Outcome of Neurocritical Disorders, A Multicenter Study from Sudan

Background: Patients with neurocritical disorders that require admission to intensive care units (ICUs) constitute about 10–15% of critical care cases. Objectives: To study the outcome of neurocritical disorders in intensive care units. Methodology: This is a prospective observational study which was conducted in neurocritical patients who were admitted in four intensive care units of major hospitals in Khartoum state during the period from November 2020 to March 2021. Results: 72 neurocritical patients were included in this study, 40(55.6%) were males and 32(44.4%) were females. 21 (29.2%) patients fully recovered, 35 (48.6%) partially recovered and 16 (22.2%) died. The mortality of the common neurocritical diseases were as follows: Stroke 30.4%, Encephalitis (8.3%), Status epilepticus (11.1%), Guillain-Barre syndrome (GBS) (16.7%) and Myasthenia gravis (MG) (25%). This study identied that near two third of the patients required mechanical ventilation. Delayed admission was observed due to causes distributed between the medical side and patient side. The majority of patients were discharged from ICU with partial recovery.


Introduction
Neurocritical care (or neurointensive care) is a medical eld that concerns with the management of lifethreatening neurological disorders as well as identifying, preventing and treating secondary brain injury.
Patients with neurocritical disorders that require admission to ICU constitute about 10-15% of critical care cases [1]. In addition, many critically ill patients with sepsis or respiratory failure develop neurological complications, such as delirium, non-convulsive status epilepticus, or neuromuscular weakness, which may in turn contribute to morbidity and an increased risk of mortality [2].
Critical care was an ancient eld developed over time. Intensive care begin with centers to treat the poliomyelitis outbreak during the mid-twentieth century. Initially these early respiratory care units utilized a negative and positive pressure unit called the "Iron Lung" to aid patients in respiration and greatly decreased the mortality rate of Poliomyelitis [3]. Dr. BjørnAage Ibsen, a physician in Denmark, "birthed the intensive care unit", when he used tracheostomy and positive pressure manual ventilation to keep polio patients alive in the setting of an in ux of patients and limited resources (only one iron Lung); [4].
Neurocritical care focuses on the care of critically ill patients with an acute neurological disorders and has developed remarkably in the past few years. However, there is a lack of data that describe the scope of this practice and epidemiological data on the types of patients and treatments used in neurocritical care units worldwide [5].
ICU neurological cases are of two types, primary neurological cases admitted from the start by neurologist/internist and consultation for neurological manifestations of already admitted patients in ICU under care of internist or intensivist [5].
There is limited information regarding epidemiological data, disease characteristics, and variability of clinical care and in-hospital mortality of neurocritically ill patients worldwide.  Care Unit in Saudi Arabia", a retrospective before and after cohort study comparing the outcomes of neurologically injured patients. Group1 met criteria for NICU admission but were admitted to the general ICU as the NICU was not yet operational. Group 2 were subsequently admitted thereafter to the NICU once it had opened. The following results were obtained: admission to NICU was a signi cant predictor of increased hospital discharge with an odds ratio of 2.3 (95% CI: 1.3-4.1; ). Group 2 (n = 208 patients) compared to Group 1 (n = 364 patients) had a signi cantly lower ICU LOS (15 versus 21.4 days). Group 2 also had lower ICU and hospital mortality rates (5.3% versus 10.2% and 9.1% versus 19.5%, respectively; all ). Group 2 patients had higher discharge glasgow coma scale (GCS) and underwent fewer tracheostomies but more interventional procedures (all). They concluded that admission to NICU, within a polyvalent Middle Eastern ICU, was associated improvement in the mortality and morbidity [7].

Ines etal in their retrospective study (Predictors for good functional outcome after neurocritical care) in
Germany investigated 796 consecutive patients admitted to a non-surgical neurologic intensive care unit over a period of two years (2006 and 2007). They came with the following results: About 60% of all patients suffered from stroke (ischemic stroke: 31% and ICH: 26%). Patients were diagnosed with subarachanoid hemorrege in 5%, epileptic seizures in 12%, meningoencephalitis in 6%, Guillain-Barré-Syndrome and myasthenia gravis in 3%, neurodegenerative diseases and encephalopathy in 3%, cerebral neoplasm in 3%, and intoxications in 3%. The remaining 63 patients were patients outsourced from general ICUs due to space limitations as well as patients temporarily monitored after neuroradiological procedures. Overall in-hospital mortality amounted to 22.5% of all patients, and a good long-term functional outcome was achieved in 28.4%. The parameters age, length of ventilation (LOV), admission diagnosis of intracerebral hemorrhage (ICH), GBS/MG, and inoperable cerebral neoplasm as well as Omdurman teaching hospital is one of the oldest hospitals in Sudan. It is located in Omdurman city. It is the largest hospital in the city that receives patients from different states of Sudan with full day services. The intensive care unit of the hospital has a capacity of 10 beds.
Bashir University hospital a full day University hospital. It is located in the Southern part of Khartoum city, the capital of Sudan. The intensive care unit of the hospital has a capacity of 6 beds.
Ibrahim Malik teaching hospital is located in middle of Khartoum city .The intensive care unit of the hospital has a capacity of 6 beds.
Soba University hospital in Khartoum city. The intensive care of the hospital has 6 beds capacity.

