Tag Archives: neurocritical care

Enhanced Recover After Surgery (ERAS) for Neuro-oncologic Surgeries

Enhanced Recovery After Surgery (ERAS) was originally conceptualized to decrease morbidity after colorectal surgery and has since been expanded to encompass other abdominopelvic surgeries.  A review article from Journal of Clinical Neuroscience (2015) applied the ERAS concept to elective craniotomies for tumor resections to facilitate hospital discharge for cancer patients, expedite subsequent chemoradiothrapy and improve patient outcome.

The guidelines proposed include:

  1. Pre-operative
    1. Patients should routinely be counselled on what to expect from surgery. (Low, Strong)
    2. Patients should abstain from alcohol and smoking 1 month prior to surgery (Mod, Strong)
    3. Patients should be given enteral nutrition preoperatively. (Mod, Strong)
    4. Patients may benefit from immunonutrition perioperatively. (Mod, Weak)
    5. Patient should be encouraged to load with carbohydrates perioperatively.*  (Low, Strong)

*Perioperative oral CHO loading up to 2 hours prior to surgery has been shown to attenuate insulin resistance and improve subjective feelings of hunger, thirst, and post-operative fatigue compared with fasting.  As CHO beverages are a clear liquid, perioperative CHO loading should be encouraged.

  1. Intra-operative 
    1. Surgeon should minimize scalp shaving. (Mod, Weak)
    2. Cefazolin should be given within 1 hour prior to skin incision.  For patients with MRSA, vancomycin should be initiated 1 hour prior to skin incision. (High, Strong)
    3. Surgeon should utilize scalp in filtration and scalp blocks for craniotomies. (Mod, Strong)
    4. There is no evidence that short-acting anesthetics are superior to longer acting anesthetics, nor TIVA to pure inhalational anesthetics.
    5.  Minimally invasive surgery may improve patient recovery and satisfaction. (Very low, Weak)
  2. Post-operative
    1. Gabapentin / pregabalin / tramadol have side effect profiles that are unfavorable for craniotomy. (Low, Weak)
    2. Low evidence for efficacy of intravenous acetaminophen, but side effect profile is favorable.  (Mod, Strong)
    3. There may be a role for limited dosing of COX-2 inhibitors and flupirtine pending further research.  (Low, Weak)
    4. Routine serotonin receptor antagonists and dexamethasone is recommended for PONV.  (High, Strong)
    5. Aprepitant should be reserved for patients at high risk of PONV due to higher cost and limited effectiveness.  TEAS (transcutaneous electrical acupoint stimulation) requires further study.  (Low, Weak)
    6. Scopolamine and promethazine side effect profiles make them undesirable as first-line nausea meds.  (Low, Weak)
    7. Avoid hypothermia.  (High, Strong)
    8. Remove Foley on posteroperative day 1 or as early as feasible.  (Mod, Strong)
    9. Post-operative TPN not needed except for patients in prolonged comatose state.  (Mod, Strong)
    10. Encourage early mobilization.  (High, Strong)
  3. Others:
    1. Patients should use graduated compression stockings and intermittent pneumatic compression to prevent VTE.  Routine use of anticoagulants is not recommended. (High, Strong)
    2. Audit measure routinely.  (Mod, Strong)




Sample Neurosurgery-ERAS Guideline given to patients from Penn medicine: ERAS Neurosurgery


Hagan, K., Bhavsar, S., Raza, S., Arnold, B., Arunkumar, R., Dang, A., Gottumukkala, V., Popat, K., Pratt, G., Rahlfs, T. and Cata, J. (2016). Enhanced recovery after surgery for oncological craniotomies. Journal of Clinical Neuroscience, 24, pp.10-16.



Procedure for Securing Integra Lumbar Drain





LHH Department of Neurosurgery Guideline. <pdf attached>


Arteriovenous Malformation Scores

Table.  Predictive grading systems for procedural risk in the endovascular treatment of brain AVMs.Capture


Buffalo score best predicts procedural risks, although predictive value is modest (AUC ~0.7).



