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Neurologic Emergencies

Neurologic Emergencies. Joseph D. Burns, M.D. Attending Neurointensivist Assistant Professor of Neurology and Neurosurgery. Learning Objectives. Gain an appreciation for the significant public health burden created by neurologic emergencies

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Neurologic Emergencies

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  1. Neurologic Emergencies Joseph D. Burns, M.D. Attending Neurointensivist Assistant Professor of Neurology and Neurosurgery

  2. Learning Objectives • Gain an appreciation for the significant public health burden created by neurologic emergencies • Understand the diagnostic and treatment considerations unique to emergencies involving diseases of the nervous system • Be familiar with the differential diagnosis and diagnostic and therapeutic approach to common neurologic emergencies

  3. Why does this matter?

  4. Clinical and Economic Relevance of Neurologic Emergencies • Stroke • Incidence • 795,000 new strokes each year in the US • 1 stroke every 40 seconds • Prevalence • 2.5% of American adults • Mortality • Third leading cause of death in US • Someone dies of stroke every 3-4 minutes • Disability • 15-30% permanently disabled • 20% require institutional care at 3 months post-stroke • Cost • $68.9 billion in the US in 2009 • Acute care, long-term care, lost productivity Lloyd-Jones, Circulation, 2009

  5. Clinical and Economic Relevance of Neurologic Emergencies • Emergency care burden • 5-15% of all ED visits involve non-traumatic neurologic problems • 20% of non-surgical admissions are for neurologic problems Nawar EW, Advance Data, 2007

  6. What’s different about neurologic emergencies?

  7. Goal 1: Don’t let the patient die • Not unique • ACLS, ATLS, other strategies common to all emergency medical care • Not complicated

  8. Goal 2: preserve as much nervous system tissue as possible (complicated)

  9. Neurologic Emergencies are Complex • CNS exquisitely vulnerable to ischemia and hypoxia • Normal CBF: 50-100 mL/100g/min • Ischemia (loss of function): 20 mL/100g/min • Infarction: 10 mL/100g/min

  10. Neurologic Emergencies are Complex • CNS heals poorly • Tissue that dies is not replaced • Function never returns to normal

  11. Neurologic Emergencies are Complex • Treatment depends on a rapid, accurate neurologic diagnosis • Requires (unfortunately) unique training and experience • Attention to detail • As many as 1/3 of patients with Neurology consultation in ED are misdiagnosed by the requesting physician Moeller JJ, Can J Neurol Sci, 2008

  12. General Approach • ABCs • MORE – not less – important • Hypotension and hypoxemia exacerbate CNS injury • Hypercapnia elevates intracranial pressure

  13. General Approach • History • ALWAYS the key to diagnosis • Key elements • Time of symptom onset • Last time seen normal • Temporal profile of symptom onset • Paroxysmal? • Minutes? • Hours? • Days?

  14. General Approach • Physical examination: Is there evidence of brainstem dysfunction? • Mental status: level of arousal • Cranial nerves: pupillary responses • Motor: • Hemiparesis? • Pathologic reflexes? • Pathologic posturing

  15. General Approach • Imaging: non-contrast CT • Fast • Widely available • Labs • ALWAYS look for hypoglycemia • CBC, electrolytes, aPTT, PT/INR, LFTs, BUN, Cr • CSF • Lumbar puncture • CNS infections, subarachnoid hemorrhage, Guillain-Barre Syndrome

  16. Pearls • Time is brain • Successful treatment depends on accurate diagnosis • Use only normal saline for IV fluids • Time is brain

  17. Common Neurologic Emergencies

  18. Vignette #1 • 55yo woman with a history of rheumatic heart disease suddenly falls while walking and is unable to move her left limbs • She has a mechanical mitral valve replacement and stopped warfarin one week ago in preparation for unrelated surgery

  19. Sudden-onset hemiparesis • Differential diagnosis • Ischemic stroke • Intracerebral hemorrhage • Post-ictal paresis (Todd’s paralysis)

  20. Sudden-onset hemiparesis • Rapid diagnosis • History • Time of onset or time last seen normal • Cerebrovascular risk factors • Anticoagulant use • History of seizures • Exam • Large deficit with preserved arousal: ischemic stroke • Decreased arousal or vomiting: ICH or posterior circulation • Delirium, visual problems, dizziness, cranial nerve dysfunction: posterior circulation

  21. Sudden-onset hemiparesis • Rapid diagnosis • Imaging: CT head, CTA head and neck • Labs: serum glucose, CBC, aPTT, PT/INR

  22. Time is Brain Saver JL. Stroke. 2006

  23. Time is Brain Lees KR. Lancet. 2010

  24. Ischemic Stroke Emergent Treatment • Goal: maximize perfusion to limit infarction • Earlier reperfusion = more salvaged brain = better functional outcome • Allow hypertension, give IV normal saline, lay head of bed < 30 degrees • Do NOT treat hypertension unless >220/110 mmHg or end-organ dysfunction • IV tissue plasminogen activator (tPA) • Within 4.5h of symptom onset • Exclusion criteria extensive (bleeding) • Endovascular therapy • Contraindications to or failure of IV tPA • Mechanical thrombectomy • Intra-arterial tPA • Within 6h in anterior circulation (ACA, MCA) • Within 12h in posterior circulation (vertebral, basilar)

  25. ICH Emergent Treatment • Goal • Prevent hematoma expansion • Occurs in 70% of patients, mostly in 1st 6h • 10% volume increase = • 5% mortality increase • 16% increase in chance of worsening by 1 point on the modified Rankin scale • Treat hypertension • Goal SBP 130-150 mmHg • IV Drugs!!! • Prns: labetalol, hydralazine • Nicardipine gtt • Correct coagulopathy FAST! • Goal INR < 1.4, platelets > 100k • PCC, Vitamin K, fresh frozen plasma

