Neurological and Neurosurgical Emergencies
Time-critical stroke and altered consciousness
The candidate must know the stroke chain: recognition with a validated screen, last-known-well time, glucose check, noncontrast imaging, and reperfusion decision within the window. Know that thrombolysis eligibility depends on time, imaging, blood pressure, anticoagulation, and bleeding risk, and that blood glucose and seizure are the great mimics. For hemorrhagic stroke, blood pressure control and reversal of anticoagulation are priorities.
Level of consciousness and herniation
Use a consistent coma scale and trend it. A falling score plus a new pupil asymmetry suggests expanding intracranial mass and impending herniation; the classic progression is ipsilateral blown pupil from uncal herniation, then contralateral weakness, then deterioration. Elevate the head of the bed, avoid hypoxia and hypotension, and anticipate osmotic therapy and neurosurgical consultation. Do not confuse the Cushing response (hypertension with bradycardia and irregular respirations) with a benign finding - it is a late herniation sign.
Seizures and headaches
Status epilepticus needs benzodiazepines first, then a second-line antiseizure drug; protect the airway and check glucose. Thunderclap headache is a subarachnoid hemorrhage until proven otherwise. Meningitis needs antibiotics and dexamethasone without delay when suspected, and droplet precautions.
Traps in questions
- Do not give glucose before checking it in a patient with altered mental status, but do treat hypoglycemia immediately once identified.
- Nuchal rigidity may be absent in older or immunocompromised patients with meningitis.
- A lucid interval after head injury does not exclude epidural hematoma.
- Fever with altered mental status is not automatically psychiatric.
Rule of thumb
In any neuro deterioration, check glucose and oxygen before assuming a primary brain event. Worked example: a patient on warfarin presents with headache and a declining score after a fall; the priorities are airway protection, blood pressure and coagulation management, urgent imaging, and reversal planning - not observation.