, surgical critical care, medical critical care, we all come together on a single platform sharing our experiences, sharing our knowledge, our expertise in our respective fields, and applying that to different populations. That would be the next frontier in getting neuroultrasound platform to be tested for patient care paradigms.
Dr. McLaughlin: So we know that people have looked at specialty care and that it does influence patient outcomes. Are there any other factors that you see that can promote positive patient outcomes in neuroinjured patients?
Dr. Sarwal: So you're talking specific to neuroinjured patients? Let me think about it. The previous answer was, by the way, very long-winded.
You might have to... It was a good answer. So you want to know what changes care in neuroinjured patients?
Dr. McLaughlin: I'm hoping that you say that we don't withdraw on every patient.
Dr. Sarwal: Yes, yes. I was trying to see how to get there. Yeah.
I think I want to highlight interprofessional collaboration and multidisciplinary approach. I do want to have optimal use of neuromonitoring. And then third is accepting the fallacy of imperfectness of neuroprognostication.
Okay. That this falls on... Yeah.
Okay. So first thing is interdisciplinary care. Second is neuromonitoring.
Third would be prognostication. Okay.
Dr. McLaughlin: So we just brought up interdisciplinary. So not every institution... That wasn't my answer.
I know. That's why I'm just trying to think of how to work it back. Sounds good.
So you mentioned interdisciplinary care. And sitting here representing SCCM, not only is it a very interdisciplinary society, speaking as a nurse and nurse practitioner, it's also a very friendly multidisciplinary society. How does the interplay of team dynamics influence the care of the patient?
Dr. Sarwal: You bring a very good question. And this is where I quote my favorite quote, which is medicine is a team sport. With increasing complexity of patients we are dealing with, with increasing complexity of technology we are applying by bedside to manage these patients, with increasing complexity of the medical, legal, ethical milieu surrounding the decisions we make on these patients every day, we just can't operate in silos anymore.
So I think more so than ever multidisciplinary care, interprofessional care is important in day-to-day critical care, not just across the whole bubble of critical care, but a continuum of care across where does the patient come from and where does the patient go once they leave the ICU. So I think I would expand that question to a whole continuum of care of professionals that work in identifying patients to bring them to the ICU so they can be brought at a good time. We recently released guidelines on rapid deterioration of patients outside the ICU and how that should be managed with rapid response teams and the best practice recommendations around that.
ICU obviously is the core focus of our clinical practice and we've learned the incorporation of interdisciplinary care there, but even important is when the patient get out of the ICU, what are we doing for keeping them out of the ICU, providing them enough resources, enough expertise, and enough science to support their recovery, which sometimes may take months to years.
Dr. McLaughlin: So that brings up a good point regarding when do you bring a patient to the ICU? Because I think one of the questions for people that don't have neuro-ICU is when is the appropriate time to escalate to people that are able to provide specialty care? Can you give some common scenarios that you might see in a smaller hospital that might require expert attention and transfer to a different facility?
Dr. Sarwal: Diane, that's a very good question and something obviously our health policy experts and our health administrators try to answer on a daily basis. And I hope that more guidance will come on a systematic level through societies like Society of Critical Care Medicine. So far what we've learned is that there are certain diseases or certain pathological processes where we have very good evidence that taking care of these patients in a specialized center from the perspective of offering specialty care, specialty procedures, and being accustomed to the needs of such patients, which are very specific and may not come naturally to, I don't want to use the word generally trained, but an intensive care professional that has not been exposed to these paradigms. There are quite a few disease processes where we have evidence towards that. Subarachnoid hemorrhage is a very good example.
Early coiling in these patients through neuroendovascular procedures has been shown significantly superior to any other paradigm that causes delay in these. Screening of these patients with a highly specialized team of expert professionals that know the nuances of neuromonitoring in these patients, how to interpret them, and the therapeutic advances available has shown to improve outcomes over years. Over the last two decades, as you and I both know, the whole landscape of subarachnoid hemorrhage outcomes have changed.
