1. Neurological Emergencies
Dr David Eagle
Neurological Emergencies

2. Content Based on 3 cases from A&E and Ward 21 (Neurology):
Acute presentation, history and examination findings
Initial Management
Guidance
Key learning points

3. Case 1 – Back Pain Cover Sheet Text: 62 year old man.
Back pain for 5 months after heavy lifting, more severe last 2 weeks, now unbearable.
Not seen GP, taken Paracetamol to some effect.
YAS History:
Severe back pain, unable to weight-bear.
Required Entonox and Morphine 10mg to transport.

4. Case 1 – Back Pain Formal Clerking Pc: HxPc:
5 month history of low back pain, 2 weeks of increasing severity, 3 days of being unable to stand.
HxPc:
Well until December 2012.
Sudden onset of low back pain while lifting shopping onto bus just before Xmas.
Variable pain over next 4 months, taken Paracetamol, avoided too much rest, not seen GP.
Last 2 weeks pain much more severe and difficulty mobilizing.
Last 3 days been unable to stand, just lying on living room floor...

5. Case 1 – Back Pain HxPc continued: PMHx: Meds & Allergies:
Currently severe (10/10) low back/left buttock pain...
Dull ache with sharp twinges on movement,
Radiates down left leg to knee,
Exacerbated by movement, no comfortable position,
Relieved slightly by simple analgesia,
Associated with weakness in both legs Left > Right, altered sensation both feet Left > Right.
No recent bladder or bowel change, no recent diarrhoea or LRTI, eating and drinking, systemically well.
PMHx:
HTN, otherwise well.
Meds & Allergies:
Nil regular, no known drug allergies.

6. Case 1 – Back Pain Soc Hx: Fam Hx: On Examination: Retired builder.
Lives with wife in a house with stairs, supportive family close by.
Ex-smoker of 20 pack years, stopped 5 years ago.
Occasional drinker.
Fam Hx:
Nil relevant.
On Examination:
Obs: all stable
A, B, C, D: all NAD
Abdo: soft and non-tender, no organomegally, BS present, no AAA palpable, no renal angle tenderness, increased BMI
CNS: II  XII all NAD

7. Case 1 – Back Pain Examination continued: PNS:
PR: Peri-anal sensation intact, normal tone
Right
Left
Upper Limb:
All NAD
Lower Limb:
Inspection -
Tone
Increased
Power
3-4/5
1/5 throughout
Reflexes
++, downward plantar
++, upward plantar
Sensation
Inconsistent reporting ?reduced up to knees
Co-ordination
Unable due to reduced power

8. Case 1 – Back Pain Anything missing? Impression? Clonus +++
Impression: UMN spinal lesion
Discussion with Neurology & Neurosurgery
Urgent MRI Spine:
Cord compression at T11
Partial destruction of T11 with vertebral tumour – mets or myeloma
L3 disc herniation
To neurosurgery that night for debulking and fixation
At 5 days:
Pain free, no return of function
PSA 600+
CT Thorax, Abdo, Pelvis: prostate ca with widespread mets
Referral to Urology & palliation

9. Case 1 – Back Pain Learning points: Focussed neuro exam
UMN vs LMN – locating the lesion
Suspected cord compression guidelines

10. Case 2 – “Not himself” Cover Sheet Text: 71 year old man.
?previous TIA, increasing memory loss.
1 day history of confusion/odd behaviour.
Seen by BAT:
ROSIER: 0
No focal neurology.
Wife states “not his usual self”.
Appears confused, delirious, fluctuating, agitated.
?delirium, ED to see...

11. Case 2 – “Not himself” Formal Clerking Pc: HxPc:
1 day history of sudden onset odd/inappropriate behaviour on background of mild memory loss.
HxPc:
Well recently – no infections, no cough, fever, diarrhoea, SOB.
Banged his head on kitchen cupboard 2 days ago but only mild.
Sudden onset behaviour change yesterday afternoon while wife was at shops, “not himself”, including:
Stood to watch TV for 2 hours.
Went for meal out, made very unusual meal choices, didn’t fasten trousers after bathroom visit, episode of urinary incontinence.
Sat up all night watching ‘inappropriate’ TV.

12. Case 2 – “Not himself” HxPc continued: PMHx: Meds & Allergies:
Himself denies headache, nausea, vomiting or change in behaviour.
PMHx:
GORD, high cholesterol, migraines with aura (used to be 1 every 2 years, 2 in last month).
Meds & Allergies:
Simvastatin, Omeprazole, Aspirin; no known drug allergies.
Social Hx:
Lives with wife who is well.
Retired electrical engineer.
12 units alcohol per week, ex-smoker of 20 pack years.
Family Hx:
Nil relevant.