Pulli, B., Stapleton, C., Walcott, B., Koch, M., Raymond, S., & Leslie-Mazwi, T. et al. (2019). Comparison of predictive grading systems for procedural risk in endovascular treatment of brain arteriovenous malformations: analysis of 104 consecutive patients. Journal Of Neurosurgery, 1-9. doi: 10.3171/2019.4.jns19266


Guidelines for DVT Prophylaxis in Neurocritical Care (from NCS)

DVT Chemoprophylaxis Guideline Recommendations (summary) from the Neurocritical Care Society (published in 2016).



  1. We recommend initiating VTE pharmacoprophylaxis as soon as is feasible in all patients with acute ischemic stroke. (Strong recommendation and high-quality evidence)
  2. In patients with acute ischemic stroke and restricted mobility, we recommend prophylactic-dose LMWH over prophylactic-dose UFH in combination with IPC. (Strong recommendation and high-quality evidence)
  3. Due to insufficient evidence, the panel could not issue a recommendation regarding the use of CS for VTE prophylaxis although their use does not appear to be harmful.
  4. In stroke patients undergoing hemicraniotomy or endovascular procedures, we suggest the use of UFH, LMWH, and/or IPC for VTE prophylaxis in the immediate postsurgical or endovascular epoch except when patients have received rTPA, in which case prophylaxis should be delayed 24 h. (Weak recommendation and low-quality evidence)


  1. We recommend the use of IPC and/or GCS for VTE prophylaxis over no prophylaxis beginning at the time of hospital admission. (Strong recommendation and high-quality evidence)

  2. We suggest using prophylactic doses of subcutaneous UFH or LMWH to prevent VTE in patients with stable hematomas and no ongoing coagulopathy beginning within 48 h of hospital admission. (Weak recommendation and low-quality evidence)

  3. We suggest continuing mechanical VTE prophylaxis with IPCs in patients started on pharmacologic prophylaxis. (Weak recommendation low-quality evidence)



  1. We recommend VTE prophylaxis with UFH in all patients with aSAH (Strong recommendation and high-quality evidence) except in those with unsecured ruptured aneurysms expected to undergo surgery. (Strong recommendation and low-quality evidence)

  2. We recommend initiating IPCs as VTE prophylaxis as soon as patients with aSAH are admitted to the hospital. (Strong recommendation and moderate-quality evidence)

  3. We recommend VTE prophylaxis with UFH at least 24 h after an aneurysm has been secured by surgical approach or by coiling. (Strong recommendation and moderate-quality evidence)


  1. We recommend initiating IPC for VTE prophylaxis within 24 h of presentation of TBI or within 24 h after completion of craniotomy as supported by evidence in ischemic stroke and postoperative craniotomy. (Weak recommendation and low-quality evidence)
  2. We recommend initiating LMWH or UFH for VTE prophylaxis within 24–48 h of presentation in patients with TBI and ICH, or 24 h after craniotomy. (Weak recommendation and low-quality evidence).
  3. We recommend using mechanical devices such as IPC for VTE prophylaxis in patients with TBI, based on data from other Neurological injuries such as ischemic stroke. (Weak recommendation and low-quality evidence).


We recommend VTE prophylaxis with either LMWH or UFH upon hospitalization for patients with brain tumors who are at low risk for major bleeding and who lack signs of hemorrhagic conversion. (Strong recommendation and moderate-quality evidence).


