Neurological and Neurosurgical Emergencies
What the board tests
Time-critical stroke decisions, recognition of subarachnoid and intracerebral haemorrhage, seizure termination, meningitis sequencing, and safe control of raised intracranial pressure.
Ischaemic stroke
- Establish the last known well time, not the arrival time. Non-contrast CT within 20 min of arrival.
- Thrombolysis up to 4.5 h: alteplase 0.9 mg/kg (10% bolus, rest over 60 min) or tenecteplase 0.25 mg/kg. Mechanical thrombectomy up to 6 h, and up to 24 h with favourable perfusion imaging.
- Blood pressure must be below 185/110 mmHg before lysis and below 180/105 mmHg after; do not lower blood pressure aggressively in the non-thrombolysed patient.
Haemorrhage and raised ICP
- Intracerebral haemorrhage: target systolic near 140 mmHg, reverse anticoagulation immediately (vitamin K plus prothrombin complex concentrate for warfarin), and do not give steroids.
- Subarachnoid haemorrhage: thunderclap headache; CT within 6 h is highly sensitive, otherwise lumbar puncture after 12 h; give nimodipine and secure the aneurysm.
- Raised ICP: head up 30 degrees, avoid hypoxia and hypotension, hypertonic saline or mannitol, and short hyperventilation to PaCO2 30-35 mmHg only as a bridge to definitive care.
Seizures and infection
Status epilepticus is a seizure lasting 5 min or more. Give a benzodiazepine first (IV lorazepam 4 mg, or IM midazolam 10 mg without access), then a second agent such as levetiracetam 60 mg/kg, fosphenytoin 20 PE/kg or valproate. For suspected bacterial meningitis give dexamethasone with or before the first antibiotic dose, plus ceftriaxone 2 g and vancomycin; do not delay antibiotics for CT or lumbar puncture.
Worked example
A 65-year-old was last seen well at 18:00 and arrives at 21:30 with dense right hemiparesis, NIHSS 14, BP 190/105 and glucose 7 mmol/L. CT excludes haemorrhage. Lower BP below 185/110, then give alteplase after checklist screening, admitting to a stroke unit. Reasoning: within 4.5 h of last known well, no haemorrhage, no contraindication; the 3.5 h delay does not exclude treatment because the window runs from last known well.
Traps
Waking the patient to re-assess and losing the window; lowering BP too far in ischaemic stroke; lumbar puncture before CT when signs of raised ICP exist; steroids in intracerebral haemorrhage.