  26. Acute hypertension and ICH • Occurs in 50-75% of patients • Mechanism • Destruction/interruption of autonomic centers • Prefrontal cortex, insula, hypothalamus • Increased ICP • Associated with increased risk of hematoma expansion and poor outcome in a number of retrospective studies • Chicken or Egg? Quereshi AI. Circulation. 2008

  27. Acute hypertension and ICH • Retrospective, single center study from Japan • Patients • 76 consecutive adult hypertensive ICH • Outcome • Hematoma growth by ≥ 40% Ohwaki K et al. Stroke. 2004

  28. Acute hypertension and ICH • Post-hoc analysis of prospectively collected data on 98 ICH patients • Normal INR • Within 3h of symptom onset • No relationship between hematoma • SBP • DBP • MAP • Pulse pressure (PP) • PP x HR • MAP x HR Jauch EC et al. Stroke. 2006

  29. Lower the Blood Pressure • INERACT (Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial) • Open-label, blinded outcome, randomized, controlled trial of antihypertensive treatment initiated within 6 hours of ICH onset • Exclusion criteria • <18yo • SBP <150 or >220 • Clear indications for or contraindications against lowering BP Anderson CS et al. Lancet Neurology. 2008

  30. Vignette #2 • 20yo male college student is found confused and drowsy by his friends on a Sunday morning • He has a history of epilepsy, is known to be poorly compliant with medications, and was drinking the night before • 5 minutes after arriving at the ED, he begins to convulse. 3 min into the convulsion, he is not slowing down

  31. Generalized Convulsive Status Epilepticus • Status epilepticus • Any single seizure lasting > 5min • ≥ 2 seizures without clearing of mental status between them • Differential diagnosis • Underlying epilepsy with or without AED withdrawal • Drug intoxication (many types) or withdrawal (esp. EtOH and benzodiazepines) • Hypoglycemia • Vascular disease (infarct, ICH, SAH, AVM) • Electrolyte abnormalities (↓Na, Mg, Ca; ↑Na) • CNS infection • Tumor • Psychogenic, non-epileptic seizure (conversion disorder)

  32. Generalized Convulsive Status Epilepticus • Rapid diagnosis • History: epilepsy, other neurologic disease, diabetes, drug ingestion/withdrawal, infectious symptoms, pre-seizure neurologic symptoms • Exam: • subtle signs of ongoing seizure (periorbital/perioral clonus, forced horizontal conjugate eye deviation, hippus)

  33. Generalized Convulsive Status Epilepticus • Rapid diagnosis • Imaging: CT for associated mass lesion • Labs: glucose, electrolytes, urine and serum toxicology screens • CSF • Evidence of infection OR • No other clear cause from history, exam, CT, and labs

  34. Generalized Convulsive Status Epilepticus • Seizures beget seizures • Early treatment = higher chance of success • Balance this with side effects of treatment (need for intubation, hypotension) • Excitotoxic neuronal death

  35. Status epilepticus Lactic andrespiratoryacidosis Cardiacarrhythmias Rhabdomyolysis pH  pCO2  Lactate  Myoglobinuria Aspiration pneumonia Pulmonary edema Shoulderdislocation Ribfracture CP1142808-43 Figure courtesy of Dr. Eelco F.M. Wijdicks

  36. Emergency Treatment of Generalized Convulsive Status Epilepticus • Abort the seizure • Lorazepam 4-6mg IV push • Repeat 5min later if seizure continues or returns • Prevent future seizures • Phenytoin load: 20mg/kg IV infusion • DO NOT just give 1g  only enough for a small, 50kg person • Alternatives: • IV valproic acid 20-30mg/kg • IV levetiracetam 25-30mg/kg

  37. Vignette #3 • 35yo woman with a history of migraine headaches was awakened by the worst headache of her life and severe nausea. A few minutes later, she vomited. • ED: BP 170/90. Ill and uncomfortable. Holding an emesis basin, preferred to keep her eyes closed. Slightly drowsy. Resisted passive neck flexion.

  38. Sudden, Severe Headache • Differential diagnosis • Aneurysmal subarachnoid hemorrhage • Aneurysmal subarachnoid hemorrhage • Aneurysmal subarachnoid hemorrhage • Aneurysmal subarachnoid hemorrhage • Aneurysmal subarachnoid hemorrhage

  39. Sudden, Severe Headache • Differential diagnosis • Cervical artery dissection • Cerebral venous sinus thrombosis • Intracranial mass • Pituitary apoplexy • Meningitis • Encephalitis • Spontaneous intracranial hypotension

  40. Sudden, Severe Headache • Rapid diagnosis • History (features of aneurysmal SAH) • Instantaneous onset of headache • Decrease in arousal/loss of consciousness at onset • Nausea, vomiting • Family history of aneurysm, SAH • Neck stiffness

  41. Sudden, Severe Headache • Exam • Meningismus • Retinal subhyaloid hemorrhages (Terson syndrome) • CN III palsy (ptosis; deviation “down and out”; pupil fixed and dilated)

  42. Sudden, Severe Headache • Rapid diagnosis • Imaging • CT sensitivity declines with time after ictus • Nearly 100% sensitive within 6h • >95% sensitive for SAH within 12h • CT angiogram: identifies aneurysm • Treatment planning • 20% will have multiple aneurysms • CSF • LP required if SAH diagnosis is considered and CT negative • 90-95% sensitive for SAH when CT negative • Findings • Gross blood • Xanthochromia

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