  1. We recommend initiating VTE prophylaxis as early as possible, within 72 h of injury. (Strong recommendation and high-quality evidence)
  2. We recommend against using mechanical measures alone for VTE prophylaxis. (Weak recommendation and low-quality evidence)
  3. We recommend LMWH or adjusted dose UFH for VTE prophylaxis as soon as bleeding is controlled. (Strong recommendation and moderate-quality evidence)
  4. If VTE prophylaxis with LMWH or UFH is not possible, we suggest mechanical prophylaxis with IPC. (Weak recommendation and low-quality evidence)


  1. We recommend using prophylactic doses of UFH (bid or tid) LMWH, or fondaparinux as the preferred method of VTE prophylaxis. (Strong recommendation and moderate-quality evidence)
  2. We recommend using IPC for VTE prophylaxis for patients in whom the bleeding risk is deemed too high for pharmacologic prophylaxis. (Strong recommendation and moderate-quality evidence)
  3. We suggest combining pharmacologic and mechanical VTE prophylaxis (with IPC) in patients with neuromuscular disease. (Weak recommendation and low-quality evidence)
  4. We suggest using GCS only for VTE prophylaxis in patients in whom neither pharmacologic prophylaxis nor IPC use is possible. (Weak recommendation and low-quality evidence)
  5. We suggest continuing VTE prophylaxis for an extended period of time, at a minimum for the duration of the acute hospitalization, or until the ability to ambulate returns. (Weak recommendation and very low-quality evidence)


  1. Ambulatory back surgery with unique positioning strategies such as prone or kneeling has been associated with zero rates of VTE, and we suggest considering the use of IPC only for VTE prophylaxis in this surgical population. (Weak recommendation and low-quality evidence)
  2. In standard elective spine surgery, we recommend using ambulation with mechanical VTE prophylaxis (GCS or IPC) alone, or combined with LMWH. In patients with increased risk for VTE, we recommend combined therapy with ambulation, GCS or IPC, and LMWH. (Strong recommendation and moderate-quality evidence).
  3. Because of the increased risk of bleeding, we recommend using UFH only as an alternative to other methods of VTE prophylaxis. (Strong recommendation and moderate-quality evidence)


  1. We recommend using IPC with LMWH or UFH. (Strong recommendation and moderate-quality evidence)
  2. We recommend against the routine use of IVC filters in the setting of severe spinal cord injury or complicated spine surgery. (Weak recommendation and low-quality evidence)
  3. We suggest considering a removable prophylactic IVC filter as a temporary measure only in patients with PE and DVT or those with DVT at risk for PE who cannot be anticoagulated. (Weak recommendation and low-quality evidence)


  1. We recommend using IPC with either LMWH or UFH within 24 h after craniotomy. (Strong recommendation and moderate-quality evidence)
  2. We recommend the use of IPC with LMWH or UFH within 24 h after standard craniotomy in the setting of glioma resection. (Strong recommendation and moderate-quality evidence)


  1. We suggest the use of CS and IPC until the patient is ambulatory. (Weak recommendation and low-quality evidence)
  2. We suggest immediate prophylactic anticoagulation with LWMH or UFH. (Weak recommendation and low-quality evidence)


  1. We recommend initiating pharmacoprophylaxis with UFH and/or mechanical VTE prophylaxis with IPC or CS in patients with hemiparesis from stroke or other neurological injury within 24 h if activated prothrombin time is measured. (Weak recommendation and low-quality evidence) If during the procedure rTPA or other thrombolytics are used, then extra caution is advised, and delay of initiation of chemoprophylaxis only for at least 24 h after the procedure should be considered. (Weak recommendation and low-quality evidence)
  2. Patients undergoing elective procedures may not require LMWH or UFH, but may benefit from early ambulation, and/or mechanical prophylaxis with IPC or CS. (Weak recommendation- very low-quality evidence)



Nyquist, P., Bautista, C., Jichici, D., Burns, J., Chhangani, S., DeFilippis, M., Goldenberg, F., Kim, K., Liu-DeRyke, X., Mack, W. and Meyer, K. (2015). Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocritical Care, 24(1), pp.47-60.


Cilostazol for DCI Prevention

Cilostazol is a phosphodiesterase III inhibitor which increases cAMP and leads to reversible inhibition of platelet aggregation, vasodilation and inhibition of vascular smooth muscle cell proliferation.  A systematic review was recently published in the Journal of Neurology on the effect of cilostazol on the incidence of delayed cerebral ischemia in subarachnoid hemorrhage (Department of Neurosurgery, West China Hospital).

