Diagnosis and Management of Rare Neurological Emergencies

Introduction:

Neurological disorders affect the brain, spinal cord, and nervous system of the human body. A problem arises when there are structural, biochemical, or electrical abnormalities in the brain, spinal cord, or other nerves that hamper the normal functioning of the nervous system and negatively affect other systems that are under the control of the nervous system, resulting in a wide range of clinical symptoms. Neurological disorders result from multifactorial causes, including genetic, congenital, environmental, lifestyle, environmental, or trauma. Whatever might be the cause, understanding the emergency and delivering the optimum care within limited time constraints is an integral aspect of emergency medicine practice.

What Are the Common Neurological Emergencies Encountered in an Emergency Medicine Department?

1. Acute Ischemic Stroke:

Introduction:

• The prevalence of stroke rates has been increasing rapidly in recent years. Stroke happens to be a progressive complication following many lifestyle diseases in recent times.

• Most commonly occurring are ischemic strokes, which occur due to reduced blood supply to the brain.

Causes:

• Atherosclerosis.

• Diabetes mellitus.

• Obesity.

• Hypertension.

• Unhealthy eating habits.

• Sedentary lifestyle.

• Atrial fibrillation.

Symptoms:

• Facial droop.

• Unilateral weakness or numbness.

• Aphasia.

• Gaze deviation.

• Unsteadiness of gait or waddling gait.

Diagnosis:

• Laboratory tests that assess blood glucose levels, coagulation studies, kidney and liver function tests, lipid profiles, and complete blood count serve the purpose.

• CT (computed tomography)scanis carried out to rule out the possibility of acute hemorrhage. Acute brain ischemia is often not apparent on CT during the first few hours of injury.

Management:

• Patients with acute ischemic stroke can be managed by lowering the head of the bed as it enables blood flow to the brain tissue. However, it is not indicated in patients with increased intracranial pressure.

• Permissive hypertension treatment is constituted where antihypertensives will be given if the blood pressure is above 220/110 mm Hg to provide adequate blood supply to the brain.

• Intravenous tissue plasminogen activator therapy is a treatment of choice for ischemic stroke patients in the initial hours. However, it is contraindicated in diabetics, older patients, and patients with a history of neurological disorders.

• Antiplatelet agents are the treatment of choice in patients who cannot receive tissue plasminogen activator therapy.

• Controlling the blood sugar levels in the range ( 140 to 180 mg/dL) is crucial in post-stroke care as it prevents further damage to the brain tissue.

2. Acute Hemorrhagic Stroke:

Introduction:

• Hemorrhagic stroke occurs as a result of bleeding from a ruptured blood vessel in the brain.

• Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).

• Hemorrhagic stroke should be diagnosed and managed as soon as possible as it leads to devastating outcomes and hence increases morbidity and mortality rates.

Causes:

• Hypertension.

• Aneurysms (weakened area of a blood vessel wall caused due to abnormal widening).

• Cavernous malformation (refers to closely packed abnormal tiny blood vessels with thin walls).

• Cerebral venous thrombosis (blood clot in the venous sinuses or spaces of the brain).

• Metastatic diseases (cancerous).

• Cerebral amyloid angiopathy (building of proteins in the walls of the arteries of the brain).

• Infective Endocarditis (refers to inflammation of the inner lining of the heart called the endocardium and also of the inner lining of the valves through which the blood is pumped between the upper and lower chambers of the heart).

• Contusions ( a bruise happens due to a direct blow to the body, which can damage the skin and even affect the deeper tissues based on the severity of the blow).

• Drug-induced coagulopathies (drug-induced bleeding disorders).

Symptoms:

• Thunderclap headache.

• Photosensitivity.

• Dizziness or vertigo.

• Nausea and vomiting.

• Seizures.

• Fainting.

• Aphasia (refers to a language disorder where a person fails to communicate).

• Dysarthria (difficulty in speaking due to the weakening of the muscles that support speaking).

• Paralysis (unilateral).

• Neck stiffness.

Diagnosis:

• Radiological studies like CT scans and MRIs (magnetic resonance imaging)are useful.

• Laboratory tests to detect any infectious source, heart damage, blood glucose levels, kidney and liver function tests, and clotting disabilities aid in diagnosis.

Treatment:

• Immediate control of blood pressure is done by administering IV (intravenous) Nicardipine or Labetalol to bring down below 140 mm of Hg to ensure better outcomes.

• Coagulation abnormalities need to be reversed. as they are the precipitating factors of intracranial hemorrhage.

