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Neurological Emergencies

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Neurological Emergency	Clinical Presentation	Diagnostic Tests	Treatment
Acute Ischaemic Stroke	Sudden onset of focal neurological deficits, such as unilateral weakness, speech disturbances (aphasia), visual disturbances, or loss of coordination. Symptoms may be accompanied by headache, dizziness, or altered consciousness. Risk factors include hypertension, atrial fibrillation, diabetes, and previous stroke.	Non-contrast CT scan of the head to exclude haemorrhage and confirm ischaemic stroke. MRI of the brain for more detailed imaging in ischaemic stroke. ECG to detect atrial fibrillation, echocardiography to assess for cardiac emboli. Blood tests including glucose, electrolytes, coagulation profile, and cardiac enzymes.	Thrombolytic therapy (e.g., IV alteplase) within 3-4.5 hours of symptom onset for eligible patients. Aspirin for patients not eligible for thrombolysis or as secondary prevention. Endovascular thrombectomy for large vessel occlusions if within 24 hours of onset. Management of blood pressure, blood glucose, and other risk factors. Rehabilitation and secondary prevention strategies, including antiplatelet therapy and statins.
Intracerebral Haemorrhage	Sudden onset of severe headache, vomiting, altered mental status, and focal neurological deficits. May present with rapidly increasing symptoms of raised intracranial pressure (e.g., decreased level of consciousness, pupil abnormalities). Commonly associated with hypertension, anticoagulation, or vascular abnormalities (e.g., aneurysms, AV malformations).	Non-contrast CT scan of the head to identify the location and extent of bleeding. Blood tests including complete blood count (CBC), coagulation profile, renal and liver function tests. Consider MRI or CT angiography if vascular malformation is suspected.	Immediate blood pressure control, often with IV antihypertensives (e.g., labetalol, nicardipine). Reversal of anticoagulation if applicable (e.g., vitamin K, prothrombin complex concentrate for warfarin). Surgical intervention (e.g., decompressive craniectomy, evacuation of haematoma) in selected cases. Monitoring in an ICU setting for signs of increased intracranial pressure or herniation.
Subarachnoid Haemorrhage	Sudden onset of "thunderclap" headache, often described as the worst headache of the patient’s life. May be associated with neck stiffness, photophobia, nausea, vomiting, and loss of consciousness. Commonly caused by rupture of a cerebral aneurysm or arteriovenous malformation (AVM).	Non-contrast CT scan of the head to identify subarachnoid blood. Lumbar puncture if CT is negative but suspicion remains high; looking for xanthochromia and RBCs in the CSF. CT or MR angiography to identify the source of bleeding (e.g., aneurysm, AVM).	Early neurosurgical or endovascular intervention (e.g., aneurysm clipping or coiling). Control of blood pressure to prevent rebleeding (e.g., with IV labetalol, nimodipine to prevent vasospasm). Supportive care including pain management, anticonvulsants if seizures occur, and monitoring in an ICU setting.
Status Epilepticus	Continuous or recurrent seizures lasting more than 5 minutes without regaining consciousness between episodes. May present with tonic-clonic movements, altered consciousness, and possible respiratory compromise. Common causes include epilepsy, head trauma, CNS infections, and withdrawal from antiepileptic drugs.	Clinical diagnosis based on seizure activity. Blood tests including glucose, electrolytes, and toxicology screen to identify precipitating factors. Consider CT or MRI brain to rule out structural abnormalities if the cause is unclear. EEG monitoring in refractory cases to assess seizure activity and response to treatment.	Immediate administration of IV benzodiazepines (e.g., lorazepam, diazepam) to terminate seizures. Follow with IV antiepileptics (e.g., phenytoin, valproate) if seizures persist. ICU admission for continuous EEG monitoring and management if seizures are refractory. Identify and treat underlying causes (e.g., infection, electrolyte imbalance).