The meta-analysis included seven studies, all of which were done in Japan:  three were randomized controlled studies, 3 were retrospective studies and one was a prospective study.  Most studies used cilostazol at 200mg per day for 14 days.


Forest plots for the outcomes provided below:

A. Severe angiographic vasospasm

forest plot 1

B. Symptomatic vasospasm

forest plot 2

C. New cerebral infarction

forest plot 3

D. Poor outcome

forest plot 4

E.  Mortality

forest plot 5

Adverse effects related to cilostazol administration in the studies include diarrhea, transaminitis, tachycardia, headaches, hemorrhagic and cardiac events.

The meta-analysis concluded that cilostazol effectively reduced the incidence of severe angiographic vasospasm, symptomatic vasospasm, new cerebral infarction and poor outcome in patients with aneurysmal subarachnoid hemorrhage, but does not reduce mortality significantly.

It is important to note that all of the studies included in the meta-analysis were from one country (Japan), which precludes the generalization of the results to the general population.  Also, none of the patients in the studies received nimodipine, which has not been approved for SAH treatment in Japan.  Whether or not the co-administration of nimodipine would add to or nullify the benefits seen with cilostazol requires further investigation.

Take home message:  should not change current practice, needs further research.



Shan, T., Zhang, T., Qian, W., Ma, L., Li, H., You, C. and Xie, X. (2019). Effectiveness and feasibility of cilostazol in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Journal of Neurology.

Uptodate.com. (2019). UpToDate. [online] Available at: https://www.uptodate.com/contents/cilostazol-drug-information?sectionName=Adult&topicId=8872&search=cilostazol&usage_type=panel&anchor=F151445&source=panel_search_result&selectedTitle=1~36&kp_tab=drug_general&display_rank=1#F151413 [Accessed 6 Apr. 2019].

A New Algorithm to Differentiate Salt-wasting Syndrome from SIADH

In cerebral salt-wasting (CSW), natriuretic factor is produced in response to a central insult.  Natriuretic factor decreases sodium transport in proximal renal tubule which leads to urinary loss of sodium (and water) and depletion of extracellular volume.  Hypovolemia then triggers secretion of ADH, renin and aldosterone, which provides a negative feedback to decrease secretion of natriuretic factor.


Differentiating CSW from syndrome of inappropriate antidiuretic hormone (SIADH) is problematic, laboratory work-up (urine and plasma sodium levels and urine and plasma osmolarity) is similar in both conditions.  CSW patients are usually volume depleted while SIADH patients are euvolemic.  The traditional approach of examining patient clinically to to determine volume status is inaccurate.

An interesting paper published in 2014 suggested a new algorithm to differentiate SIADH from CSW based on the effect of sodium correction on the fractional excretion of urate (FEUa).  FEurate is calculate using the folllowing formula:






Another formula:



Normal FEUa = 4-11%, SIADH & CSW FEUa = >11%.  FEUa determines the percent excertion of the filtered load of urate at the glomerulus.

In SIADH, FEUa normalizes after correction of hyponatremia (see graph below):


whereas in CSW, FEUa remains elevated >11% after correction of hyponatremia.  The reason is probably because natriuretic factor also decreases urate transport in the proximal tubule.



Based on this finding, the paper suggests a new algorithm for determining the etiology of hyponatremia that omits reliance of UNa (and also plasma renin, aldosterone, atrial or brain antriuretic peptide, BUN/creatinine ratio).


Based on this algorithm, a patient with hyponatremia should undergo correction of sodium by any means (water restriction or isotonic / hypertonic saline). Observing whether FEUa normalizes or remains increased would differentiate SIADH from CSW syndrome.






Maesaka, J., Imbriano, L., Mattana, J., Gallagher, D., Bade, N. and Sharif, S. (2014). Differentiating SIADH from Cerebral/Renal Salt Wasting: Failure of the Volume Approach and Need for a New Approach to Hyponatremia. Journal of Clinical Medicine, 3(4), pp.1373-1385.



