What is the immediate management of basic neurological emergencies, including stroke, status epilepticus, meningitis, and subarachnoid hemorrhage?

Management of Basic Neurological Emergencies

Immediate recognition and aggressive management of neurological emergencies is critical to reduce morbidity and mortality, as early deterioration is common in conditions such as intracerebral hemorrhage, stroke, status epilepticus, and meningitis. 1

General Approach to Neurological Emergencies

Initial Assessment and Stabilization

• Airway, Breathing, Circulation (ABC): Ensure patent airway, adequate ventilation, and cardiovascular support
• Rapid neurological assessment: Glasgow Coma Scale (GCS), pupillary response, focal deficits
• Vital signs: Monitor blood pressure, heart rate, respiratory rate, temperature, oxygen saturation
• Laboratory studies: Complete blood count, electrolytes, glucose, coagulation studies, toxicology screen
• Neuroimaging: Urgent CT scan or MRI as indicated by clinical presentation

Specific Neurological Emergencies

1. Stroke Management

Ischemic Stroke

• Immediate CT scan: To rule out hemorrhage within minutes of arrival 1
• Time-sensitive treatment:
  • IV thrombolysis (rtPA) if within appropriate time window
  • Consider endovascular thrombectomy for large vessel occlusions
• Blood pressure management:
  • If receiving thrombolysis: Maintain BP <180/105 mmHg
  • If not receiving thrombolysis: More liberal acceptance of hypertension unless other comorbidities require intervention 1
• Supportive care:
  • Maintain euvolemia with normal saline (75-100 mL/hr)
  • Treat fever (>37.5°C)
  • Monitor for neurological deterioration
  • Admit to stroke unit for specialized care 1

Hemorrhagic Stroke (Intracerebral Hemorrhage)

• Immediate management:
  • Secure airway and ensure adequate ventilation
  • Reverse anticoagulation if applicable
  • Control blood pressure (target depends on clinical scenario)
  • Consult neurosurgery for possible intervention 1
• Critical care considerations:
  • Monitor for increased intracranial pressure (ICP)
  • Consider external ventricular drainage for hydrocephalus
  • Evaluate for hematoma expansion with follow-up imaging 1
• Surgical considerations:
  • Hematoma evacuation in select cases
  • External ventricular drainage for hydrocephalus 1

Subarachnoid Hemorrhage

• Immediate CT scan: Non-contrast head CT (sensitivity >95% within 24 hours)
• Lumbar puncture: If CT negative but clinical suspicion high
• Neurosurgical consultation: For aneurysm management (clipping or coiling)
• Critical care management:
  • Nimodipine 60mg every 4 hours to prevent vasospasm
  • Maintain euvolemia
  • Monitor for hydrocephalus, vasospasm, rebleeding 2
  • Treat seizures if they occur

2. Status Epilepticus Management

• Definition: Continuous seizure activity >5 minutes or recurrent seizures without recovery between episodes
• First-line treatment:
  • Lorazepam 4mg IV given slowly (2mg/min)
  • If seizures continue after 10-15 minutes, administer additional 4mg IV 3
• Second-line treatment:
  • Fosphenytoin, valproate, or levetiracetam IV
• Refractory status:
  • Intubation and mechanical ventilation
  • Continuous EEG monitoring
  • Midazolam, propofol, or pentobarbital infusion 3
• Critical care considerations:
  • Maintain patent airway
  • Monitor respiration closely
  • Have ventilatory support available
  • Identify and treat underlying causes (metabolic derangements, infection, stroke, trauma) 3

3. Meningitis Management

• Immediate interventions:
  • Empiric antibiotics within 30 minutes of presentation (don't wait for LP results)
    • Adults: Ceftriaxone 2g IV + Vancomycin 15-20mg/kg IV
    • Add Ampicillin 2g IV q4h if age >50 years or immunocompromised
  • Dexamethasone 10mg IV before or with first dose of antibiotics
  • Obtain blood cultures before antibiotics if possible
• Diagnostic procedures:
  • Lumbar puncture (unless contraindicated)
  • CT head before LP if focal neurological signs, immunocompromised, or altered mental status
• Supportive care:
  • Monitor for increased ICP
  • Manage seizures if they occur
  • Maintain adequate cerebral perfusion

4. Traumatic Brain Injury

• Initial management:
  • Secure airway, ensure adequate oxygenation and ventilation
  • Maintain systolic BP >100 mmHg or MAP >80 mmHg 4
  • Immediate CT scan
  • Consult neurosurgery for surgical lesions
• ICP management:
  • Elevate head of bed 30°
  • Maintain adequate sedation
  • Consider osmotic therapy (mannitol or hypertonic saline)
  • Consider ICP monitoring for GCS ≤8
• Surgical interventions:
  • Evacuation of epidural/subdural hematomas
  • Decompressive craniectomy in select cases 4

Systems of Care for Neurological Emergencies

• Prehospital care:
  • Use stroke recognition tools
  • Immediate activation of emergency response system
  • Early notification to receiving hospital 1
• Hospital systems:
  • Establish critical pathways for neurological emergencies
  • Ensure availability of neurology, neurosurgery, neuroradiology, and critical care
  • Consider transfer to tertiary care center if specialized resources not available 1

Common Pitfalls and Caveats

1. Delayed recognition: Neurological deterioration can occur rapidly; frequent reassessment is crucial
2. Inadequate airway management: Patients with decreased level of consciousness require close airway monitoring
3. Failure to reverse anticoagulation: In hemorrhagic stroke, rapid reversal of anticoagulation is essential
4. Delayed neurosurgical consultation: Early involvement of neurosurgery is critical for time-sensitive interventions
5. Inadequate seizure management: Status epilepticus requires aggressive treatment to prevent neuronal injury
6. Missing underlying causes: Always search for and treat the underlying cause of neurological emergencies

Remember that neurological emergencies require a multidisciplinary approach involving emergency medicine, neurology, neurosurgery, and critical care for optimal outcomes.