Twenty-two years ago, I wandered into an eight-bed ICU dedicated to caring for critically ill neurologic and neurosurgical patients to begin my fellowship training in Neurosciences Critical Care. Very few such units existed; there were only two trained Fellows in the country, and this was the only one that actually paid the Fellows a salary. Having just completed my residency in neurology, I was not particularly well prepared for the task ahead, in terms of either knowledge or approach to patient care. I had much to learn not only about the brain but also about how the heart, lungs, kidney, etc. affected the brain. More importantly, I had to learn how to take care of “sick” patients, manage ventilators, insert Swan-Ganz catheters, feed patients, and treat infections. Finally, I had to radically alter how I approached patients. No longer was the adage “time is a neurologist's best friend” an acceptable approach to diagnosis and treatment. No one had even considered writing a textbook on neurocritical care. Most of my peers could not understand why I would want to pursue neurocritical care.

Since then things have changed considerably. Most academic centers have or want a neuro ICU; some have more than thirty beds. There is now board certification for neurointensivists, who are recognized by Leapfrog and have a thriving subspecialty journal and a society with almost a thousand members. Equally important is the growing appreciation by other intensivists of what they can offer to critically ill patients with neurologic conditions. No longer do they see the brain as a “black box” that is best ignored, but rather they are embracing brain-specific monitoring and interventions.