Emerging subspecialties in neurology: neurocritical care.

Asma Zakaria, MD J. Javier Provencio, MD George A. Lopez, MD, PhD Historically, neurology has been a primarily outpatient specialty.1 The advent of modern neurosurgical techniques, as well as more elegant means of artificial ventilation in the 1960s, brought increasing numbers of neurologic patients to the intensive care units (ICU). Although these patients were primarily managed by medical and surgical–anesthesiologist intensivists, occasional consults for neurophysiologic testing, management of neuromuscular failure, and, more commonly, prognostication, would bring neurologists to the ICU. In the 1980s and 1990s, the surge in new neurosurgical procedures and advances in cardiovascular disease spurred on the development of a newer, different subset of neurologist. Some developed an interest in cerebrovascular diseases, while others ventured into the ICUs and carved a niche for a new subspecialty: neurocritical care. A small number of neurologists, anesthesiologists, neurosurgeons, and medical intensivists aimed to identify and correct the factors that were contributing to the high mortality rates in neurologic intensive care units (NICUs). Through the 1980s and 1990s, four major centers of NICU training emerged. These centers were headed by Dr. Allan Ropper at Massachusetts General Hospital, Dr. Matthew Fink at Columbia University, Dr. Thomas Bleck at University of Virginia at Charlottesville, and Dr. Dan Hanley at Johns Hopkins.2 These “Four fathers”3 of neurocritical care in the United States have trained numerous fellows who then went on to run their own ICUs across the country.