Emergency Appendix

Neurologic Emergency Appendix

Acute Ischemic Stroke


Acute ischemic stroke, rtPA, mechanical thrombectomy

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  1. 1. Additional work-up is indicated, including but not limited to electrolytes with renal function studies, cardiac markers, and electrocardiogram (EKG). However, administration of tissue plasminogen activator (tPA) should not be delayed to obtain these additional tests.
  2. 2. Contraindications to intravenous recombinant tissue plasminogen activator (IV r-TPA) in the 3- to 4.5-hour window: age > 80 years, National Institutes of Health Stroke Scale (NIHSS) > 25, taking an oral anticoagulant regardless of international normalized ratio (INR), history of both diabetes, and prior ischemic stroke.
  3. 3. Relative contraindications to IV tPA: age < 18 years, systolic blood pressure (SBP) > 185 mm Hg or diastolic blood pressure (DBP) > 110 mm Hg, blood glucose (BG) < 50, INR > 1.7, platelets < 100,000/mm3, low molecular weight heparin (LMWH) within 24 hours, novel oral anticoagulant (NOAC) use within 48 hours, active internal bleeding, previous/recent intracerebral hemorrhage (ICH), severe head trauma within 3 months, recent intracranial or intraspinal surgery (within 3 months), computed tomography (CT) showing hypodensity > 1/3 of the cerebral hemisphere.
  4. 4. IV r-tPA dose: 0.9 mg/kg (maximum dose of 90 mg); 10% as a bolus and the remainder infused over 1 hour.
  5. 5. Patients eligible for IV tPA should receive IV tPA even if endovascular treatment is being considered.


Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46–e110.

Nogueira, R.G., Jadhav, A.P., Haussen, D.C., et al. (2018). Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med, 378, 11–21.

Bacterial Meningitis and Severe Encephalitis


Meningitis, encephalitis, neuro ICU care of meningitis.

Treatment starts with the empiric antibiotics (ceftriaxone, vancomycin, ampicillin, metronidazole, acyclovir).

Neurocritical care

Airway and respiratory care

Circulatory care

Gastrointestinal care

Other supportive care

Myasthenic Crisis


Myasthenic crisis, myasthenia gravis crisis, myasthenia gravis exacerbation, cholinergic crisis



Headache Management


Headache, primary headache, secondary headache, migraine, tension type headache, cluster headache

Approach to the headache

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Diagnosis of headache

International headache society classification of migraine headache

  1. 1 Migraine without aura

    1. 1.2 Migraine with aura

      1. 1.2.1 Migraine with typical aura
      2. 1.2.2 Migraine with prolonged aura
      3. 1.2.3 Familial hemiplegic migraine
      4. 1.2.4 Basilar migraine
      5. 1.2.5 Migraine aura without headache
      6. 1.2.6 Migraine with acute onset aura

    2. 1.3 Ophthalmoplegic migraine
    3. 1.4 Retinal migraine
    4. 1.5 Childhood periodic syndromes that may be precursors to or associated with migraine

      1. 1.5.1 Benign paroxysmal vertigo of childhood
      2. 1.5.2 Alternating hemiplegia of childhood

    5. 1.6 Complications of migraine

      1. 1.6.1 Status migrainosus
      2. 1.6.2 Migrainosus infarction

    6. 1.7 Migrainosus disorder not fulfilling above criteria

Hemorrhagic Stroke, Intracranial Hemorrhage, Subarachnoid Hemorrhage, See Stroke


Stroke, hypertension, cerebral edema, herniation, coma, anticoagulants

Hemorrhagic strokes account for about 15% of all strokes. The most commonly encountered neurological emergencies of hemorrhagic stroke are subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH). ICH is commonly seen with uncontrolled hypertension and located in the typical deep location such as basal ganglia, brainstem, and cerebellum. On the other hand, lobar ICH is commonly caused by amyloid angiopathy, tumor (primary or metastatic), infectious such as herpes encephalitis, and anticoagulation/coagulopathy. Common tumors that lead to hemorrhagic metastasis are lung cancer, breast cancer, renal cell carcinoma, and melanoma. The most important factor in predicting outcome following ICH is the volume of the hematoma. Estimating the ICH score that takes into account the hematoma volume, patient age, Glasgow coma scale on admission, and ICH location may help in prognostication (see “Stroke” chapter).

Spontaneous SAH is commonly caused by ruptured cerebral aneurysm and leads to prolonged hospital course and complications. The most common events following SAH are: obstructive hydrocephalus, rebleeding, seizure, sedation, dry mouth stomatitis, hyponatremia, vasospasm, and strokes. Management focuses on blood pressure (BP) control for both ICH and SAH and treating the underlying etiology (see ICH and SAH chapters).

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Long B., Koyfman A., Runyon M.S. Subarachnoid hemorrhage: updates in diagnosis and management. Emerg Med Clin North Am. 2017;35(4):803–824.

Zhao Y.N., Chen X.L. Endoscopic treatment of hypertensive intracerebral hemorrhage: a technical review. Chronic Dis Transl Med. 2016;2(3):140–146.

Intracranial Pressure Management


ICP management, neurologic emergency, cerebral perfusion pressure, mannitol, hypertonic saline

Current guidelines for the management of increased intracranial pressure (ICP) recommend maintaining an ICP < 20 mm Hg as well as maintaining a cerebral perfusion pressure (CPP) between 50 and 70 mm Hg, depending on the status of cerebral pressure autoregulation. In general, patients with increased ICP should be mechanically ventilated with adequate sedation and analgesia. Ventilator settings should be adjusted to maintain normocapnia; prophylactic hyperventilation is not recommended, although brief periods of mild hyperventilation (PaCO2 30 to 35 mm Hg) can be used to treat acute neurological deterioration caused by increased ICP.

Core body temperature should be maintained at normothermia to slight hypothermia (36.5 to 37 °C). The mainstay of medical management of increased ICP is osmotic therapy, including administration of mannitol and hypertonic saline. Mannitol 20% is given as an intravenous bolus of 0.25 to1 g/kg. This can be repeated as needed for sustained elevations in ICP if serum osmolality is less than 330 milliosmoles (mOsm). Mannitol must be used cautiously, because the subsequent osmotic diuresis can lead to hypovolemia, decreased cardiac preload, and hypotension, which could compromise CPP, lead to vasodilation, and increase ICP again. Hypertonic saline may be used instead of mannitol. Dosing includes a 30-mL bolus of 23.4% solution via a central line. Alternatively, a 250-mL bolus of 3% solution (also through a central line) or 2% solution (through a peripheral line) can be given followed by a continuous infusion at the rate of 30 to 150 mL/hr. The target serum sodium is between 150 and 160 mEq/L.

An essential step of a raised ICP management is offering neurosurgical interventions if indicated. It depends on the lesion, but this includes external ventricular drain placement, which can be diagnostic and therapeutic (measures ICP and drains cerebrospinal fluid volume to reduce ICP), craniotomy, and mass lesion resection (e.g., intracranial hemorrhage or brain tumor).

The patient, or more commonly, family members, need to be informed as to course and prognosis as it develops within limits of legal disclosure and to help facilitate care planning.


Aug 12, 2020 | Posted by in NEUROLOGY | Comments Off on Emergency Appendix
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