Neurological EmergenciesNeurological Emergencies

Prof. Dr. Çiğdem ÖzkaraProf. Dr. Çiğdem Özkara

Goal of an emergent Neurological Goal of an emergent Neurological ExaminationExamination

Is there a neurologic condition ?Is there a neurologic condition ?

Where is (are) the lesion(s) located ?Where is (are) the lesion(s) located ?

What are the possible causes?What are the possible causes?

Can the patient discharged from ER safely Can the patient discharged from ER safely or is hospitalisation needed ?or is hospitalisation needed ?

Anatomical basis of NEAnatomical basis of NE

BrainBrain

Brain stemBrain stem

Spinal cordSpinal cord

NervesNerves

MusclesMuscles

Anatomical basis of NEAnatomical basis of NE

BrainBrain– Alteration of thought process or Alteration of thought process or

consciousness, consciousness, – Seizures, involuntary movementsSeizures, involuntary movements– Motor and sensory deficit on the Motor and sensory deficit on the

same sidesame side

BrainstemBrainstem– Cranial nerve deficits in Cranial nerve deficits in

association with motor association with motor and sensory deficitand sensory deficit

– Diplopi, vertigo, dysartria, Diplopi, vertigo, dysartria, dysphagia,disequilibriumdysphagia,disequilibrium

NervesNerves– Motor and sensory deficitsMotor and sensory deficits– Reflex absent or Reflex absent or

decreaseddecreased– Findigs limited to nerve Findigs limited to nerve

root or spesific nerveroot or spesific nerve– Distal symptoms prominent Distal symptoms prominent

than proximalthan proximal

MusclesMuscles– Weakness (bilat and simm Weakness (bilat and simm

prominent)prominent)– Sensation usually normalSensation usually normal– Reflexes generally Reflexes generally

preservedpreserved

Spinal cordSpinal corda)a) Well demarcated level Well demarcated level

sensory or motor. sensory or motor. b)b) Sensory dissociation:Sensory dissociation:

a)a) decreased pain on decreased pain on one side,decreased one side,decreased vibration and position vibration and position on the other sideon the other side;;

b)b) sensory deficit on one sensory deficit on one side, motor deficits on side, motor deficits on the other sidethe other side

a)a) Mixed upper and lower Mixed upper and lower MNMN

Spesific conditions presenting Spesific conditions presenting as emergencyas emergency

CVA (cerebro vascular CVA (cerebro vascular accedant)accedant)

InfectionsInfections

Movement disordersMovement disorders

PNS (polyneuritis) and PNS (polyneuritis) and neuromuscular disordersneuromuscular disorders

Guillain-Barre Synd.Guillain-Barre Synd.

Myastenia GravisMyastenia Gravis

Musculoscletal and Musculoscletal and neurogenic painneurogenic pain

Multiple SclerosisMultiple Sclerosis

Neuro-ophtalmologicalNeuro-ophtalmological

DementiaDementia

Brain tumorsBrain tumors

Increased Intra Cranial Increased Intra Cranial Pressure and herniation synd.Pressure and herniation synd.

Normal pressure Normal pressure hydrocephalushydrocephalus

Nontraumatic spinal cord Nontraumatic spinal cord emergenciesemergencies

Sleep disordersSleep disorders

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

SeizuresSeizures

Gait disturbancesGait disturbances

Altered mental statusAltered mental status

CNS dysfunction; global, diffuse, bilateral CNS dysfunction; global, diffuse, bilateral hemispheric, unilateral hemispheric with hemispheric, unilateral hemispheric with brain stem impairment (i.e.compression) brain stem impairment (i.e.compression) or primary brainstem dysfunctionor primary brainstem dysfunction

Function;Function;– decreased: coma, coma like statesdecreased: coma, coma like states– Increased: deliriumIncreased: delirium

ComaComa

Coma can be described as an eyes closed Coma can be described as an eyes closed unresponsive state. unresponsive state. – Obtundation: a blunting of consciousnessObtundation: a blunting of consciousness– Stupor: a sleep like state from which the Stupor: a sleep like state from which the

patient can be aroused by vigous stimulationpatient can be aroused by vigous stimulation

Delirium: Other end of the spectrum with Delirium: Other end of the spectrum with agitation, hallusinations and excessive agitation, hallusinations and excessive motor and verbal activitymotor and verbal activity

Glasgow Coma Scale Eye Opening  

Spontaneous 4

To loud voice 3

To pain 2

None 1

 