We used to say half of them pass away within 30 days when we were in our training days. And now our systematic mortality in this disease population is dramatically less compared to that. And even that mortality is coming from our withdrawal of care, not really the disease process itself, which shows the value of highly specialized care being provided to these patients.
At the end of the day, I think resources are limited. Every patient wants to be taken care of at the best place that they can be cared for. But on a bigger scale, we as critical care professionals who are leaders in the health administration world need to create evidence-based clinical paradigms that provide guidance to our soldiers on the field on which patients don't have those specialist needs that can be taken care of in smaller community hospitals and identifying these disease processes that truly need specialized care and can be transferred.
Dr. McLaughlin: So you mentioned a few things that I'm going to want to come back to, but I think one of the most interesting topics here is the changes in neuromonitoring. Can you go into some specifics regarding the types of specialty neuromonitoring tools that are available now and that have changed how these patients do?
Dr. Sarwal: Diane, you have asked me my favorite question. Brain, fortunately or unfortunately, is one of the most monitored organs. Dr. Rajagopalan and myself recently published a review in Critical Care Medicine sharing our perspective on neuromonitoring. And this is something I got from one of my mentors. I've always looked at brain as a house. And when I talk about neuromonitoring, I talk about components of neuromonitoring as if brain was a house.
There are structural neuromonitoring paradigms available, neuroimaging, CT scan, MRI, CT perfusion, CT angio that has changed the landscape of how we deal with acute ischemic strokes. Then there are electrical components of the brain that can cause problems. Too much electricity, which is seizures and status epilepticus, that is one cornerstone of what we take care of in the neuro-ICU.
And diagnosing these disorders using continuous EEG and some point-of-care EEG devices that are widely available now is one part of our day-to-day care. And then not enough electricity, hypoactive dillidium, lack of neurotransmitters or too much neurotransmitters. All these disorders are something that we deal with that can be monitored using electroencephalography.
On the neuromuscular part, having neuromuscular weakness and respiratory failure caused by that is often a disease process that we deal with. And on the plumbing side, cerebrovascular disorders have seen a significant amount of emphasis on research that has been facilitated by neuromonitoring. Our ability to use CT NGOs, transcranial Dopplers, emboli monitoring has changed the landscape of how we manage acute ischemic stroke.
And my hope is that this soon translates to hemorrhagic stroke as well. Vasospasm management in subarachnoid hemorrhage has been a big focus of our neurocritical care for decades now. And we have spent a significant amount of time learning neuromonitoring techniques like transcranial Doppler, spectral array in EEG or cortical spreading depolarization or even multimodality monitoring in trying to predict and manage vasospasm.
And then when plumbing, electricity and structure doesn't explain the patient's decline, we have this whole miscellaneous micro-level issues at the cellular level like anaerobic glycolysis, which we can monitor using microdialysis and active thyroid ratios. Lots of these neuromonitoring modalities are still under investigation and are being trialed to create clinical paradigms, like the BOOST3 trial is looking at brain tissue oxygenation. And my hope is that in the next few years, we come up with bedside clinical application of a multimodality neuromonitoring paradigm that gives people like you and me guidance on how to combine this approach to better take care of our patients at risk of acute brain injury.
Dr. McLaughlin: So we've seen similar patterns in other areas of critical care when every ICU patient had a pulmonary artery catheter. And we see these trends where we use all of these monitoring tools and then we've seen it go the opposite direction, that it all goes back to looking at the patient. And neuro has kind of been the marriage between those things right now, and I'm seeing this shift occurring.
As of now, is there any evidence that this is changing outcomes, the use of multimodal monitoring?
Dr. Sarwal: I think ongoing trials are addressing that question. There have been efforts. The one challenge with neuromonitoring has been that the information technology infrastructure required to translate the visualization of these neuromonitoring modalities by bedside has been a big focus of research in the last few years.
