What are the most common neurological complaints that require immediate medical attention?

Most Common Neurological Complaints Requiring Immediate Medical Attention

The most common neurological complaints requiring immediate medical attention are stroke, status epilepticus, thunderclap headache, altered mental status, and traumatic brain injury, as these conditions are associated with high morbidity and mortality if not promptly treated.

Life-Threatening Neurological Emergencies

1. Stroke

• Presents with sudden onset of focal neurologic deficits including:
  • Hemiparesis or monocular blindness (affecting left eye or left visual field)
  • Aphasia or dysphasia
  • Cranial nerve deficits
  • Visual field loss 1
• Requires immediate evaluation with non-contrast CT or MRI of the brain to exclude hemorrhage 1
• Time-sensitive interventions (thrombolysis, thrombectomy) must be initiated within hours of symptom onset

2. Status Epilepticus

• Continuous seizure activity or recurrent seizures without recovery of consciousness
• Requires immediate airway management and medication administration
• Equipment to maintain patent airway must be immediately available 2
• Standard treatment: Lorazepam 4 mg IV given slowly (2 mg/min) for adults; may repeat once after 10-15 minutes if seizures continue 2
• Mortality risk increases with seizure duration beyond 30 minutes

3. Thunderclap Headache

• Sudden, severe headache reaching maximum intensity within seconds to minutes
• Most concerning for subarachnoid hemorrhage but can also indicate spontaneous intracranial hypotension 1
• Requires immediate neuroimaging and often lumbar puncture if imaging is negative

4. Altered Mental Status (AMS)

• Presents as confusion, delirium, decreased consciousness
• May indicate intracranial hemorrhage, ischemic stroke, or other life-threatening conditions
• CT head examinations for AMS have a critical result yield of 9.8% 1
• Risk factors for abnormal brain imaging in febrile elderly with AMS: lower Glasgow Coma Scale, lateralizing signs, higher systolic blood pressure, and lower body temperature 1

5. Traumatic Brain Injury

• Requires urgent neurological evaluation (pupils + GCS motor score) and brain CT scan 1
• After control of life-threatening hemorrhage, patients with life-threatening brain lesions require urgent neurosurgical consultation 1
• Patients at risk for intracranial hypertension require ICP monitoring 1

Other Common Neurological Complaints

1. Vertigo/Dizziness

• Acute vestibular syndrome with persistent vertigo, nausea/vomiting, and gait instability requires evaluation for stroke 1
• The presence of neurologic symptoms with vertigo increases stroke risk 1
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) can help distinguish central from peripheral causes 1

2. Severe Headache (non-thunderclap)

• May indicate increased intracranial pressure, meningitis, or encephalitis
• Red flags: fever, immunocompromised state, sudden onset, neurological deficits, papilledema

3. Acute Weakness

• May indicate stroke, Guillain-Barré syndrome, myasthenia gravis crisis, or spinal cord compression
• Pattern of weakness (symmetric vs. asymmetric, proximal vs. distal) helps determine etiology

Epidemiology of Neurological Complaints in Emergency Settings

• Neurological complaints account for approximately 9% of emergency department visits 3
• The most frequent chief complaints in neurological emergencies are:
  • Headache (20%)
  • Motor deficit (13%)
  • Vertigo (12%)
  • Epileptic seizure (11%) 4
• Among patients with severe hypertension in the ED, 19.9% present with neurological complaints, with non-migraine headache and vertigo being most common 5

Clinical Decision-Making Algorithm

1. Assess ABCs (Airway, Breathing, Circulation)
2. Perform rapid neurological assessment:
   • Level of consciousness (GCS)
   • Pupillary response
   • Motor function
   • Speech
3. Determine time-sensitive emergencies:
   • Stroke symptoms within treatment window
   • Active seizures
   • Thunderclap headache
   • Rapidly declining mental status
   • Focal neurological deficits
4. Initiate immediate management:
   • Secure airway if GCS < 8
   • Maintain SBP > 100 mmHg or MAP > 80 mmHg 1
   • Control seizures with appropriate medications
   • Obtain urgent neuroimaging
   • Consult neurology/neurosurgery as indicated

Common Pitfalls to Avoid

1. Delayed recognition of posterior circulation stroke - Presents with dizziness, nausea, ataxia rather than typical stroke symptoms
2. Missing subarachnoid hemorrhage - CT scan may be negative; consider lumbar puncture if clinical suspicion is high
3. Inadequate seizure management - Ensure proper dosing and timing of antiepileptic medications
4. Attributing symptoms to hypertension alone - In patients with severe hypertension and neurological complaints, consider underlying cerebrovascular disease 5
5. Overlooking non-convulsive status epilepticus - Consider in patients with unexplained altered mental status

By recognizing these common neurological complaints requiring immediate attention and following appropriate management protocols, clinicians can significantly reduce morbidity and mortality associated with neurological emergencies.