Verbal Response  

Oriented 5

Confused, Disoriented 4

Inappropriate words 3

Incomprehensible words 2

None 1

 

Motor Response  

Obeys commands 6

Localizes pain 5

Withdraws from pain 4

Abnormal flexion posturing 3

Extensor posturing 2

None 1

Coma like conditionsComa like conditions

Locked-in state:Locked-in state: patient is alert, lost all patient is alert, lost all voluntary control except for extraoculer voluntary control except for extraoculer eye movements (basis pontis)eye movements (basis pontis)Akinetic mutism:Akinetic mutism: bilateral, deep, medial bilateral, deep, medial frontal lobe disease;awake attentive state frontal lobe disease;awake attentive state devoid of verbal or motor outputdevoid of verbal or motor outputVegetative state:Vegetative state: Chronic state of Chronic state of unresponsiveness, intact sleep-wake unresponsiveness, intact sleep-wake cycles , appear to be awakecycles , appear to be awake

EvaluationEvaluation

Abnormal Vital signs:Abnormal Vital signs: heart rate (atrial fibrill, heart rate (atrial fibrill, ventriculer tachycardias; embolic, ischemic…) ventriculer tachycardias; embolic, ischemic…) blood pressure ( hypertensive encephalopathy, blood pressure ( hypertensive encephalopathy, ICH,stroke), fever (menengitis, encephalitis, heat ICH,stroke), fever (menengitis, encephalitis, heat stroke..)etcstroke..)etc

Respiratory abnormalities: Respiratory abnormalities: – Cheyne- stokes: bi-hemispheric(ischemic, metabolic)Cheyne- stokes: bi-hemispheric(ischemic, metabolic)– Hyperventilation: hypothalamic rostral midbrainHyperventilation: hypothalamic rostral midbrain– Apneustic:mid-lower pontineApneustic:mid-lower pontine– Ataxic: medullaAtaxic: medulla

Focal neurologic findings:Focal neurologic findings:– Brainstem reflexes: Brainstem reflexes:

Pupillary reflexPupillary reflex is resistant to metabolic is resistant to metabolic insult , presence of pupillary dysfunction of insult , presence of pupillary dysfunction of asymmetry distinguish structural from asymmetry distinguish structural from metabolic coma !!!! ( generally small metabolic coma !!!! ( generally small reactive)reactive)

There are pharmacologic agents affective:There are pharmacologic agents affective:

Opiates: pinpoint, poorly reactive pupilsOpiates: pinpoint, poorly reactive pupils

Barbiturates: variaus sized relatively fixed Barbiturates: variaus sized relatively fixed

Third nerve, sympathetic pathwaysThird nerve, sympathetic pathways, .., ..

Ocular reflexes; oculocephalic and Ocular reflexes; oculocephalic and oculovestibuler lie adjacent to oculovestibuler lie adjacent to brainstem areas critical for brainstem areas critical for maintenance of consciousnessmaintenance of consciousness

Motor responseMotor response

Differential diagnosisDifferential diagnosisI.I. Cerebral dysfunction without focal signsCerebral dysfunction without focal signsTraumaTraumaMetabolic encephalopathies Metabolic encephalopathies – electrolyte, glycemia..electrolyte, glycemia..– Organ involvement ; hepatic/ amonnia, renal/urea, Organ involvement ; hepatic/ amonnia, renal/urea,

endocrine/ myxedema, Addison’sendocrine/ myxedema, Addison’s

HypertensiveHypertensiveToxic: CO, alcohol, opioidsToxic: CO, alcohol, opioidsNutritionalNutritionalPostictal (seizures)Postictal (seizures)Anoxic/hypoxicAnoxic/hypoxicEnvironmental (hypo/hypertermia)Environmental (hypo/hypertermia)

II.Cerebral dysfunction with focal signsII.Cerebral dysfunction with focal signs

StrokeStroke

Seizure Seizure – PostictalPostictal– Nonconvulsive SE Nonconvulsive SE

TraumaTrauma

Intra Cranial infectionsIntra Cranial infections

Intoxications Intoxications

32 yrs man32 yrs manSudden severe headache, vomiting, Sudden severe headache, vomiting, GTC seizure on the way to the hospitalGTC seizure on the way to the hospitalPE: tachicardia, fever, sweatingPE: tachicardia, fever, sweatingNE: Confused, agitated, meningeal irritation NE: Confused, agitated, meningeal irritation signs: +signs: +What is this?What is this?Where can be the lesion?Where can be the lesion?What to do?What to do?