CPT Codes Relevant to Neurocritical Care Practice



  • 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30 to 74 minutes
  • 99292 each additional 30 minutes (list separately in addition to code for primary service

Document and explain why patient is critically ill.  Critically ill indicates “a high probability of imminent or life-threatening deterioration in the patient’s condition.”  Decision making and treatment must include an indication that the patient’s condition met that definition as well as considerations and plans to prevent life-threatening deterioration or organ system failure.

Code 99291 covers the initial 30 to 74 minutes on that day. Code 99292 covers the additional 30-minute time increments. Use 99292 when time totals 75 minutes or more. When using 99292, documentation should show why time was needed beyond the first hour.

Below is a list of the commonly encountered neurologic disorders that often justify use of critical care codes

  • Acute spinal cord compression or injury
  • Acute stroke
  • Coma after cardiac arrest
  • Coma of unknown etiology
  • Guillain-Barré syndrome
  • Intracerebral hemorrhage
  • Malignant intracranial pressure
  • Meningoencephalitis
  • Myasthenic crisis
  • Neuroleptic malignant syndrome
  • Paraneoplastic encephalitis
  • Status epilepticus
  • Subarachnoid hemorrhage
  • Traumatic brain injury


  • Consulting on a patient who is critically ill is not necessarily a critical care service. The use of the critical illness code is dependent on the patient’s critical illness and the neurointensivist’s actions to address the illness.
  • The patient’s location is not key. A patient may be in the emergency department or still on a floor unit and yet be critically ill.
  • Only one neurointensivist may submit critical care code 99291 on a particular calendar date. Provider must document at least 30 minutes of critical care time. Additional time may be aggregated with a second neurointensivist from the same practice group (ie, one physician may code for the sum of time of both physicians). Or, additional time may be submitted by second neurointensivist with code 99292.
  • A physician may not aggregate time with nonphysician practitioners or residents. Nonphysician practitioner’s time is counted separately from that of any physician.
  • Rules for physician assistants vary depending on hospital, carrier or state. Some combine nurse practitioners and physician assistants under the term nonphysician practitioner.

Total time for critical care services include:

  • time spent on the patient’s unit reviewing test results or imaging studies
  • time spent discussing the patient’s case with other medical staff
  • time spent documenting critical care services
  • time spent caring for the patient in the ED or in radiology department while the patient is in radiology

Total time for critical care services does not include:

  • resident’s time and teaching sessions with residents
  • providing routine updates to the family
    • Time with a surrogate decision maker can count as critical care time if the patient is unable to give a history or make decisions. Document the discussion as necessary to determine treatment decisions, preferably summarizing the conclusions or options discussed.

Procedures bundled into CPT codes 99291 and 99292 that do not require separate coding include the following:

  • Blood draw for specimens including for blood gases
  • Gastric intubation
  • Information data stored in computers (eg, ECGs)
  • Interpretation of cardiac output measurements
  • Interpretation of chest x-rays
  • Pulse oximetry
  • Temporary transcutaneous pacing
  • Ventilator management
  • Vascular access procedures


Procedures that may be coded separately include:

  • lumbar puncture
  • endotracheal intubation
  • placement of a flow-directed catheter
  • cardiopulmonary resuscitation
  • placement of a ventricular catheter
  • interpretation of an EEG
  • performance of nerve conduction studies

When performing these other procedures, use modifier 25 with the critical care codes to indicate that procedures and evaluation and management were performed on the same day.

Lumbar puncture has three different CPT codes. The three CPT codes are:

  • 62270 Spinal puncture, lumbar, diagnostic
  • 62272 Spinal puncture, therapeutic, for drainage of CSF (by needle or catheter)
  • 62273 Injection, epidural, of blood or clot patch

Neurodiagnostic and monitoring procedures for EMG, nerve conduction studies, and EEG may be coded separately.

