Neurologic Emergencies

What must be done in the first 5 minutes of presentation to the ER with a neurologic emergency?

1. Airway and vitals

2. Glucose

3. Start the clock (last known well)

4. Focused exam

What are the immediate threats?

Herniation, status epilepticus, hypoglycemia, hypoxemia, and hypotension.

What question does non-contrast CT answer and when is it the right first move?

Blood? Large infarct? Mass effect?

Every acute stroke alert, head trauma requiring imaging; thunderclap headache

What question does CTA of head and neck answer and when is it the right first move?

Is there a large vessel occlusion? Aneurysm? Dissection?

Acute stroke when LVO is possible, SAH/aneurysm; neck pain + focal deficit

What question does CT venography/MRI answer and when is it the right first move?

Venous sinus thrombosis?

Headache + seizure, papilledema, pregnancy/postpartum or risk factors.

What question does MRI answer and when is it the right first move?

Small/posterior infarct? Encephalitis?

Posterior stroke concern; CT-negative focal syndrome; selected wake-up/extended window patients

What question does LP answer and when is it the right first move?

CNS infection? Xanthochromia?

Suspected meningitis/encephalitis; selected CT negative suspected SAH

What question does EEG answer and when is it the right first move?

Ongoing electrical seizure activity?

Persistent unexplained AMS or failure to return to baseliene after seizure

What is the BE in BE-FAST?

Posterior circulation:

B - Balance

E - Eyes

These two capture strokes FAST alone misses

What is the FAS in BE-FAST?

Anterior circulation

F - Face

A - Arm

S - Speech

What is the T in BE-FAST?

T - Time

What things can mimic a stroke?

Hypoglycemia

Seizure/Todd paresis

Migraine with aura

Toxic metabolic/systemic illness

Functional neurologic disorder

What is a patient with a last known well of 0-4.5 hours prior eligible for?

Alteplase or Tenecteplase

Do not delay for advanced imaging

What is a patient with a last known well of 4.5-9h prior eligible for?

Imaging-selected thrombolysis

Selected patients may still qualify

DWI-FLAIR or perfusion mismatch

What is a patient with a last known well of 24 hours prior eligible for?

Selected patients with treatable vessel occlusion

Eligibility depends on clinical and imaging selection.

What should be done in the first 10 minutes of stroke alert?

1. ABCs + glucose

2. LKW + NIHSS

3. NCCT + CTA

4. Decide and treat

What is the NIHSS?

NIH Stroke Scale

Standardized way to qualify neurologic deficit and track change.

Score 0-42, higher the score the greater the neurologic deficit.

What does NIHSS test?

LOC, gaze, visual field, face, arm, legs, ataxia, sensation, language, dysarthria, neglect

What does NIHSS help you do?

Establish a baseline, communicate severity, follow progression or improvement, support acute stroke decisions.

What does NIHSS not do?

Diagnose or rule out a stroke

Replace a complete neuro exam

Reliably capture every posterior deficit

Tell you whether a deficit is disabling

What does non-contrast CT tell you?

Excludes hemorrhage

Often normal in early ischemia

Shows early ischemic change/core burden and mass effect

What does CTA tell you?

Identifies LVO

Defines vascular anatomy for thrombectomy

May identify dissection/aneurysm

What does perfusion/MRI tell you?

Helps distinguish infarct core from salvageable tissue

Helps select some late window or unknown onset patients

DWI-FLAIR mismatch may support imaging selected thrombolysis

What are the IV thrombolysis options?

Tenecteplase (first line, max 25 mg, single bolus)

Alteplase (max 90 mg)

What is the standard window for IV thrombolysis?

≤4.5 hours in eligible patients with disabling deficits

Selected patients in 4.5-9 hours or unknown onset may qualify using advanced imaging.

What are some absolute CI to thrombolysis?

Intracranial hemorrhage on imaging

Extensive celar hypoattenuation/established infarction

Active major internal bleeding

Severe coagulopathy

What are some relative CI to thrombolysis (assess risks vs benefits first)?

Recent DOAC exposure (

What are some non-automatic barriers to thrombolysis (historic exclusions)?

Age >80

Low NIHSS if deficit is disabling

Seizure at onset

Prior stroke + diabetes

What must be fixed before pushing thrombolytics?

BP > 185/100, if you try to lower and it doesn't work don't give IVT

Hypoglycemia, correct and then reassess neurologic deficit

What is an LVO?

Large vessel occlusion

Treatable intracranial arterial occlusion on CTA

What do you do for a patient with an LVO of 0-6 hours?

Rapid EVT for eligible patients with treatable LVO

Do not delay for perfusion imaging when otherwise clearly eligible

What do you do for a patient with an LVO of 6-24 hours?

Selected patients may still benefit from EVT

Eligibility based on clinical and imaging findings, not time alone.