PearlsPearls

Evaluation and management will go on at Evaluation and management will go on at the same timethe same time

Focal localising signs were described in Focal localising signs were described in drug overdoses and metabolic coma !!!drug overdoses and metabolic coma !!!

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

SeizuresSeizures

Gait disturbancesGait disturbances

Headache: Headache: Nasty NineNasty Nine1.1. First/ new , severe headacheFirst/ new , severe headache

2.2. Abrupt onsetAbrupt onset

3.3. Progressive and changing patternProgressive and changing pattern

4.4. Headache with neurologic symptoms>1hrHeadache with neurologic symptoms>1hr

5.5. Abnormal neurological findingsAbnormal neurological findings

6.6. Headache with syncope and seizuresHeadache with syncope and seizures

7.7. New headaches in children <5yr,>50 yrNew headaches in children <5yr,>50 yr

8.8. New headaches in pregnancy, with cancer, New headaches in pregnancy, with cancer, immunosuppressionimmunosuppression

9.9. Headaches worsening with exertion, sex, Headaches worsening with exertion, sex, Valsalva maneuverValsalva maneuver

Primary headache syndromesPrimary headache syndromes

tension-typetension-type

ClusterCluster

migrainemigraine

Secondary headache Secondary headache syndromessyndromes

SAHSAHMenengitisMenengitisIntracranial mass lesionsIntracranial mass lesionsCerebro Vascular DiseaseCerebro Vascular DiseaseInflammatory disordersInflammatory disordersDisorders of CSF volume and flow Disorders of CSF volume and flow (hydrocephalus, pseudotumor cerebri, (hydrocephalus, pseudotumor cerebri, intracranial hypotension)intracranial hypotension)

PearlsPearls

Focus on the Focus on the newnew or or differentdifferent headaches headaches not merely the worstnot merely the worst

Suspected SAH needs CT and LPSuspected SAH needs CT and LP

New or different headaches over 50 , New or different headaches over 50 , suspect temporal arteritis, investigate suspect temporal arteritis, investigate sedimentation ratesedimentation rate

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

SeizuresSeizures

Gait disturbancesGait disturbances

Evaluation of WeaknessEvaluation of WeaknessOnset: Onset: – Acute; initial manifestation of newly onset disease,Acute; initial manifestation of newly onset disease,– Exacerbation of a known progressive; Myastenia GravisExacerbation of a known progressive; Myastenia Gravis– Slowly progressive; Amyotrophic Lateral Sclerosis Slowly progressive; Amyotrophic Lateral Sclerosis

LocationLocation– ProximalProximal– DistalDistal– CranialCranial

Associated symptoms: pain, cramp, GIS(intox: bot)Associated symptoms: pain, cramp, GIS(intox: bot)

Medical historyMedical history

Muscle weaknessMuscle weakness

Cerebral hemispheric lesions: stroke,tmCerebral hemispheric lesions: stroke,tm

Spinal cord disordes: tm, inf, disc,Spinal cord disordes: tm, inf, disc,

Anterior horn cell disorders: ALSAnterior horn cell disorders: ALS

Nerve root disorders: Guillain-Barre S.Nerve root disorders: Guillain-Barre S.

Neuromuscular junction disorders: MG, Neuromuscular junction disorders: MG, botbot

Myopathies: Myopathies:

The most serious presentation of The most serious presentation of severe muscle weaknesssevere muscle weakness

““Acute Neuromuscular respiratory Acute Neuromuscular respiratory failurefailure””

Form of restrictive pulmonary diseaseForm of restrictive pulmonary disease

Myastenia gravisMyastenia gravis

Guillain-Barre syndromeGuillain-Barre syndrome

Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis

65 yrs old woman65 yrs old womanDeveloped R hemiparesisDeveloped R hemiparesisMedical history: hypertensionMedical history: hypertensionFE: 170/95mmHg, 115 /min pulse rateFE: 170/95mmHg, 115 /min pulse rateNE: R central facial paresis, motor 2/5, 4/5NE: R central facial paresis, motor 2/5, 4/5What is this?What is this?Where can be the lesion?Where can be the lesion?What to do?What to do?

