Neurological Emergencies

Neurological Emergencies
ELIAD CULCEA, MD.

ATLAS NEUROLOGY
GREAT FALLS
Alteration in Consciousness
Consciousness
 Arousal
 primitive set of responses
 depends on structures located in the brainstem. ARAS
 Awareness
 high level integration of multiple sensory inputs.
 Resides into the cerebral cortex.

Vegetative state
 Bilateral diffuse cerebral cortex failure.

 Intact arousal mechanism.
 Most commonly results from diffuse anoxic or
ischemic injury.
Brainstem failure
 Impaired arousal mechanisms.

Diagnosis of Consciousness Alterations
 History is important:
 trauma
 illnesses
 medications
 drugs, alcohol.
 Psychiatric disorders.
Physical exam
 General:
 vital signs
 skin (trauma, needle marks, etc)
 head (trauma)
 neck stiffness (attention in trauma)
 chest, abdomen, heart, extremities
 breath (liver dysfunction, alcohol, uremia, ketoacidosis in

diabetes)
Neurological exam
 Observation of patient
 position
 spontaneous motions
 open eyelids and/or hanging jaw =extremely deep coma.

Neurological exam
 Level of consciousness (from mild to severe)

 confusion, delirium
 drowsiness
 stupor
 light coma
 deep coma
Neurological exam
 Position of head and eyes

 deviations of the head and eyes
 spontaneous rowing eye movements
 Funduscopy exam
 Pupils (reactivity to light, asymmetry)
 Doll’s eyes test
 Ice water caloric
Coma etiology
 Non convulsive status epilepticus

 Trauma
 Vascular diseases
 Infectious
 Neoplasms
 Systemic causes
 metabolic
 hypoxic
 toxic
Laboratory Tests
 Routine tests
 Toxins screen
 MRI or CT scan
 Spinal Tap
 EEG
 Angiography
Infections
Infections
 Meningitis
 Viral
 Bacterial
 Fungus
 Encephalitis
 Viral
 Bacterial
 Usually abscess
Clinical Presentation
 Fever
 Headache
 Stiff neck
 Change in the level of consciousness
 Seizures
 History of immunosuppression, head trauma,
sickle cell anemia, local infections.
 Type of bacteria depending on age and immune
status
Diagnosis
 Spinal tap is the most important tool.

 A CT scan of head should be performed.
 PT, PTT and thrombocyte count.
 Informed consent.
CSF Studies
 Tube 1
 glucose (get a fingerstick BS too)
 protein
 Tube 2
 Cultures
 bacterial
 PCR meningitis panel
 AFB,
 fungus cultures
CSF Studies cont.
 Tube 3
 cell count with differential
 Tube 4
 cytology if needed
 Remember to order to hold the remaining CSF

Prognosis
 Depends on the offending agent

 Depends on the age of patient
 Depends on the Immune system status
Treatment
 Initial treatment is empirical based on the age and

other contributory factors.
 When CSF data is available then modify the
treatment accordingly
Status Epilepticus
Status Epilepticus
 Definition
 generalized seizures lasting more than 30 minutes or repeated
seizures without regain of consciousness between the seizures
for 30 minutes.
Status Epilepticus
 Can occur in new onset seizure disorder

 Patient known with seizure disorder who stop
suddenly the medications
 Alcohol withdrawn
 Drug abuse (cocaine, amphetamines)
 CNS infections (especially herpes encephalitis)
Treatment
 Start Lorazepam 1-4 mg iv.

 Prepare and start Fosphenytoin (Cerebrix) 20 mg
PE/Kg IV at a rate of up to 50mg PE/min.
 If seizures not stopped then give IV 10 more
milligrams PE/Kg
 If seizures not stopped then Keppra 1g IV.
 If seizures not stopped then Phenobarbital IV 20
mg/Kg (attention to the BP)
 If seizures not stopped then intubate and start
barbituric coma under EEG monitoring.
Treatment
 After the seizures stopped do further diagnosis tests

to clarify the etiology of the event.
 If possible treat the etiology of the status epilepticus.
Stroke
Stroke
 Ischemic about 90%

 Anterior circulation about 80%
 Posterior circulation about 20%
 Hemorrhagic about 10%

TPA protocol for ischemic stroke
 Inclusion criteria:
 age 18 or older
 time of onset less than 4.5 hours
 clear stroke presentation

 significant weakness
 significant speech difficulty (aphasia)
 substantial visual deficit
 patient awake or drowsy
 Exclusion criteria:
 history of stroke in the previous 3 months
 history of intracranial hemorrhage ever
 serious head trauma in the previous 3 months
 history of GI or urinary bleeding in the previous 21 days
 major surgery in the previous 14 days
 lumbar puncture in the previous 7 days

 Exclusion criteria: (cont.)

 arterial puncture in a non-compressible site
 pregnancy, lactation, or parturition within previous 30 days
 coma
 minor stroke symptoms
 major stroke symptoms improving rapidly
 clinical presentation of arachnoid hemorrhage with normal CT

examination
 Exclusion criteria: (cont.)