Guillain-Barré Syndrome	Progressive symmetrical weakness starting in the legs and ascending to involve the arms and respiratory muscles. May be associated with paresthesia, areflexia, and autonomic dysfunction (e.g., tachycardia, blood pressure instability). Often follows a recent infection, such as Campylobacter jejuni, influenza, or CMV.	Clinical diagnosis supported by nerve conduction studies showing demyelination. CSF analysis may show elevated protein with normal cell count (albuminocytologic dissociation). Pulmonary function tests (e.g., vital capacity) to assess respiratory muscle involvement. Consider MRI spine if diagnosis is unclear or to rule out other causes of weakness.	Plasmapheresis or intravenous immunoglobulin (IVIG) to reduce immune-mediated nerve damage. Supportive care, including monitoring of respiratory function and ICU admission if respiratory failure is imminent. Physical therapy to maintain muscle strength and prevent complications from immobility. Monitor for complications such as autonomic dysfunction and deep vein thrombosis (DVT).
Meningitis	Fever, headache, neck stiffness, photophobia, and altered mental status. May present with a rash, particularly in meningococcal meningitis. Can be caused by bacterial, viral, or fungal infections, with bacterial meningitis being the most severe.	Blood cultures and lumbar puncture to obtain CSF for analysis (e.g., cell count, glucose, protein, Gram stain, culture). CT scan of the head may be done prior to lumbar puncture if there are signs of raised intracranial pressure. CSF analysis showing elevated white cells, low glucose, and high protein in bacterial meningitis. Consider PCR or serology for specific pathogens, especially in viral meningitis.	Empirical IV antibiotics (e.g., ceftriaxone, vancomycin) started immediately after blood cultures are taken. IV corticosteroids (e.g., dexamethasone) may be used to reduce inflammation in bacterial meningitis. Supportive care including IV fluids, antipyretics, and monitoring for complications such as seizures or septic shock. Isolation and public health notification if meningococcal meningitis is suspected.
Acute Myasthenic Crisis	Severe muscle weakness leading to respiratory failure, difficulty swallowing, and bulbar symptoms. May be triggered by infection, surgery, medication changes, or stress. Often occurs in patients with underlying myasthenia gravis, particularly those with thymoma.	Clinical diagnosis based on history of myasthenia gravis and presentation of symptoms. Electromyography (EMG) showing decremental response to repetitive nerve stimulation. Serum antibodies against acetylcholine receptor (AChR) or muscle-specific kinase (MuSK) may be positive. Pulmonary function tests (e.g., forced vital capacity) to assess respiratory function.	IVIG or plasmapheresis to rapidly reduce antibody levels and improve symptoms. High-dose corticosteroids or other immunosuppressive therapy to control the underlying disease. Monitoring and management of respiratory function in an ICU setting if necessary. Adjustment of medications that may worsen myasthenia (e.g., aminoglycosides, beta-blockers).
Acute Encephalitis	Fever, headache, altered mental status, seizures, and focal neurological deficits. May also present with behavioural changes, confusion, and coma in severe cases. Commonly caused by viral infections, such as herpes simplex virus (HSV), or autoimmune encephalitis.	CSF analysis showing lymphocytic pleocytosis, normal or elevated protein, and normal glucose. MRI brain may show changes consistent with encephalitis, especially in the temporal lobes with HSV. EEG may show diffuse slowing or focal abnormalities. CSF PCR for HSV or other viral pathogens; autoimmune antibodies if autoimmune encephalitis is suspected.	Empirical IV acyclovir should be started immediately if HSV encephalitis is suspected. Supportive care including IV fluids, seizure management, and monitoring of intracranial pressure. Immunotherapy (e.g., steroids, IVIG, plasmapheresis) for autoimmune encephalitis. Consider transfer to an ICU for severe cases with altered mental status or respiratory compromise.
Acute Subdural Haematoma	Headache, confusion, drowsiness, and focal neurological deficits, often following head trauma. May present with loss of consciousness followed by a lucid interval, then deterioration. More common in elderly patients or those on anticoagulants.	Non-contrast CT scan of the head showing crescent-shaped hyperdense area. MRI may be used in subacute or chronic cases to assess the extent of the haematoma. Coagulation profile and blood tests to assess for anticoagulation status and overall health.	Surgical intervention (e.g., craniotomy, burr hole evacuation) for large or symptomatic haematomas. Reversal of anticoagulation if the patient is on anticoagulants (e.g., vitamin K, FFP). Monitoring for signs of increased intracranial pressure and neurological deterioration. Rehabilitation and monitoring for potential long-term neurological deficits.

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