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

Gait disturbancesGait disturbances

SeizuresSeizures

DizzinessDizziness : the disturbed sense of well : the disturbed sense of well being usually perceived as an altered being usually perceived as an altered orientation in spaceorientation in space

VertigoVertigo: illusion of movement of oneself : illusion of movement of oneself or one’s surroundingsor one’s surroundings

DizzinessDizziness

VestibulerVestibulerPeripheral (inner ear sensory organs, Peripheral (inner ear sensory organs,

afferents and brainstem efferents,) afferents and brainstem efferents,) Central (vestibuler nuclei, CNS connections)Central (vestibuler nuclei, CNS connections)

NonvestibulerNonvestibuler

DizzinessDizziness

VertigoVertigo

Important vestibuler system Important vestibuler system disordersdisorders

Benign positionel vertigoBenign positionel vertigo

Vestibuler neuritisVestibuler neuritis

LbyrinthitisLbyrinthitis

Meniere’s diseaseMeniere’s disease

Cerebello pontine angle tumorsCerebello pontine angle tumors

Vascular diseaseVascular disease

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

Gait disturbancesGait disturbances

SeizuresSeizures

Gait disturbancesGait disturbances

HemipareticHemipareticAtaxic: dorsal column, cerebellum, peripheral Ataxic: dorsal column, cerebellum, peripheral nervenerveSteppage: foot drop; L5 radiculopathy, peroneal Steppage: foot drop; L5 radiculopathy, peroneal HystericalHystericalSpastic Spastic Parkinsonian conditionsParkinsonian conditionsEarly gait apraxia: elderly, small uncertain stepsEarly gait apraxia: elderly, small uncertain stepsLate gait apraxia: dementia; small hesitant stepsLate gait apraxia: dementia; small hesitant stepsWaddling Waddling

Common neurological Common neurological PresentationsPresentations

Altered mental statusAltered mental status

HeadacheHeadache

WeaknessWeakness

DizzinessDizziness

Gait disturbancesGait disturbances

SeizuresSeizures

STATUS EPILEPTICUS is recurrent STATUS EPILEPTICUS is recurrent seizures without complete recovery of seizures without complete recovery of consciousness between attacks or consciousness between attacks or continuous seizure activity for more than continuous seizure activity for more than 30 minutes with or without impaired 30 minutes with or without impaired consciousness.consciousness.

Do not start medication unless the seizure Do not start medication unless the seizure is SE !!is SE !!

Causative factorsCausative factors

TraumaTrauma

TumorTumor

CVACVA

IC inf.IC inf.

Acute metab. disorderAcute metab. disorder

Intoxication Intoxication

Drugs (ciprofloxacin, baclofen, flumazenil..)Drugs (ciprofloxacin, baclofen, flumazenil..)

Mycoplazmosis pneumonia, cat scratch disease Mycoplazmosis pneumonia, cat scratch disease encephalitis, HSV6, AIDS, dural metastasis)encephalitis, HSV6, AIDS, dural metastasis)

Types of SETypes of SE

Generalized convulsive SEGeneralized convulsive SE

Epilepsia partialis continuaEpilepsia partialis continua

Myoclonic status in comaMyoclonic status in coma

Nonconvulsive SENonconvulsive SE– Complex Partial seizuresComplex Partial seizures– AbsenceAbsence

Tonic clonic SE Tonic clonic SE pathophysiologypathophysiology

Motor activityMotor activityEEGEEGPhysiological changesPhysiological changes– 1. phase: Compensation: SEizure activity increases 1. phase: Compensation: SEizure activity increases

cerebral metabolism,blood flow increases to cerebral metabolism,blood flow increases to compansate the situation. compansate the situation.

– Blood pressure increase, cardiac output and rate Blood pressure increase, cardiac output and rate increase, autonomic features (sweating, hypertermia, increase, autonomic features (sweating, hypertermia, bronchial secretion, salivation,vomit ) Hyperglicemiabronchial secretion, salivation,vomit ) Hyperglicemia

Phase 2Phase 2

Decompansation: cerebral autoregulation Decompansation: cerebral autoregulation progressively worsen, cerebral blood flow (CBF) progressively worsen, cerebral blood flow (CBF) depends on systemic blood pressure and depends on systemic blood pressure and hypotension occur, (IV AED HypoTA hypotension occur, (IV AED HypoTA ))Systemic and cerebral hypoxia, pulmonary Systemic and cerebral hypoxia, pulmonary hyperTA, eodema, cardiagenic arrytmia very hyperTA, eodema, cardiagenic arrytmia very oftenoftenleft vent cont left vent cont card outputcard output Cardiac failure Cardiac failureIC pressure syst pre CBF impair EODEMAIC pressure syst pre CBF impair EODEMA