What are the target BP for different scenarios?

Before IVT:

What is the supportive care bundle for the penumbra?

Glucose: treat hypoglycemia

Temperature

Oxygen and airway

Swallow: NPO until dysphagia screen passed

Perfusion: avoid hypotension and hypovolemia

When is a stroke patient sent to neuro ICU?

Airway compromise or depressed consciousness

Large hemispheric/cerebellar infarct (edema risk)

Hemodynamic instability

When is a stroke patient sent to stroke unit or transfered?

Confirmed stroke

Transfer if EVT or higher level care needed

When is a stroke patient sent for expedited outpatient?

Symptoms resolved and no high risk finding

What are the 3 types of hemorrhagic strokes?

Intracerebral

Subarachnoid

Subdural

Describe intracerebral hemorrhage

Pattern: hyperdense blood within blood parenchyma +/- intraventricular extension/mass effect

Cause: deep hemorrhage often hypertensive; lobar hemorrhage has broader etiologies

First move: BP control and reverse anticoag if present

Describe SAH

Pattern: star-shaped blood in the cisterns and sylvian fissures

Cause: rupture aneurysm

First move: CTA, nimodipine, analgesia, neurosurgery

Describe SDH

Pattern: crescent on the convexity, crosses suture lines

Cause: bridging vein tear; elderly, anticoag, minor or unrecalled fall

First move: reverse anticoag, assess GCS trend, surgical opinion

What should be done in the first hour of ICH?

1. Control BP

2. Reverse anticoag

3. Call neurosurgery

4. Monitor

Bundle not in sequence, do multiple things at once

What is the pathway for suspected SAH?

1. Screen with Ottawa SAH rule (new severe headache within 1 hour, age ≥40, neck pain/stiffness, witnessed LOC)

2. Non contrast CT within 6 hours

3. If CT is negative or still suspected, do LP for xanthochromia.

What should be done in the first 2 hours of aneurysmal SAH?

1. Treat BP

2. Reverse anticoag

3. Nimodipine 60 mg q4h PO

4. ICP and seizures

5. Secure aneurysm early

What are the venous strokes?

1. Cerebral venous thrombosis: headaches evolving

2. Cavernous sinus thrombosis

3. Diagnose and treat

What is the workup for the first seizure event in the ED?

1. Look for provoker

2. Imaging - NCCT now

3. EEG/LP

4. Disposition of patient, and see when to discharge

5. Counseling

What is the sequence of treatment for status epilepticus?

1. 1-5 minutes give full dose benzo

2. If still seizing give second-line ASM

3. If refractory status intubate

What are reversible causes of AMS?

Glucose + O2

Naloxone + Thiamine

Na + temp

Sepsis + CNS infection

Drugs + withdrawal

What is included in the 60 second neuro exam for comatose patients?

Level and pupils

Brainstem reflexes

Motor and breathing

What are the steps for herniation treatment?

1. Recognize

2. Position and airway

3. Osmotherapy

4. Definitive care

What are headache red flags?

Thunderclap headache

Fever, neck stiffness, rash

Focal deficit, seizure, papilledema

New headache >50 + jaw claudication/visual sx

Pregnancy/postpartum, cancer, positional pattern

What are common routes of brain abscess infection?

Sinus, ear, dental, hematogenous spread

What is the typical imaging pattern of brain abscess infection?

Ring enhancement, edema and restricted diffusion

Who is at high risk after minor head injury?

GCS < 15 at 2 hours

Suspected open/depressed skull fracture

Signs of basilar skull fracture

≥2 episodes of vomiting

Age ≥65

Who is at medium risk after minor head injury?

Retrograde amnesia >30 min

Dangerous mechanism

Anticoag/antiplatelet therapy

Intoxication or unreliable exam

Who is safe for discharge after minor head injury?

No CT criteria met or CT negative

Baseline neuro exam

Reliable observation/follow up

What are the vitals signs to prevent secondary injury after intracranial trauma?

SpO2 ≥94%

SBP ≥110

PaCO2 35-45

What are spinal emergencies?

Cauda equina

Spinal epidural abscess

Spinal trauma

What is central vertigo?

Continuous vertigo + spontaneous nystagmus + trained examiner

Head impulse

Nystagmus

Test of skew

Do stroke eval

What is the peripheral pattern of Guilliain-Barre?

Progressive symmetric weakness

Decreased/absent reflexes

Paresthesias and facial/bulbar weakness

Recent infection

What are the respiration limits for GB?

FVC + serial respiratory assessment

Weak cough or bulbar weakness = danger

FVC ≤20 mL/kg consider intubation

How do you manage GB?

Admit pt

IVIG or plasma exchange

No steroids

ICU for respiratory decline, bulbar weakness or dysautonomia.