Management of Acute Neurological Emergencies: An Overview

Introduction:

Neurological emergencies are common, and if not managed quickly, it can lead to long-term disability or even death. The main symptoms include altered consciousness and respiratory paralysis. The management of acute neurological emergencies is discussed in detail below.

What Are Acute Neurological Emergencies?

Acute neurological emergencies are conditions that affect brain function and, if not treated early, can cause long-term disabilities. Acute neurological emergencies include status epilepticus, acute stroke, subarachnoid hemorrhage, spinal cord injury, and neuromuscular weakness.

How Are Acute Neurological Emergencies Managed?

Some of the acute neurological emergencies and their management include:

1. Acute Ischemic Stroke

• Definition: An acute ischemic stroke occurs when the blood vessels that supply blood and nutrients to the brain get hindered (blocked) by aggregation of platelets (blood clots). It starts with less blood flow to a single area of the brain, and the core part is called an area of infarction where the death of tissues occurs.

• Symptoms: Paralysis of the face, leg, or arm mostly affects one side of the body, severe headache, dizziness, trouble speaking, inability to concentrate, problems in vision, loss of balance, and altered consciousness.

• Diagnosis: Complete clinical history, basic neurologic examination, and NIH (National Institutes of Health) stroke scale to assess the severity of a stroke should be obtained, and the score ranges from zero to 42 (worst). Apart from these, blood glucose should be measured using a finger stick test, complete blood count, and basic metabolic profile should be measured. CT (computed tomography) scan should be done to exclude acute hemorrhage.

• Management: The head of the bed should be lowered, but in case of high intracerebral pressure, it should be avoided. Anti-hypertensive treatment should be given only if the blood pressure is more than 220/110 mmHg (millimeters of mercury) and should receive Urapidil 10 to 12.5 mg IV(intravenous), or Metoprolol in 5 to 10 mg steps IV. IV administration of tissue plasminogen activator (TPA, a type of protein that destroys the clot) 0.9 mg/kg over 60 minutes should be given within 3 hours of the onset of the symptom. In order to receive TPA, the patient should not have had a stroke within the past three months, severe head injury, intracerebral hemorrhage, neoplasm, glucose less than 50 mg/dL (milligrams per deciliter), hemorrhage on CT scan, low platelet count, or ischemia in greater than 33 percent. A thrombolysis (removal of the clot) procedure should be initiated. In case of hypoglycemia, (decreased blood sugar levels) of less than 60 mg/dL (milligrams per deciliter), 30 mL (milliliter) 20 to 40 percent glucose IV is given. In case of hyperglycemia (increased blood sugar levels) of more than 200 mg/dl, adequate intake of liquid is recommended. In the case of atrial fibrillation, early anticoagulant therapy within 72 hours should be given.

2. Acute Hemorrhagic Stroke

• Definition: It is a type of stroke that occurs due to leakage of blood vessels in the brain. It is of two types, intracerebral hemorrhage (ICH, bleeding within the brain) and subarachnoid hemorrhage (SAH, bleeding in the area between the tissue and brain).

• Symptoms: Headache, vomiting, seizure, Loss of all sensory modalities, and coma.

• Diagnosis: A CT scan has high sensitivity in detecting acute hemorrhagic stroke. Other tests such as bleeding time, prothrombin time, platelet count, clotting time, and liver function tests should be done.

• Management: Blood pressure should be maintained and reduced to 150/90 mmHg with the help of beta-blockers such as Labetalol or Esmolol), ACE inhibitors such as Enalapril, calcium channel blockers such as nicardipine, and hydralazine. Reversal of coagulation should be done with the help of fresh-frozen plasma, vitamin K, prothrombin complex concentrate, or recombinant factor VIIa. Increased intracranial pressure is treated by elevating the bed head to 30 degrees and osmotic agents such as Mannitol 20 % 1.0 to 1.5 g/kg or hypertonic saline can be used. Prophylactic anti-epileptic treatment should be given since some patients will have a seizure (within two weeks).

3. Intracranial Hypertension

• Definition: It is a condition in which the pressure around the brain is increased. It can be due to a severe head injury, brain aneurysm (bulging of the blood vessel), stroke, meningitis (inflammation of the brain covering), brain abscess, or brain tumor.

• Symptoms: Inability to stay alert, pupillary abnormalities, headache, tinnitus (ringing sensation in the ears), blind spots, neck pain, and side vision loss.

