Neurological Emergencies

Stroke

Hemorrhagic Stroke

Symptoms:

  • Nausea, vomiting
  • Severe headache
  • Sensitivity to light (photophobia)

Goals: Prevent further brain damage
Risk Factors: High cholesterol (HLD), congestive heart failure (CHF), atrial fibrillation (AFib)
Priorities:

  • Blood pressure control is the main focus
  • Anti-seizure medications may be considered (seizures can occur due to blood irritating the meninges or increased intracranial pressure [ICP])

Ischemic Stroke

  • tPA (tissue plasminogen activator) dosing:
    • 0.9 mg/kg
    • 10% of dose given via IV push, remainder infused over 60 minutes
    • Maximum dose: 90 mg

Basilar Artery Stroke:

  • Often involves cerebellar symptoms
  • Vertigo may be the only symptom
  • MRI is the priority, as CT may not detect these lesions

Four Types of Brain Hemorrhages

1. Epidural Hematoma

  • Caused by a blow to the temporal region, damaging the middle meningeal artery
  • Only 2% of brain bleeds but accounts for 15% of fatal head injuries
  • Progression:
    • Loss of consciousness → Lucid interval → Rapid deterioration
  • May cause Cushing’s response
  • Diagnosis: CT scan

2. Subdural Hematoma

  • Slow-growing venous bleed, common in patients with a history of alcohol use (ETOH abuse)
  • Fixed pupils (contrast: stroke usually causes sluggish pupils)

3. Subarachnoid Hemorrhage

  • Can be traumatic or spontaneous, often due to aneurysm rupture
  • Blood pressure goal: Keep MAP <110, managed with labetalol or nicardipine

4. Intraparenchymal Hemorrhage

  • Accounts for 10–20% of strokes
  • Caused by hypertension-related vessel damage, arteriovenous malformation (AVM) rupture, aneurysm, or tumor

VP (Ventriculoperitoneal) Shunt Malfunction

Symptoms:

  • Neurological changes (altered mental status, lethargy)
  • Fever (possible infection)
  • Nausea and vomiting

Diagnosis & Treatment:

  • X-ray (shunt series) to check for blockage/malfunction
  • Antibiotics (ABX) if infection is suspected

Posturing & Brain Injury

Decorticate Posturing (“To the Core”)

  • Arms pulled inward (toward the body)
  • Indicates damage to the cerebral cortex or brainstem

Decerebrate Posturing (“De-Cerebral”)

  • Arms extended away from the body
  • Indicates damage to the midbrain or lower brainstem

Seizure Disorders

Caused by excessive neuronal excitation or deficient GABA inhibition

  • Can also be triggered by tumors, brain injury, or infection

Focal Seizures (Previously “Partial Seizures”)

  • Affect one hemisphere or lobe
  • Without impaired awareness:
    • Localized symptoms (e.g., jerking movements)
    • If movements spread from one muscle group to another, it’s called a Jacksonian March
    • Patient remembers the seizure
  • With impaired awareness:
    • Memory loss or confusion after the event

Generalized Seizures

  • Tonic: Stiffness, falling backward
  • Clonic: Convulsions
  • Absence: Brief staring spells (spacing out)
  • Atonic: Sudden loss of muscle tone, falling forward
  • Myoclonic: Short muscle jerks/twitches

Treatment: Benzodiazepines

Postictal Phase

  • Period of confusion, disorientation, or altered consciousness following a seizure
  • Patient may appear “out of it” or unresponsive

Todd’s Paralysis

  • Temporary weakness or paralysis that occurs after a seizure
  • Can mimic a stroke
  • Affects one or more limbs (arms or legs)
  • Typically lasts up to 15 hours
  • Resolves within 48 hours

Guillain-Barré Syndrome

  • Also called acute inflammatory demyelinating polyneuropathy
  • Rapid onset of numbness, weakness, and ascending paralysis, affecting the legs, arms, diaphragm, and face
  • Requires intensive hemodynamic and neurological monitoring

Increased Intracranial Pressure (ICP)

Goal: Preserve physiological perfusion pressure

  • Exceeding ICP tolerance leads to exponential worsening of symptoms

Ways to Lower ICP:

  • Diuretics: Mannitol (osmotic diuretic)
  • Optimize CSF outflow: Keep patient in an upright position
  • CO₂ management: Prevent excessive vasodilation
    • Hyperventilation? Pros/cons depend on case
  • Prevent seizures and hypothermia

Cushing’s Triad (Herniation Indicator)

Occurs in increased ICP, subdural hematoma

  1. Widened pulse pressure (rising SBP)
  2. Bradycardia
  3. Abnormal respirations (Cheyne-Stokes or apneic patterns)

Spinal Shock

  • Temporary paralysis following spinal cord injury

Clearing C-Spine:

  1. Negative imaging (CT/MRI scans)
  2. Full movement of all extremities
  3. No pain or neurological deficits
  • Cannot clear C-spine in intubated patients

Treatment:

  • High-dose steroids within 8 hours (Stops damage but doesn’t reverse it)
  • Brachial plexus (C5–T1): Controls motor and sensory functions of the arm/hand
    • Neck trauma → hand pain

Complete vs. Incomplete Cord Lesions

Complete Cord Lesions

  • Rare but severe → Leads to paraplegia or quadriplegia
  • Associated with pathological reflexes

Incomplete Cord Lesions:

  • Central Cord Syndrome
    • Cervical hyperextension injury
    • Greater motor weakness in upper extremities
    • “Can’t play the piano but can dance on the dancefloor”
  • Anterior Cord Syndrome
    • Hyperflexion injury, can occlude anterior spinal artery
    • Motor function loss, but proprioception & vibration preserved
    • Worst prognosis
  • Cauda Equina Syndrome
    • “Saddle anesthesia” (numbness in groin/perineum)
    • Loss of bowel/bladder control
  • Posterior Cord Syndrome
    • Caused by hyperextension injuries or syphilis
    • Loss of vibration sensation, proprioception, and light touch
    • Positive Romberg sign (Sways when eyes are closed)

Giant Cell Arteritis (Temporal Arteritis)

  • Inflammatory condition → Increased CRP & ESR
  • Unilateral throbbing headache
  • Common in individuals >50 years old
  • Symptoms:
    • Jaw claudication (pain when chewing)
    • Fever
    • Asymmetric blood pressures
    • Bruits
    • Temporal artery tenderness

Treatment: High-dose steroids

Cluster Headaches

  • Unilateral pain in the retro-orbital or temporal region
  • Associated symptoms:
    • Excessive tearing (lacrimation)
    • Nasal congestion (rhinorrhea)
    • Facial swelling and edema
    • Pupil constriction (miosis)
  • Duration: 15 minutes to several hours
  • Treatment: Calcium channel blockers for prevention

Red Flags for Secondary Headaches (Consider Imaging)

  • HIV-positive patients
  • Uncontrolled hypertension
  • History of malignancy
  • Recent head trauma

Types of Skull Fractures

  • Linear Skull Fracture:
    • Non-displaced break in the skull bone
  • Depressed Skull Fracture:
    • Bone is pushed below the skull surface
    • Dura mater laceration possible → Infection risk
  • Temporal Bone Fracture:
    • Higher risk of epidural hematoma
  • Basilar Skull Fracture:
    • Dura mater laceration → Highest infection risk

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