Neurological and Neurosurgical Emergencies
Stroke
Establish the exact time last known well - wake-up strokes are usually excluded from thrombolysis but not from thrombectomy. Use a validated screen, check glucose, and obtain CT within 20 minutes to exclude haemorrhage. Thrombolysis within 4.5 hours if no contraindication; mechanical thrombectomy for large-vessel occlusion up to 24 hours with favourable imaging. Lower blood pressure below 185/110 before thrombolysis, but do not lower it aggressively otherwise - the penumbra needs perfusion.
Subarachnoid haemorrhage: thunderclap headache. CT within 6 hours is highly sensitive; if later and the CT is negative, perform lumbar puncture at 12 hours or beyond, and give nimodipine.
Meningitis: antibiotics must never be delayed for imaging or lumbar puncture. Give dexamethasone with or just before the first antibiotic dose, ceftriaxone plus vancomycin, and add aciclovir if encephalitis is possible. Image first only with focal neurology, seizures, papilloedema, immunosuppression or reduced consciousness.
Status epilepticus: a benzodiazepine first, then a second-line agent (levetiracetam, valproate or fosphenytoin), and anaesthesia if refractory. Check glucose and sodium immediately.
Head injury: avoid hypoxia and hypotension, which independently worsen mortality. Record GCS, pupils and anticoagulation status; CT within one hour for any coagulopathic patient.
Rule of thumb: in any acute neurological presentation, check glucose first - hypoglycaemia is the great stroke mimic.