 SPB >185 or DBP >110 at the time of treatment
 associated serious medical or terminal illness
 seizure at stroke onset
 acute MI or pericarditis at stroke onset
 platelet count < 100,000
 PT INR >1.7; PTT >37; blood sugar <50 or >400
 hemorrhagic stroke by CT
 in the case of early signs of stroke by CT TPA should
be avoided
 Laboratory orders:
 STAT
CBC, platelet count, PT, PTT, blood sugar, renal

panel
CT of the head
EKG
 review lab results and review inclusion/exclusion
criteria
 treat SPB > 185 or DBP > 110 with Labetalol 1- mg IV
(over 2 min.) can be repeated once after 10 minutes
 Vital signs and neuro checks q 15 min.

 give TPA dose if less than 4.5 hours from stroke
onset
 TPA dose:
 0.9 mg/kg; maximum dose 90 mg regardless of the patient weight.
 10% is given in bolus over 1 minute and the remaining 90%
infused over 60 minutes)
Mechanical Thrombectomy
 Major advancement in stroke care

 We have robust data and indications for the anterior
circulation large vessels occlusion
 Obtain CTA after TPA is administrated
 Obtain CTA if there are contraindications to the TPA
and the time of onset is less than 24 hours
 Perfusion/diffusion mismatch
Myasthenia Gravis
Myasthenia Gravis
 Autoimmune disorder were antibodies are directed

toward neuromuscular junction acetylcholine
receptors.
 Basic treatment consists in:
 Anticholinesterase drugs
 drugs that induce immunosuppression
Myasthenic crisis
 Changes in the absorption of medication or the

natural worsening of the disease may cause
increased weakness
 Anticholinesterase medication have a bell-shaped
dose-response curve and too much medication can
induce weakness
Myasthenic crisis
Medications that can worsen the

neuromuscular junction transmission
 Quinine  Polymixin
 Quinidine  Viomycin
 Procainamide  Colistin
 Propranolol  Morphine
 Lidocaine  Barbiturates
 Aminoglycoside  Sedatives
 Quinolones  Magnesium
supplements
Myasthenic crisis
 Treatment
 admit into intensive care unit for monitoring
 monitor respiratory function and not the pulse oximetry
 intubate electively if decrease in respiratory function or in

difficulties in protecting the airways
 plasmapheresis or IVIG can be used for the treatment
Myasthenic crisis
 If patient is intubated you can decrease the

anticholinesterase drugs to see if the weakness is due
to overdose
 If patient is on oral pyridostigmine (Mestinon) and
you want to give it IV the ratio oral/IV is 30/1 mg
Guillain Barré
Syndrome
Guillain Bare Syndrome
 Autoimmune disorder
 Antibodies directed toward peripheral nerves myelin
sheets
 Usually occurs a couple of weeks after a viral illness
 Patient has progressive weakness that starts distally
 It may involve respiratory muscles
Guillain Bare Syndrome
 Patient needs monitoring of respiratory function and

not pulse oximetry
 Intubate electively if decreased in respiratory
function or difficulty protecting the airways
 Treatment is either plasmapheresis or IVIG, the
steroids are not useful.
Spinal cord
compression
Spinal cord compression/myelopahy
 Trauma
 Disc herniation
 Synovial cysts
 Medical conditions
 metastasis
 multiple myeloma
 lymphomas
 lung cancer
 breast cancer
 prostate cancer
 kidney cancer
 sarcomas
Spinal cord compression/myelopathy
 Clinical features
 Examination shows upper motor neuron signs
 Babinsky present
 Brisk DTR
 prodrome (can precede the event weeks to months)
 unremitting severe back pain
 unremitting severe radicular pain
 or both
 stage of spinal compression
 subtle weakness and/or numbness in the legs
 urinary hesitancy, urgency and retention
 in a few day patient becomes paraplegic
Spinal cord compression/myelopathy
 MRI with contrast or CT myelogram are the exams of

choice
 Spinal cord ends at L1, obtain the imaging of the proper CNS
section/s
 Plain CT of spine is not enough
 Treatment
 Directed by the nature of the spinal cord lesion
 IV steroids
 radiation therapy
 surgery

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Neurological Emergencies

ELIAD CULCEA, MD.

 depends on structures located in the brainstem. ARAS

 Resides into the cerebral cortex.

 Bilateral diffuse cerebral cortex failure.

 Impaired arousal mechanisms.

 skin (trauma, needle marks, etc)

 neck stiffness (attention in trauma)

 chest, abdomen, heart, extremities

 breath (liver dysfunction, alcohol, uremia, ketoacidosis in

 open eyelids and/or hanging jaw =extremely deep coma.

 Level of consciousness (from mild to severe)

 Position of head and eyes

 spontaneous rowing eye movements

 Non convulsive status epilepticus

 Spinal tap is the most important tool.

 Remember to order to hold the remaining CSF

 Depends on the offending agent

 Initial treatment is empirical based on the age and

 Can occur in new onset seizure disorder

 Start Lorazepam 1-4 mg iv.

 After the seizures stopped do further diagnosis tests

 Ischemic about 90%

 Posterior circulation about 20%

 Hemorrhagic about 10%

 time of onset less than 4.5 hours

 clear stroke presentation

 history of intracranial hemorrhage ever

 serious head trauma in the previous 3 months

 history of GI or urinary bleeding in the previous 21 days

 major surgery in the previous 14 days

 lumbar puncture in the previous 7 days

 Exclusion criteria: (cont.)

 pregnancy, lactation, or parturition within previous 30 days

 minor stroke symptoms

 major stroke symptoms improving rapidly

 clinical presentation of arachnoid hemorrhage with normal CT

 Exclusion criteria: (cont.)

CBC, platelet count, PT, PTT, blood sugar, renal

 Vital signs and neuro checks q 15 min.

 Major advancement in stroke care

 Autoimmune disorder were antibodies are directed

 Changes in the absorption of medication or the

Medications that can worsen the

 monitor respiratory function and not the pulse oximetry

 intubate electively if decrease in respiratory function or in

 If patient is intubated you can decrease the

 Patient needs monitoring of respiratory function and

 MRI with contrast or CT myelogram are the exams of

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