13. Case 2 – “Not himself” On examination:
Obs: sO2: 95%, HR: 100, apyrexial
Patient dismissive and mildly uncooperative throughout but maintained attention and consistent conscious level
A, B, C: slight crackles right base
CBG: 8.1
AMTS: 8/10 (incorrect address and WWII dates – would have known)
CNS: II  XII all NAD (unable to perform fundoscopy)
PNS: all NAD
Gait: NAD

14. Case 2 – “Not himself” Differential? Possible causes:
Cerebrovascular: frontal stroke (?bleed secondary to lesion).
Infective: encephalitis, meningitis (neuro TB, syphilis).
Toxic: CO, acute withdrawal, opiods.
Metabolic/Endo: hypoglycaemic (metabolic encephalopathy, thyrotoxicosis, Addision’s)
Paraneoplastic
Any cause of delirium
Acute psych disorder

15. Case 2 – “Not himself” Investigations: Admitted to stroke
Urine dip: -ve
FBC, U&Es, LFTs, B12, ferritin: all NAD.
Folate: 4.5 (slightly low)
CXR: nil acute
CT head:
Intracerebral haematoma medial frontal lobe on right,
Previous small infarction left frontal lobe.
Admitted to stroke
Discharged after 4 weeks rehab
Out-patient MRI/MRA

16. Case 2 – “Not himself” Learning points:
Diagnosis easily missed – subtle symptoms, diagnosis reliant on collateral history.
BAT assessment ROSIER score (ie weakness, visual field and speech disturbance) driven – will therefore miss frontal lobe and cerebellar strokes.
CT head justified on detail of history and clear acute onset.

17. Case 3 – Headache, Fever & Seizures
Formal Clerking
Pc:
22 year old man, normally fit and well.
5 day history of generally unwell, fever, headache and seizures today.
HxPc:
Well recently – no foreign travel, symptoms of infection or bites.
5 days ago began with general flu-like symptoms – generalised headache, myalgia, runny nose, feverish, anorexia, nauseated.
Had taken some Paracetamol to little effect.
Today, increasingly drowsy, headache more severe.
@ 15:00 partial seizure, starting with left hand shaking, progressed up arm to involve all left side, lasting <2 mins, resolved spontaeuously.
2x futher seizures – one in Ambulance, one in A&E.

18. Case 3 – Headache, Fever & Seizures
HxPc continued:
Not noticed a rash, no neck stiffness, mild photophobia.
MedHx:
Usually fit & well, no history of cold sores.
Meds & Allergies:
Nil regular; no known drug allergies.
Social Hx:
Lives with girlfriend who has been well.
Works in a call centre.
Occasional light drinker, non-smoker, denies any recreational drug use.
Family Hx:
Nil relevant.

19. Case 3 – Headache, Fever & Seizures
On examination:
Obs: temp: 38.7, else NAD
A, B, C: NAD
D: drowsy but easily rousable, GCS 14 – slightly confused speech
CBG: 4.3
Abdo soft & non-tender
Marked dysarthria
CNS: left-sided facial droop with forehead sparing, drooling & watering left eye, else NAD

20. Case 3 – Headache, Fever & Seizures
Examination continued:
PNS:
Right
Left
Upper Limb:
All NAD
Tone
Normal
Reduced
Power
5/5
2/5 throughout
Reflexes +
Sensation
Reduced fine touch
Lower Limb:
4/5 throughout
+, downward plantar

21. Case 3 – Headache, Fever & Seizures
Impression?
Likely viral encephalitis
Investigations:
Urine dip: -ve
FBC, U&Es, LFTs: all NAD.
Blood cultures sent
CT Head: NAD
Immediate Management:
Rectal Diazepam followed by Phenytoin infusion
IV Aciclovir (10mg per kg)
TCI Neurology

22. Case 3 – Headache, Fever & Seizures
At 5 days:
CSF: raised lymphocytes only, negative viral PCR
MRI: right-sided temporal, parietal and frontal hyperintensities consistent with encephalitis
On 14 day course of IV Aciclovir, initial improvement, relapse at 3 days (as aciclovir incorrectly switched to oral), improved on return to IV.
Complete recovery by discharge
Usually on LP: raised protein and reduced glucose, often viral PCR inclonclusive

23. Case 3 – Headache, Fever & Seizures
Learning points:
Mortality if untreated roughly 70%.
Prognosis dependent on early recognition at treatment.
Target starting Aciclovir within 30mins of attendance – don’t wait for imaging/LP.
Suspect in anyone with altered behaviour/new seizures/focal neurology with infective prodrome.