What is the appropriate management approach for a patient with suspected neurological conditions?

Management of Suspected Neurological Conditions

For patients with suspected neurological conditions, a prompt neurological consultation with appropriate diagnostic testing and early referral to a specialist neuroscience center is essential for optimal outcomes.

Initial Assessment and Triage

• Patients with falling level of consciousness require urgent assessment by Intensive Care Unit staff for airway protection, ventilatory support, management of raised intracranial pressure, optimization of cerebral perfusion pressure, and correction of electrolyte imbalances 1
• The first step in management is to rule out CNS progression of cancer, seizure activity, infection, and metabolic derangement as causes of neurological symptoms 1
• For patients presenting with headache, evaluate for new confusion, altered behavior, aphasia, seizure-like activity, or short-term memory loss, which might suggest encephalitis rather than aseptic meningitis 1
• Consultation with a neurologist is advised for all neurologic adverse events grade 2 or higher to determine the type and severity of neurological impairment 1

Diagnostic Workup

• MRI of the brain and/or spine with and without contrast is essential and should be available within 24 hours 1
• Lumbar puncture with CSF analysis should include cell count, protein, glucose, Gram stain, culture, PCR for HSV and other viruses, cytology, oligoclonal bands, and autoimmune panels 1
• EEG is helpful for ruling out seizure activity in cases of encephalopathy 1
• For suspected transverse myelitis, include thin axial cuts through the region of suspected abnormality on MRI and blood tests for B12, HIV, RPR, ANA, Ro/La, TSH, and aquaporin-4 IgG 1, 2
• For suspected immune-related neurological adverse events, consider additional testing for paraneoplastic and autoimmune antibodies 1

Management Based on Suspected Etiology

Viral Encephalitis

• For suspected HSV encephalitis, immediately start intravenous aciclovir 10 mg/kg three times daily (adjusted for renal function) for 14-21 days 1
• For VZV encephalitis, treat with aciclovir 10 mg/kg three times daily intravenously for up to 14 days, with consideration of corticosteroids (60-80 mg prednisolone daily for 3-5 days) 1
• For enterovirus encephalitis, no specific treatment is recommended; in severe cases, consider intravenous immunoglobulin if available 1

Immune-Related Neurological Adverse Events

• For grade 1 (mild) symptoms, checkpoint inhibitor therapy may be continued under close observation 1
• For grade 2 or higher symptoms, hold checkpoint inhibitor therapy and start corticosteroids (methylprednisolone 1-4 mg/kg) 1
• For grade 3 or higher toxicity, permanently discontinue immunotherapy and consider pulse-dose methylprednisolone (1g daily for 5 days) plus IVIG or plasma exchange 1

Transverse Myelitis

• Permanently discontinue immune checkpoint inhibitors if this is the cause 1
• Administer methylprednisolone 2 mg/kg, with strong consideration of higher doses (1 g/day for 3-5 days) 1, 2
• Strongly consider IVIG as an additional treatment 1, 2
• Transverse myelitis typically presents with spastic paralysis and increased deep tendon reflexes (distinguishing it from conditions with flaccid paralysis) 2

Hospitalization and Care Setting

• Patients with suspected acute encephalitis should have access to an immediate neurological specialist opinion and be managed in a setting where clinical neurological review can be obtained within 24 hours 1
• Appropriate environments include neurological wards, high dependency units, or intensive care units 1
• When a diagnosis is not rapidly established or a patient fails to improve with therapy, transfer to a neurological unit should occur within 24 hours 1

Special Considerations

• For patients returning from malaria-endemic areas, rapid blood malaria antigen tests and three thick and thin blood films should be examined 1
• Consider the possibility of brain tumors masquerading as stroke, particularly in older patients with no prior history of cancer 3
• Be aware that tumefactive multiple sclerosis can present with headache, cognitive abnormalities, mental confusion, aphasia, seizures, and weakness, potentially mimicking a brain tumor 4

Follow-up Care

• Patients should not be discharged without either a definite or suspected diagnosis 1
• Arrangements for outpatient follow-up and plans for ongoing therapy and rehabilitation should be formulated at discharge 1
• All patients should have access to assessment for rehabilitation, as neurological conditions often cause debilitating symptoms with significant impact on quality of life 1, 5

Common Pitfalls to Avoid

• Relying solely on CT for diagnosis, as MRI is more sensitive for detecting small infarcts, encephalitis, and subtle cases of subarachnoid hemorrhage 1
• Assuming that a negative MRI at the time of clinical presentation rules out multiple sclerosis or other neurological conditions 6
• Failing to consider immune-related adverse events in patients receiving checkpoint inhibitor therapy, which can affect both the central and peripheral nervous systems 1
• Overlooking the possibility of paraneoplastic neurological syndromes and autoimmune encephalopathies 1