Metabolic and endocrinologic changesMetabolic and endocrinologic changes

Lactic acidosisLactic acidosisHypoglicemiaHypoglicemiaHypo/hyperkalemiaHypo/hyperkalemiaHyponatremiaHyponatremiaMyoglobunuriaMyoglobunuria or dehydratation or dehydratation acute tubuler necrosis, acute tubuler necrosis, fulminan renal and fulminan renal and hepatic failurehepatic failureRabdomyolisis is prevented by artificial Rabdomyolisis is prevented by artificial ventilation and muscle paralysisventilation and muscle paralysisNorAdr and adrenaline release NorAdr and adrenaline release

Other complicationsOther complications

Acute pancreatitisAcute pancreatitis

FracturesFractures

Infections (lung, skin and urinary system)Infections (lung, skin and urinary system)

TromboflebitisTromboflebitis

DehydratationDehydratation

DICDIC

Cerebral venous trombosisCerebral venous trombosis

Cerebral infarct or hemarrogeCerebral infarct or hemarroge

General approachGeneral approachA) 1. step (0-10.min): cardiorespiratory, A) 1. step (0-10.min): cardiorespiratory, airway, O2airway, O2B) 2. step: (1-60 min): B) 2. step: (1-60 min): – 1)follow the neurological status, heart rate, blood 1)follow the neurological status, heart rate, blood

pressure, fewer, blood gases, pH, coagulation, pressure, fewer, blood gases, pH, coagulation, haematologyhaematology

– 2)IV AED2)IV AED– 3)IV NaCl 0.9, don’t mix up the drugs, venous 3)IV NaCl 0.9, don’t mix up the drugs, venous

lines used for AEDs (trombosis, flebitis..)lines used for AEDs (trombosis, flebitis..)– Glucos, blood gas, renal and hepatic functions and Glucos, blood gas, renal and hepatic functions and

Ca, Mg,haematology, coagulation, AED levelsCa, Mg,haematology, coagulation, AED levels– 50ml %50 glucose (hypoglisemi), alcoholism, 50ml %50 glucose (hypoglisemi), alcoholism,

nutritional disorders. Thiamin 250mg IVnutritional disorders. Thiamin 250mg IV

3. Step (1-60/90 min) 3. Step (1-60/90 min) – Etiological investigation ie, AED stopped ? Etiological investigation ie, AED stopped ? – To treat physiological abnormalities and To treat physiological abnormalities and

complications : hypoxia, ICB increase, pulmoner complications : hypoxia, ICB increase, pulmoner eodema and hyperTA, arrytmia, cardiac failure, eodema and hyperTA, arrytmia, cardiac failure, lactic asidosis, hyperpirexia, hypoglisemia, lactic asidosis, hyperpirexia, hypoglisemia, elektrolit imbalance, renal or hepatic failure, DIC, elektrolit imbalance, renal or hepatic failure, DIC, rabdomyolisisrabdomyolisis

– HypoTA : pressor treatment: dopamin 2-5 HypoTA : pressor treatment: dopamin 2-5 micgr/kg/min, IV monitormicgr/kg/min, IV monitor

4. Step (30-90.min): ICU4. Step (30-90.min): ICU

AED administrationAED administrationA) prodromal phase: diazepam (10mg IV,2-A) prodromal phase: diazepam (10mg IV,2-5mg/min,repeat after 15 min, rectal), 5mg/min,repeat after 15 min, rectal), midozolam, paraldehid, clonozepammidozolam, paraldehid, clonozepam

B) early SE: (0-30min) diazepam, B) early SE: (0-30min) diazepam, midozolam,clonazepam (1mg/30sn)midozolam,clonazepam (1mg/30sn)

C)persistance SE(30min<): physiological C)persistance SE(30min<): physiological decompensation, phenobarbitone 10mg/kg decompensation, phenobarbitone 10mg/kg 100mg/min and/or 100mg/min and/or

Pht 15-20mg/kg 50mg/minPht 15-20mg/kg 50mg/min

D) Refractory SE(60-90min): anestesiaD) Refractory SE(60-90min): anestesia

Management of a patient during a Management of a patient during a seizureseizure

Bend towards left sideBend towards left side

Avoid to injure himselfAvoid to injure himself

Touch gentlyTouch gently

Never place anything in his mouth unless Never place anything in his mouth unless you see them in the beginningyou see them in the beginning

Stay with him until he recoversStay with him until he recovers

17 yrs old girl17 yrs old girlGTC Seizure on awakeningGTC Seizure on awakeningConfused at ERConfused at ERNo focal signsNo focal signsHistory: Birthday party until late nightHistory: Birthday party until late nightWhat is this?What is this?Where can be the lesion?Where can be the lesion?What to do?What to do?