A 10 - Emergency in Neurology

Question 1

what does neurological emergency associated with?

Answer 1

disorders of consciousness:
- respiratory
- circulatory failure
- epileptic activity

These three groups of symps interact with each other, i.e. any of them may lead to the other two or augment their effects within a short period of time.

Question 2

in which situations Neurological emergencies arise in?

Answer 2

1. A nervous system lesion causes central or peripheral respiratory failure
2. A nervous system disease leads to life threatening complications (infections, thrombotic events)
3. Nervous system dysfunction is caused by diseases and abnormal states originating outside the nervous system (metabolic disturbances, global cerebral ischemia, hypoxia, intoxication)

Question 3

what can cause resp. failure in neurological emergency?

Answer 3

caused by damage to:
○ The CNS → Raised ICP
○ The PNS → Myasthenia, Guillan-Barré syndrome
○ Neural structures, including the muscles

Question 4

what can be the complications of resp. failure?

Answer 4

Respiratory failure from any cause may also lead to secondary damage of parts of the CNS, which are sensitive to hypoxia (cortex, basal ganglia)

Question 5

examples of circulatory failure due to neuronal causes?

Answer 5

• rare *

● Neurogenic pulmonary edema
● spinal shock

● CNS complications of circulatory failure however, are common and serious (e.g. in global cerebral
ischemia, complete destruction of the brain occurs in five minutes in normal ambient temp.)

● Global cerebral functional disturbance occurs in case of impairment of parenchymal organs (e.g.
renal or hepatic failure)

Question 6

what are the 2 main groups of Disorders of consciousness?

Answer 6

Disorders of arousal (sleep-like state)

Disorder of awareness (inadequate thinking and behaviour)

Question 7

what is arousal?

Answer 7

the ability to wake up from sleep when stimuli are applied

Question 8

what is the Anatomical basis of arousal

Answer 8

intact functioning of the ascending reticular activating system (ARAS)

Question 9

what is reduced arousla?

Answer 9

• mildest to severe forms *

○ Somnolence
○ Stupor
○ Coma

Question 10

what is somnolence?

Answer 10

verbal stimuli enough to generate awakening reaction

Question 11

what is stupor?

Answer 11

verbal stimuli hardly effective, may open eyes to painful stimuli

Question 12

what is coma?

Answer 12

cannot be awakened and posture is usually abnormal (decorticate/decerebrate)
■ Coma I: Brainstem reflexes are preserved
■ Coma II: Brainstem reflex

Question 13

Disorder of awareness?

Answer 13

inadequate thinking and behaviour

● The CNSs global function is impaired
● Signs of focal cognitive deficit (e.g. alexia, acalculia) are not part of this condition
● Arousal is normal, but the content of memory is disturbed, inaccessible or their use is
inappropriate

Question 14

Clinical form in awareness disorder?

Answer 14

○ Persistent vegetative state (decorticate state/apallic syndrome)

Question 15

what could be the causes of disorders of awareness?

Answer 15

Damage to the cerebral cortex:

○ Global cerebral ischemia caused by circulatory arrest, severe metabolic conditions like hypoglycemia, renal- and hepatic failure, postconvulsive state, Wernicke’s encephalopathy, final stages of cortical dementias

○ Extensive white matter damage (diffuse axonal injury after head trauma)

○ Bilateral damage to the thalamus

Question 16

what is considered as permanent disorder of awareness?

Answer 16

when lasting longer than 30 days

Question 17

what remains intact in disorder of awareness?

Answer 17

Rostral brainstem remains intact:
- thermoreg.
- sleep-wake cycle
- cardiorespiratory
- other visceral functions + endocrine syst. is working

Question 18

how does the patient with disorder of awareness seems to be?

Answer 18

awake → eyes open and vestibuloocular reflex can be elicited, but attention cannot be aroused

Question 19

what are the characteristics of disorder of awareness if it lasts days - week but not more than 30 days?

Answer 19

• characteristic decorticate posture
• signs of corticospinal tract lesion (Babinski, suction reflex, Bulldog reflex) can be elicited

Question 20

what can Painful stimulus cause in disorders of awareness?

Answer 20

excessive sweating
tachycardia
hyperventilation

Question 21

what is Akinetic mutism?

Answer 21

• Patient is awake, but mute and lies without moving
• Mutism is not caused by aphasia (comprehension usually preserved)
• Paralysis excluded by normal withdrawal reaction to painful stimuli

Question 22

what could be the causes of Akinetic mutism?

Answer 22

● Jet bleeding (rupture of an ant. comm. artery aneurysm)
● Frontobasal contusion
● Bilateral ischemia in the territory of the ant. cerebral a.
● Subfalcial herniation
● Occlusive hydrocephalus
● Butterfly tumors growing across the corpus callosum into the prefrontal lobes
● Tumors of 3rd ventricle

Question 23

what can you say about Confusion?

Answer 23

■ Attention and thinking is impaired
■ Typical example is seen after an epileptic seizure

Question 24

what can you say about Delirium?

Answer 24

The disorder of attention and awareness is the core symptom (also abnormal preception - illusions and hallucinations)

Question 25

How quickly delirium evolves?

Answer 25

Usually evolves quickly (few hours - 24h)

Question 26

main causes of delirium?

Answer 26

• metabolic disorders
• drug
• alcohol
• may be a complication of right hemispheric lesions (at the parieto-occipito-temporal junction)

Question 27

Management of patients with disorders of consciousness
(see E-learning III/12.3)

Answer 27

(see E-learning III/12.3)

● history

● ABC, GCS

● Define the type and severity of the disorder of consciousness

● Signs of recent injuries? Immediate neuroimaging

● Neck stiffness/positive meningeal signs (meningitis, subarachnoid hemorrhage, imminent tonsillar herniation

● Brainstem reflexes and examination of the motor system

Question 28

How can you use the hostroy in Management of patients with disorders of consciousness ?

Answer 28

history is available → can point to a cause

○ Sudden onset + presence of focal signs → structural brain lesion

○ Gradual onset in pt. with known chronic renal/hepatic diseases or known psychiatric disorder → suggests other causes than structural brain lesions

Question 29

how to examine Brainstem reflexes and the motor system?

Answer 29

• Pupillary light reflex
• corneal reflex
• trigemino-facial pain reaction
• vestibuloocular reflex
• cough reflex
• apnoe test

Question 30

what causes Increased ICP?

Answer 30

○ Focal space occupying lesions (tumor, abscess, hemorrhage)

○ Disorders of CSF circulation (occlusive hydrocephalus)

○ Cerebral edema (vasogenic, cytotoxic, interstitial)

Question 31

what are the consiquences of Increased ICP?

Answer 31

Can cause herniations