Now that has been tackled to some extent. There are a couple of trials like BOOST, the one that I mentioned, that is looking at brain tissue oxygen monitoring incorporated into ICP monitoring to see outcomes. We are getting closer to the point where the infrastructure can support implementation of such clinical protocols.
So I'm very optimistic and hopeful that our research professionals will bring some clinical paradigms in the next few years using the advances we've had in data science and evaluation of big data that is the key component of the load neuromonitoring modalities create. I'm very optimistic about the future of how neuromonitoring is going to change clinical paradigms.
Dr. McLaughlin: And I could see how in the right hands, people that are well-trained and experts in this type of monitoring, how it could be useful. Is there any fear about the dangers of somebody that maybe isn't familiar with all of the nuances trying to interpret some of these neuromonitoring tools?
Dr. Sarwal: You ask great questions, Diane. Again, my critical care mentor, Dr. Stevitt used to say, a tool is only as good as the fool that uses it. And I think it is imperative upon people like you and other leaders at Society of Critical Care Medicine that we create educational platforms that translate evidence-based guidelines into something that can be scaled across our critical care community in a fashion that doesn't require extensive knowledge to understand the evidence.
So I think a marriage of good clinical scientists that create these evidence-based guidelines with our educational leaders that translate this into educational products that disseminate that information, I think that marriage is extremely important in answering the question you asked me.
Dr. McLaughlin: And I mean, we're sitting here at SCCM and I know we had a pre-course yesterday looking at neuromonitoring. So I know that we have some great opportunities for people listening that want to know more to attend and get that information.
Dr. Sarwal: And I think the best that can be done is curiosity of people in trying to...
Dr. McLaughlin: Let's skip that. That was just me being cheesy along with it. So one of the other things that you mentioned when you were talking about the subarachnoid population was that a lot of the reason now that these patients die is from withdrawal of care.
And I know I gave a neuroprognostication talk yesterday and looking at all of these neuropathologies, it indeed in most of them was the number one reason that patients dies withdrawal of care. Can you comment on first how these tools that you've developed and have mastered influence being able to predict the future? And then we'll talk maybe a little bit about prognostication in general.
Dr. Sarwal: Definitely. Diane, this is a topic close to many of us who practice in neurocritical care. Critical care in general is hard because you're dealing with a lot of uncertainties, patients at the brink of life and death.
Neurocritical care is even harder because you're not just dealing with the question of life and death, you're dealing with the question of recovery after potential management and you're dealing with the whole question of quality of life. And the biggest uncertainty that despite all our efforts and decades of research, we do not have perfect neuroprognostication paradigms. Despite all our confidence and effort to do so, we don't have an ability to predict our patient's trajectory of recovery and match that with patient's own wishes and their advanced directives.
So I think neuroprognostication itself is a big area of emphasis at this point. But as we've all known, therapeutic nihilism is a real issue in neurocritical care. Our inability to accept our imperfectness has been a very big challenge both in progressing the field of neurocritical care because no matter how phenomenal evidence we create, if we do not allow that intervention to work through the trajectory, which unfortunately is long and uncertain in many of our patients, is the key.
And we've seen this in intracranial hemorrhage. For decades, if you look at the clinical trials, a majority of the mortality, even in patients enrolled in these trials, came from withdrawal of care, not from the disease process itself. And we would have resigned to the idea of the comfortable explanation that it's a difficult disease and we are biased in trying to interpret the results of this therapeutic nihilistic trials.
But MIS-T was a trial that showed that if you do take care of these patients and allow them a chance to recover, give them the infrastructural support, both for the caregivers as well as the patients themselves, a majority of these patients, almost half, survived to a year with way better outcomes than we would have anticipated. We have seen this in subarachnoid hemorrhage. We have seen this in ischemic stroke as well.