• Warfarin should be stopped immediately as it is one of the risk factors for intracranial hemorrhage.

• Vitamin K, fresh-frozen plasma, prothrombin complex concentrate, and recombinant factor VIIa are used to reverse anticoagulation.

3. Intracranial Hypertension:

Introduction:

• When there is increased pressure built up around the brain due to an increased amount of CSF (cerebrospinal fluid) enclosing the brain and the spinal cord leads to intracranial hypertension.

• This leads to visual disturbances as the optic nerve is affected.

Causes:

• Brain tumors.

• Blood clots in the brain.

• Brain abscess.

• Stroke.

• Traumatic brain injury.

Symptoms:

• Headache.

• Tinnitus.

• Fatigue.

• Nausea and vomiting.

• Visual disturbances.

• Shoulder and neck pain.

Diagnosis:

• Brain CT scan or MRI.

• Eye tests to check for visual disturbances.

• Lumbar puncture to assess the CSF (cerebrospinal fluid).

• Tests to evaluate the various body reflexes.

• Visual field test.

Treatment:

• To reduce the intracranial pressure, the head of the bed is elevated to 30 degrees to ensure venous drainage.

• Airway compromise needs to be treated immediately with intubation.

• Hypocarbia induces vasoconstriction and thus reduces intracranial pressure. This is achieved by reducing the partial pressure of carbon dioxide to 30 to 35 mm of Hg.

• IV peripheral line of Mannitol bolus of 1 to 2 g/Kg, followed every four to six hours, is administered as a part of hyperosmolar therapy, which removes excess cerebral fluid (osmotic diuresis) and thereby reduces intracranial pressure.

• Three percent sodium chloride (hypertonic saline) is given either as a bolus or constantly to reduce cerebral edema as it shifts the interstitial fluid into the intravascular space.

4. Subarachnoid Hemorrhage (SAH):

Introduction:

• Unlike intracranial hemorrhage, subarachnoid hemorrhage occurs due to the pooling of blood in the CSF (cerebrospinal fluid) containing spaces (between the arachnoid and pia mater), leading to improper drainage of CSF, giving rise to classical thunderclap headache.

• Non-traumatic subarachnoid hemorrhage mostly results due to intracranial aneurysm rupture. Mortality rates are estimated to be 50 percent in such cases.

Causes:

• Arteriovenous malformations (AVM).

• Bleeding disorders.

• Cerebral aneurysms.

• Head injury.

• Warfarin therapy.

Symptoms:

• Altered mental status.

• Nausea and vomiting.

• Stiff neck.

• Confusion and irritability.

• Dizziness.

• Photophobia.

• Muscular weakness.

• Unilateral loss of sensation.

• Seizures.

• Visual disturbances like double vision and blind spots.

• Unilateral vision loss (temporary).

Diagnosis:

• CT scan is the most important diagnostic tool as it can detect the blood in the subarachnoid space if performed within 24 hours post hemorrhage.

• Lumbar puncture is done to assess the CSF. A yellowish pigmentation of CSF gives the clue that it appears due to degeneration of blood, suspecting the bleeding in the subarachnoid space.

Treatment:

• Labetalol and Hydralazine are most commonly given to control blood pressure and are given in intermittent doses, whereas Nicardipine and Clevidipine are given continuously.

• Labetalol is a beta-blocker given in doses from 5 to 20 mg IV every 15 minutes.

• Hydralazine is given in IV doses of 20 to 40 mg every 30 to 60 minutes.

• Nicardipine is given in an IV line in titrated doses from 5 to 15 mg/hour to maintain the systolic blood pressure of 150 to 160 mm of Hg to avoid rebleeding.

• Osmotic diuretics by Mannitol stabilize the patient until surgical or endovascular interventions.

• Surgical interventions involve craniotomy and endovascular coiling.

• Craniotomy facilitates the closing of the aneurysm and prevents rebleeding.

• Endovascular coiling involves placing the coils in the aneurysms and stents in the blood vessels to arrest the bleeding.

• Further investigations like CT angiography, magnetic resonance angiography, and catheter-based cerebral angiography are commonly employed to detect underlying vascular malformations.

Conclusion:

Acute neurological emergencies cause major threats to the life and independence of every person. Often, such emergencies strike in no time, and medical care must be provided as soon as possible. Emergency medicine needs to be equipped with adequate staff and all the necessary facilities to cater to the best care possible in such critical circumstances and contribute to providing better treatment outcomes.