Neurocritical care units are becoming the standard of care in referral centers for acute brain injury patients in North America^1,2. There is now ample evidence that neurocritical care improves overall and neurological outcomes³ of critically ill neurological patients, decreases mortality^3-5, and shortens hospital stay⁴. This evidence emerged from specialized centers mainly in North America and Europe, but the worldwide implementation of neurocritical care units is lagging. In the following article, the challenges and barriers of initiating a neurocritical care practice are discussed with potential solutions. 

Stakeholders’ interest and buy-in

Support, commitment, and buy-in from the local medical community, hospital administration, and official governmental authorities is essential to implement neurocritical care. This requires demonstration of both efficacy and cost-effectiveness, especially in resource-limited settings where priorities may vary. As an example, the RESILIENT trial randomized stroke patients in Brazil to thrombectomy vs. standard of care and showed significantly better neurological outcomes⁶. The results led to the inclusion of thrombectomy in their public health systems. In a nationwide survey in Korea⁷ on barriers to implementing neurointensivists, 57% of respondents cited increased overall hospital costs, 30% cited loss of income to certain physicians group, and 32% were concerned about loss of control by other physicians. Recently, the impact of neurocritical care on outcomes was demonstrated in multiple countries other than Europe and North America, mainly through pre- and post-intervention retrospective studies that showed improved outcomes across neurocritically ill patients⁸, and specifically in patients with traumatic brain injury (TBI)⁹ and acute ischemic stroke (AIS)¹⁰. Further research on cost-effectiveness factoring length of intensive care unit (ICU) stay, hospital stay, and years gained without disability may lead to higher acceptance and adoption by the medical community and local hospitals. 

Lack of qualified specialists

Neurocritical care fellowship training is not widely available outside Europe and North America. In the PRINCE study that included 257 institutions in 47 countries, only 27% of institutions had a formal neurocritical care fellowship, including none in the Middle East, 16% in Latin America, and up to 40% in North America¹—results that are likely biased toward more neurocritical care training, as most respondents were Neurocritical Care Society members. In the United States, only 56% of residency programs offered a Neuro-ICU resident rotation in a 2011 survey, though the number of residents entering Neuro ICU fellowships is increasing¹¹. Until international fellowship program opportunities become available, increasing the representation of international medical graduates in existing programs is of paramount importance and could potentially be incentivized by their home countries and institutions. Upon fellowship completion, these graduates can then can help initiate local neurocritical care practices and build local educational capacity through a “train the trainers” approach. A similar concept can be applied to bedside nurses, advance practice providers, and clinical pharmacists. Finally, continued efforts are needed to include neurocritical care as a separate specialty in local medical boards and local legislations for legal, billing, and practice purposes. 

Suboptimal prehospital care

Neurological emergencies are often time sensitive, and an improvement in outcomes is not possible without appropriate prehospital care and clinical care at remote sites that refer patients to a center with a neurocritical care unit. Emergency medical services (EMS), emergency department staff, and neurology staff should be targeted for training on dealing with neurological emergencies—for example, timely identification of stroke with appropriate referral and treatment pathways, resuscitation of TBI patients, rapid anticoagulation reversal in patients with intracranial hemorrhage, and implementation of protective measures in patients with high intracranial pressure. Recently, EMS training on scoring patients for possible large vessel occlusion has become possible¹². Also, Emergency Neurological Life Support training in Nepal¹³ and Cambodia¹⁴ has improved knowledge, decision making skills, and confidence of staff treating neurocritically ill patients. In addition to education and training, remote areas can be supported by neurocritical care specialist consultation through telemedicine. 

Lack of full neurocritical care coverage

It is common for one neurointensivist to be hired initially, with an inability to provide around the clock coverage. Potential solutions include implementing protocols to standardize care and decrease the dependance on highly specialized clinicians. For example, implementing clinical practice protocols in TBI patients has been associated with a decrease in hospital mortality^15,16 independent of whether a dedicated neuro ICU is present. Other solutions include having a neurocritical care consult service, and the provision of stepdown units for low-risk monitoring groups without ICU needs, such as some post-craniotomy patients and many AIS patients, who can be covered by neurologists or neurosurgeons. Telemedicine triage of patients from remote areas before transfer may help select those who could derive the most benefit from specialized neurocritical care. 

Local applicability of study findings,  protocols, and guidelines

Neurocritical care research trials, treatment protocols, and guidelines are primarily conducted and validated in high-income countries, and local adaptation is lacking in many countries who might have differences in epidemiology (e.g., higher rates of CNS infections), genetic backgrounds (potentially affecting response to therapies), healthcare systems (potentially affecting protocol applicability), and cost-effectiveness and resource use optimization strategies. This underrepresentation in research and policy-making can be addressed by collaborative research efforts in low- and middle-income countries, local adaptation of protocols, tailored education to each country’s unique needs, twinning projects with centers in high-income countries, and increased representation of low- and middle-income countries in international organizations and scientific committees. 

Resources for neuromonitoring

Resources for advanced multimodal neuromonitoring may be limited in some areas, either due to cost and availability reasons or a lack of training and adoption by local medical specialists. A focus on cost-effective neurocritical care may be pragmatic in resource limited settings, with an emphasis on bedside clinical exams that are supplemented by automated pupillometry, intracranial pressure monitoring, cerebral perfusion pressure monitoring, and short-term EEG monitoring only when needed. Transcranial doppler monitoring in the presence of trained operators can also be implemented at a relatively low cost. However, more advanced neuromonitoring techniques such as cerebral microdialysis, brain tissue oxygenation monitoring, and cerebral blood flow monitoring have not yet reached the level of standard of care, since a clear and consistent effect on outcomes has yet to be demonstrated. As a result, it is reasonable to defer these monitoring techniques in favor of higher-yield strategies based on local resources, though their availability in centers of excellence may help encourage educational initiatives, scientific research, and further technologic advances, while potentially helping to manage more complex cases. 

Variability in goals of care discussions

Prognostication and goals of care discussions are particularly important in neurocritical care. The potential of self-fulfilling prophecies needs to be balanced against the risk of providing futile therapy. Potential prognostic uncertainty coupled with unreliable prediction models at the individual patient level add another layer of difficulty in navigating goals of care discussions. In some areas, challenges may exist due to cultural differences, a lack of public awareness, and ambiguous legal framework. There is definite variability in withdrawal and withholding life-sustaining therapy practices worldwide,^17,18 with withdrawal sometimes perceived as an active hastening of the dying process¹⁹. In addition, there is a disconnect between attitudes and practices in some areas due to ambiguous laws and a fear of retribution^19,20. Inclusion of palliative care services, raising awareness of the need for advance directives and end-of-life care, and clinician training on effective communication with patients and families are all essential for any neurocritical care practice. 

Conclusion

Initiating a neurocritical care practice where none exists is challenging but feasible, even in a low-resource setting. An all-hands-on deck approach with collaboration between involved clinicians, hospital administration, official governmental authorities, and international organizations can help overcome potential barriers and ease the start-up process. However, it is imperative that educational efforts, clinical practice protocols, and relevant guidelines are tailored to local needs, while collaborative research from underrepresented areas is also a must. 
 

Neurocritical care unit team at the Lebanese American University Medical Center, the first unit in the country staffed by a neurointensivist.

At the opening of the first comprehensive stroke center in Lebanon at the Lebanese American University Medical Center - Risk Hospital (2018)