Study duration
Page 5/12 The study was conducted in the period from November 2020 to March 2021.

Study population
All neurocritical disorders admitted to the ICU in addition to medical ICU patients who required neurologist consultations during their ICU stay during study duration.

Sampling Technique and Sample size
Non -probability sampling (Total coverage of all cases during the study period).
Sample size was 72.

Data Collection Tools and Methods
The data was collected by the principle investigator (the researcher).

Data Analysis
Data was processed by using the computerized program; Statistical package for Social Sciences (SPSS) version 23.

Ethical consideration
Sudan Medical Sepecializatin Board ethical committee approval was obtained.

Distribution according to duration of ICU stay
The duration of ICU stay was as follow: less than 48 hours for 6 (8.3%) patients, 3 to 6 days for 23 (31.9%),1 to 8 weeks for 28 (38.9%) and 14 (19.4%) stayed more than 8 weeks. See Table 2 Distribution according to duration on MV Duration on MV was as follow: less than 48 hours for 7 patients, 3 to 6 days for 13 patients, 1 to 8 weeks for 23 patients and 3 patients needed more than 8 weeks MV. See Table 3 Outcome of ICU management Regarding the outcome ,21 (29.2%) patients fully recovered ,35 (48.6%) partially recovered and 16 (22.2%) died. See Figure 2 Mortality of the common diseases in ICU The mortality of the common neurocritical diseases were as follows: stroke 30.4%. encephalitis (8.3%), status epilepticus (11.1% ) GBS (16.7%) and MG (25% ).

Some predictors of outcome
There was signi cant relation between the need for mechanical ventilation and the outcome as well as the delayed ICU admission and the outcome. See Table 4 Discussion The outcome of neurocritical disorders are with no doubt affected by the worldwide variability of the critical care services. So discrepancy is expected due to where such condition were being managed, whether in general ICU or NICU.
The need of MV was the main indication for ICU admission which was compatible with literature review and the GCS 8 or less was the main neurological indications for mechanical ventilation as usual in similar studies [10]. The delayed admission from patient side was due to two reasons either coming from outside Khartoum or due to wondering between private and governmental sectors. The duration in ICU was to some extent is similar to literature review as ,this is obvious when looking to what was found by Andreas et al, in their study : Declining mortality in neurocritical care patients, in which longer ICU length of stay may be due to delaying decisions about withdrawing life-sustaining interventions [11]. The outcome of neurocritical care management showed some differences than what was found in previous studies in the countries with well-established system of specialized intensive care, but some similarity with neighbouring countries was noticed particularly if we consider the mortality of each neurocritical disease .The outcome of managementwas compatible with some studies and not with others, this was obvious when compared with what was identi ed by Max-etal in the study : ICNARC Study of Mortality in Neurocritical Patient on ICU ,and on the other hand when compared with study that was conducted in NICU the overall mortality was higher (22% in our study versus 5.3% in study by Ibrahim et al [7]. When considering the mortality of the common diseases separately, stroke mortality was to some extend compatible with the literature review(30.4% versus 34.1%) respectively.Mortality of encephalitis was not compatible with literature review(8.2% versus 37.3%) respectively [12], but I think this is may be due to the limitations in the work up of suspected cases of encephalitis may had an impact on the diagnosis. Regarding the mortality of status epilepticus,it was compatible with range found in previous studies(11.1% versus the range of 10 to 30%) respectively [13]. The mortality of myasthenic crisis was higher when compared to what was found in NICU studies(25% versus 18.6%) respectively, on the other hand it was not so far from other studies in the countries with similar facilities in which MC mortality reached 30% [13]. GBS mortality was higher than which was found in very recent literature review (16.7% versus 6.8%) respectively.

Conclusion
This study identi ed that near two third of the patients required mechanical ventilation. Delayed admission was observed due to causes distributed between the medical side and patient side. The majority of patients were discharged from ICU with partial recovery.

RECOMMENDATIONS
Constructing NICU and comprehensive stroke units or at least stroke high dependency units is an urgent requirement for facing such very common problem.
We need increase our knowledge about neurocritical care as specialty required a joined effort between intensivists and neurologists or why not neurointensivist in the future by encouraging workshops in this eld.

Declarations
Con icts of interest: All authors declare that there are no con icts of interest. Funding: There are no funds.     Figure 1 Illustrates the need for mechanical ventilation among the study population Figure 2 Illustrates the outcome of neurocritical patients.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Outcomesupplementary.docx