The following monitoring and emergency procedures also are among those commonly coded separately in the critical care unit:

  • 31500 Intubation, endotracheal, emergency procedure
  • 93503 Insertion and placement of flow-directed catheter (eg, Swan-Ganz) for monitoring purposes
  • 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest)


Two CPT codes allow for coding of the time spent in discussions and preparation of advance care plans.  These codes cannot be used by the same physician on the same day he or she uses CPT code 99291.  Examples of written advance directives include healthy care proxy, durable power of attorney for health care, living will and MOLST.  The two CPT codes for time spent in discussion and preparation of these forms are:

  • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 each additional 30 minutes (list separately in addition to code for primary procedure)


Prolonged services are not used with the primary codes 99291 and 99292. Subsequent day hospital management is coded as 99233, base time for this code is 35 minutes. When time spent exceeds base time by more than 30 minutes, physician may add a prolonged service code:


  • 99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for Evaluation and Management service)
  • 99357 each additional 30 minutes (list separately in addition to code for prolonged service)


Telemedicine is coded using the standard CPT codes plus a modifier. In January 2017, the modifier of choice changed from GT to 95. Modifier 95 identifies a “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.”

CPT specifies two codes for telehealth critical care:

  • 0188T Remote real-time interactive video-conferenced critical care, evaluation, and management of the critically ill or critically injured patient; first 30 to 74 minutes
  • 0189T each additional 30 minutes (list separately in addition to code for primary service)

When providing telehealth, use Place of Service 02, which is a new place of service code as of January 2017.

Patients covered by Medicare Part B are eligible for remote critical care only if they are hospitalized in a rural area.  Medicare uses different codes for remote critical care. Medicare also makes an exception by covering certain teleconsultations for acute stroke within 4.5 hours of symptom onset. The critical care telehealth codes for patients with Medicare are included in the Healthcare Common Procedure Coding System:

  • G0508 Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth
  • G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth


A neurointensivist might provide a telephone consultation directly with a physician who is caring for a patient at a remote hospital.  These circumstances include urgent situations where a timely face-to-face service with the consultant may not be feasible.  The codes may not be used if the consultant has or will see the patient within 14 days. This code is not to arrange for transfer of care.  The time for the service may include review of records and images if the time consulting with the primary physician is more than half of the documented time. The code may be used only once per week for the same patient by the same physician.

The CPT codes for interprofessional telephone/Internet consultations are as follows:


  • 99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5 to 10 minutes of medical consultative discussion and review
  • 99447 11 to 20 minutes of medical consultative discussion and review
  • 99448 21 to 30 minutes of medical consultative discussion and review
  • 99449 31 minutes or more of medical consultative discussion and review


  1. Downcoding: might happen when an attending physician’s note uses accurate language in referring to the patient as critically ill with a high probability of imminent or life-threatening deterioration, but a resident’s note on the same day makes such a statement as, “stable and may be transferred to the floor tomorrow.”
  2. Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient’s condition continues to require the level of attention necessary in critical care. Notes that fail to change over days give the auditor the impression that the patient’s condition is stable, even if that is not true.  Details in the note should show the work accomplished and planned that day.
  3. The neurocritical care patient is at risk of imminent death due to further brain injury, which can occur unpredictably and rapidly cause multiorgan dysfunction and death.
  4. Include high-risk rationale. Emphasize specific reasons for neuroprotective strategies in critical care such as mechanical ventilation, osmolar therapy, temperature management.
  5. Document existing protocols and specific interventions in the physician’s progress notes. For example, document a 50% risk of imminent stroke or death if that is the case for that patient with new-onset vasospasm.


All CPT codes listed above are copyrighted.  CPT © 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


Link to file in MS Word: CPT Codes Relevant to Neurocritical Care

Link to file in pdf:  CPT Codes Table NCC

Link to file in pdf:  CPT Codes List NCC


Nuwer, M. and Vespa, P. (2018). Neurocritical Care Coding for Neurologists. CONTINUUM: Lifelong Learning in Neurology, 24(6), pp.1800-1809.