Surgery and ICU: Collaborating for the best outcomes

As a fully integrated practice, Mayo Clinic has the breadth of expertise to offer the best possible neurological care to critically ill patients. Collaboration between neurological surgeons and neurointensivists helps provide excellent functional outcome even for patients with aneurysmal subarachnoid hemorrhage (aSAH), historically considered a devastating disease.

A study published in the February 2015 issue of the Journal of Neurosurgery found that 63.3 percent of patients treated for aSAH at Mayo Clinic's Minnesota campus from 2001 to 2013 had excellent functional outcome — defined as modified Rankin Scale score of 0 or 1 (no symptoms or mild symptoms, but no disability) at last follow-up visit within one year of aSAH. The retrospective review of 373 patients included the severe cases referred by tertiary centers to Mayo Clinic's neurointensive care unit (neuro-ICU).

"We believe that our outcomes are a reflection of our multidisciplinary approach and a lack of turf battles in our group practice," says Alejandro A. Rabinstein, M.D., a consultant in Neurology at Mayo Clinic in Rochester, Minnesota. "Our neurointensivists and surgeons have a very close relationship throughout a patient's acute course and follow-up treatment."

Continuity of care

"The degree of expertise that a single patient receives is unparalleled," adds Giuseppe Lanzino, M.D., a consultant in Neurosurgery at the Rochester campus of Mayo Clinic. "Each one of us brings to the table particular expertise, and by working closely together we ensure continuity of care."

When a patient with aSAH is referred to Mayo Clinic, the neurointensivist and neurosurgery groups communicate while the patient is en route. "A physician from both groups goes to meet the patient as soon as the patient arrives at our ICU," Dr. Rabinstein says. "We work together because those first few hours are essential to the outcome of the patient."

The neurointensivists focus on aspects of care such as ventilation, oxygenation, stabilization of blood pressure and treatment of brain swelling, while the surgeons treat hydrocephalus. "There is a multidisciplinary conversation about the best treatment for the patient," Dr. Rabinstein says. "For example, if there is a question of sacrificing a certain blood vessel during treatment, the surgeon might ask the neurointensivists if they think the patient will tolerate that."

At Mayo Clinic, neurological surgeons have experience in both endovascular and surgical treatment of aneurysm. "Once the patient is sufficiently stable, we transfer the patient to our angiography suite and, if possible, treat the aneurysm there," Dr. Lanzino says. "But if the aneurysm is not amenable to endovascular treatment, then we fix it with surgery and a clip."

After treatment for aSAH, patients generally spend at least 10 to 14 days in the neuro-ICU. At Mayo Clinic, patients in the neuro-ICU aren't routinely kept sedated and intubated for the duration of acute treatment. "We try to wake up the patient as soon as we can," Dr. Rabinstein says. "Induced coma generally doesn't prevent secondary complications such as brain swelling. Whenever possible, we want to assess the patient through physical examination rather than relying on brain-monitoring devices, which are commonly invasive."

The most notable complication experienced by these patients is vasospasm, which puts them at risk of stroke. "We deal with vasospasm not only with medical treatment — typically, raising the blood pressure while maintaining adequate fluid balance — but also by pursuing endovascular therapy if medical treatment fails," Dr. Rabinstein says.

After a patient returns home, surgical and neurointensivist groups continue to follow up. Appointments with both groups are typically scheduled at four to six weeks and at six months after treatment.

"It's important for patients to go to centers that have expertise and all the services that they need," Dr. Rabinstein says. "We think we can benefit even patients who are severely ill. When I was in medical school, a case of subarachnoid hemorrhage was a spectacular success if the patient was able to walk and talk after treatment. Now, although outcomes for aSAH have generally improved, there is still an acceptance that some deficits are unavoidable. At Mayo Clinic, our definition of success is essentially a patient who is back to baseline at six weeks."

For more information

Pegoli M, et al. Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery. 2015;122:414.