Common neurologic emergencies for nonneurologists: When minutes count

Mohan Kottapally; S. Andrew Josephson

doi:10.3949/ccjm.83a.14121

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FIGURE 1
A patient who presents with active seizures who does not return to baseline function may be in status epilepticus. Video electroencephalographic monitoring helps guide therapy, and the choice of antiepileptic drug is often based on physician preference.^34–36

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TABLE 1

Stroke mimics

The initial evaluation of stroke should include consideration of stroke mimics. Common metabolic derangements may unmask areas of previous ischemic cerebral injury, as well as potentiate seizures. Conditions most commonly encountered are marked with an asterisk.

Neurologic
Seizure with or without Todd paralysis (postseizure focal weakness)*
Complicated migraine*
Bell palsy*
Brain tumor
Brain abscess
Encephalitis
Spinal cord injury
Intracerebral hemorrhage

Metabolic
Hypoglycemia*
Systemic infection*
Hyperglycemia
Hyponatremia
Hypernatremia
Hyperammonemia
Uremia

Vascular
Arteriovenous malformation
Dural arteriovenous fistula
Intracranial aneurysm

Traumatic
Subdural hematoma
Epidural hematoma

Toxic
Medication or drug overdose*

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TABLE 2

Causes of intracerebral hemorrhage

Hypertension

Coagulopathy
Drug-related (eg, anticoagulants, antiplatelet drugs)
Idiopathic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura
Disseminated intravascular coagulation

Vascular
Aneurysm (spontaneous, mycotic)
Arteriovenous malformation
Dural arteriovenous fistula
Cavernous malformation
Cerebral venous thrombosis
Cortical vein thrombosis

Neoplastic
Primary central nervous system neoplasm
Metastatic disease

Spontaneous
Hypertensive hemorrhage
Cerebral amyloid angiopathy

Other
Infective endocarditis
Ischemic stroke
Contusion
Diffuse axonal injury

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TABLE 3

Causes of a dilated pupil

Unilateral
Trauma
Optic neuritis
Tonic pupil (Adie pupil)
Acute angle-closure glaucoma
Local contamination with drugs such as albuterol, stimulants (cocaine, amphetamine), anticholinergics (scopolamine, atropine, hycosamine)
Compression of cranial nerve III
Uncal herniation
Posterior communicating artery aneurysm

Bilateral
Systemic disease (eg, botulism, paraneoplastic syndrome, Miller Fisher variant of acute inflammatory demyelinating polyneuropathy)
Systemic drugs (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, stimulants such as cocaine and amphetamine)
Midbrain injury

Transient
Unilateral episodic mydriasis
Seizures
Migraine

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TABLE 4

Differential diagnosis of nontraumatic myelopathy

Compressive	Noncompressive
Infectious Epidural abscess Neurocysticercosis Neoplastic Astrocytoma Ependyoma Hemangioblastoma Lymphoma Metastasis Hematologic Epidural hematoma Degeneration Herniated disk Disk-osteophyte complex Congenital Arnold-Chiari malformation Meningocele Myelomeningocele	Infectious Herpes infection Human immunodeficiency virus Tuberculosis Toxoplasmosis Bacterial infection Fungal infection Vascular Spinal cord stroke Spinal arteriovenous malformation Fibrocartilaginous embolism Vasculitis Demyelinating Multiple sclerosis Neuromyelitis optica