Neurological Emergencies
What to know
Neurologic emergencies hinge on time and on separating stroke from its mimics. Establish the last known well time and check glucose immediately, because hypoglycemia can mimic stroke. Anterior circulation strokes produce contralateral hemiparesis, aphasia, and gaze deviation; posterior circulation strokes produce vertigo, ataxia, diplopia, and dysarthria. IV thrombolysis is generally considered within 3 to 4.5 hours, and thrombectomy in selected large-vessel occlusions up to 24 hours. Blood pressure must be below 185/110 before lysis; otherwise permissive hypertension is usual in ischemic stroke. Subarachnoid hemorrhage presents with a thunderclap headache and may have a normal early CT, requiring lumbar puncture. Status epilepticus is treated first with a benzodiazepine, then a second-line agent. Meningitis requires droplet precautions, antibiotics, and dexamethasone. Traumatic brain injury care emphasizes avoiding hypoxia and hypotension, serial GCS and pupil checks, and recognizing Cushing triad as a late herniation sign.
Traps
Assume stroke until proven otherwise, but screen for mimics: seizure, migraine, hypoglycemia, sepsis, and toxic-metabolic states. Do not lower blood pressure aggressively in acute ischemic stroke. "Wake-up" strokes have unknown onset and need imaging-based selection. Delirium is frequently mislabeled as dementia or psychosis.
Worked example
A 71-year-old was last seen well at 08:00 and arrives at 15:00 with right arm weakness and expressive aphasia. Outside the IV lysis window, she may still qualify for thrombectomy; obtain CT and CTA without delay. Rule of thumb: the last known well time - not symptom discovery - starts the clock.