So I think the biggest challenge neuroprognostication in general is we'll have to have a multi-pronged approach that combines basic scientists in translating biomarkers of neuroprognostication to clinical science. We'll have to have pragmatic trials of clinical effectiveness of these biomarkers and predicting prognostication in a good way. But at the same time, once we do have these biomarkers that are clinically proven to be useful, no matter how perfect they are, they can't be 100%.
We still have to have infrastructural support for these patients to survive through their recovery. Their caregivers have the support. So post-acute care is equally important.
And campaigns like the Curing Coma Campaign run by Neurocritical Care Society is trying to address this question. And it's a complex question that you and I probably can't answer in topics like these. And I really appreciated your perspectives in the talk yesterday.
But I think a continuum of care approach across multiple disciplines will have to come together, create some kind of guidance to change the neuroprognostication paradigms we have now, which are absolutely imperfect.
Dr. McLaughlin: So there's not just one thing that'll tell you how a patient's going to do. And so I think we all recommend giving these patients time. But a question that was brought to me, which I didn't have a great answer for, is in places that are resource limited and we have patients that still require high level of support, they're not hemodynamically unstable necessarily.
There's not a good place for them to be. So how long is too long?
Dr. Sarwal: I wish I'd answered that question, Diane. I was hoping I'd ask you and you for the answer. We'll have to find somebody way more wiser and experienced than me.
And I hope with time and technology, and new science, we'll be able to answer that question. I think so far, we still need to have this question in clinical context. I think resources are not limited, unlimited, whether it comes on a personal level or a society level.
And I think a shared decision-making model, which incorporates both the resources available, the caregiver support available for the patient, and hopefully, improvement in neuroprognostication will also give us more definitive answers on helping understand what's going to take for this patient, how much time it's going to take for the patient. I don't have those answers today. I hope you and I see those answers in a lifetime.
And we are more confident when we talk about this to our patients' families and their caregivers in a day-to-day practice.
Dr. McLaughlin: So kind of wrapping things up. So we've talked a little bit about how do you address generally critically ill patient from a neurologic perspective? We've talked about the monitoring tools.
We've talked about when do you need a higher level? And we've talked a little bit about when is the end? And so when we put this all together, if you had to give, and you're like me, you're not going to be able to pick one.
So let's say if you had to pick three key pieces of information that you want somebody listening to walk away with from this discussion, what would those three things be?
Dr. Sarwal: I think I want to steal one of your quotes in one of the three, if you'll forgive me. If there were three things I would want people to take away from this discussion that you and I had is number one, brain is the barometer of critical illness. Preserving our patient's ability to interact while taking care of their comfort is paramount.
Clinical neurological exam is going to be the eventual neuromonitoring tool no matter how advanced we get. And preserving that and respecting that and understanding its nuances and recognizing when a deficit happens and responding to that would still be a very important part of our clinical care no matter how advanced we get technologically. That would be number one.
Number two I would say is my cliche which is brain is the eventual power of brain is the eventual target of all resuscitation. We spend so much time monitoring everything else and trying to prevent its injury. We need to be as proactive about protecting the brain and giving it the best chance to recover no matter what critical illness brings your patient to the intensive care unit.
And emphasizing that across our continuum of critical care is extremely important. The third thing I would say is this is the decade of the brain this is the century of the brain. I am extremely excited and humbled at collaborative platforms that Society of Critical Care Medicine has given us where I get to share my little expertise with professionals from other specialties other professions and combining that in a collaborative fashion and learning from each other is the way our patients are going to get better.
And the shared decision making is not just between me our patients and their caregivers. The shared decision making needs to be a multi-professional multi-disciplinary inter-professional approach to our patients that addresses the whole continuum of care where they come from how we take care of them and where they go when they leave the ICU.
Dr. McLaughlin: I would definitely say it's not little expertise it's great expertise. And I hope that everybody listening has enjoyed this as much as I have. And with that this will conclude another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Diane McLaughlin. Thank you.
Announcer: Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound committees, and is a social media ambassador for SCCM.
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