• Diagnosis: Noncontrast CT of the head shows signs of increased pressure. Decreased muscle strength, and balance.

• Management: The bed head should be elevated to 30 degrees, and intubation to create an airway is carried out. Hyperosmolar therapy with IV Mannitol of bolus 1 to 2 grams per kilogram followed by a bolus every four to six hours should be given. Hypotension should be monitored. Apart from this, hypertonic saline is given to decrease cerebral edema.

4. Status Epilepticus

• Definition: A continuous seizure (sudden abnormal electrical activity of the brain that causes abnormal movements, behavior, and mood) that lasts for more than five minutes without gaining normal mental status.

• Symptoms: Unusual movements, urine incontinence, vomiting, clenched teeth, confusion, and irregular breathing.

• Diagnosis: An electroencephalogram (EEG) test should be done which measures the electrical activity of the brain. A CT scan can be carried out to detect any structural brain abnormality. Cerebrospinal fluid should be analyzed for meningitis.

• Management: Early treatment should be carried out because antiepileptic drugs are effective in the early stages. ABCDE (airway, breathing circulation, disability, and exposure) approach and IV fluid administration should be carried out. In case of an active seizure (before five minutes), Lorazepam 2 milligram IV boluses are given with a maximum dose of 0.1 milligrams per kilogram, followed by Thiamine 100 milligram IV, and one ampule of dextrose 50 percent in water should be given. In the case of the second stage (more than five minutes), 15 to 20 mg of phenytoin should be given.

5. Spinal Cord Injury

• Definition: Spinal cord injury can cause devastating neurological impairment. It can be due to traumatic or non-traumatic, such as inflammatory myelopathies (compression of the spinal cord due to joint disorders such as arthritis or spinal degeneration).

• Symptoms: Head injury, severe back pain, twisted body or neck, difficulty in breathing, sensation of a band around the abdomen or chest, numbness, paralysis, or weakness of bowels, bladder, or limbs.

• Diagnosis: MRI (magnetic resonance imaging), and CT scan show injury or fracture to the spinal cord.

• Management: The affected person should not be moved. Heavy towels or sheets should be kept beside the head to avoid movement, and the collar should be stabilized. In the case of difficulty breathing or coughing, CPR (cardiopulmonary resuscitation, which includes artificial ventilation and chest compressions) is used, but avoid tilting the head. Bladder decompression should be carried out. Mean arterial pressure should be maintained at more than 85 to 90 mm Hg during the first week. Surgical stabilization in case of body misalignment should be carried out. In the case of nontraumatic myelopathies, antibiotics and surgical drainage should be considered.

6. Neuromuscular Disease

• Definition: These are the disorders of the peripheral nervous system (PNS, the part outside the spinal cord and brain). These have high mortality rates because of weak diaphragm, upper-airway muscles, and intercostal muscles, which can cause difficulty in breathing. Some neuromuscular diseases include Guillain-Barré syndrome (an autoimmune disorder that damages PNS) and myasthenia gravis (autoimmune disorders that cause weak skeletal muscles).

• Symptoms: Patients with myasthenia gravis show muscle weakness, nasal speech, fatigue, respiratory distress, dysphagia, and ophthalmoparesis (paralysis of eye muscle). Patients with Guillain-Barré syndrome develop muscle weakness, cardiac arrhythmia, blood pressure instability, and ascending paralysis.

• Diagnosis: Diagnosis of myasthenia gravis should include electromyography (a test to measure the electrical activity of muscle), serum autoantibody testing, and nerve conduction studies should be done. The diagnosis of Guillain-Barre syndrome should include nerve conduction studies, electromyography, and cerebrospinal fluid profile (increased protein and low white blood cells) should be done.

• Management: Mechanical intubation with maximum inspiratory force and vital capacity should be carried out. In the case of myasthenia gravis or Guillain-Barre syndrome, edrophonium should be given to treat ptosis (drooping eyelid), intravenous immunoglobulin 2 g/kg (grams per kilogram) for two to five days or plasmapheresis (exchange of blood plasma) is given and after improvement, Pyridostigmine along with immunosuppressive medications are given. Corticosteroids should not be administered.

Conclusion:

Neurological emergencies are life-threatening disorders that have to be diagnosed early and treated as soon as possible. If the treatment is not quickly performed, it can cause long-term disabilities or even death. Individuals should be aware of the situations and risk factors that can trigger emergencies.