Nervous System Disorders
Core approach
Neurologic emergencies demand a structured assessment of airway, ventilation, glucose, pupillary reactivity, focal deficits, and level of consciousness. Core topics include ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, seizures and status epilepticus, coma, meningitis/encephalitis, headache, elevated intracranial pressure, and neuromuscular weakness. Establish the last-known-well time in stroke, obtain noncontrast CT, and identify thrombolysis or thrombectomy candidates. Treat status epilepticus promptly with benzodiazepines, then a second-line antiseizure medication.
Traps
Always check glucose; hypoglycemia is a reversible stroke mimic. Posterior circulation strokes may present with dizziness, diplopia, ataxia, or altered mental status without weakness. Early CT is insensitive for ischemia and may miss subarachnoid hemorrhage; timing and lumbar puncture matter. Do not delay antibiotics for lumbar puncture in suspected bacterial meningitis with instability. Nuchal rigidity may be absent. In coma, avoid anchoring on intoxication when trauma, hypoglycemia, or infection is possible.
Worked example
A patient reports a thunderclap headache and has a normal noncontrast CT four hours after onset. If suspicion remains, proceed to lumbar puncture and CSF analysis for xanthochromia, after assessing contraindications. Rule of thumb: sudden maximal headache is subarachnoid hemorrhage until a appropriate evaluation excludes it.
Key concepts
Status epilepticus is a time-critical emergency; benzodiazepines first. Stroke mimics include seizure, migraine, hypoglycemia, and conversion disorder. Elevated intracranial pressure may produce bradycardia, hypertension, and irregular respirations.