Overview of Neurological

Emergency in Daily Practice

Iswandi Erwin
National Brain Center (NBC) Hospital
Prof.Dr.dr. Mahar Mardjono Jakarta
Nov 2020
 Curriculum Vitae
• General Practitioner : Trisakti University, 2011
• Neurologist : Universitas Sumatera Utara, 2017
• CPD : Asian Stroke Summer School 2019, SIS Can Tho Hospital,
Can Tho City, Vietnam
• Area of Interests : Pain and Headache, Neurovascular
• Working : NBC Hospital Prof Dr.dr. Mahar Mardjono, Jakarta
• Professional Membership: Indonesia Medical Association (IDI), Indonesian Neurological
Association (PERDOSSI), Pain Intervention Study Group, International Association for
Study of Pain (IASP), Indonesian Stroke Society (InaSSoc), European Stroke Organization
(ESO), Angels Initiatives.
 General Overview of Neurological
Emergencies
• Stroke dan Neurovascular Emergency
• Neuroinfection Emergency
• Head and Spinal Neurotrauma
• Status Epilepticus
• Emergency in Low Back Pain
• Emergency Headache and Vertigo

DISCLOSURES:
At this point , as I worked in specialized divisions in my hospital (mainly in Pain and Stroke cases):
1. Some of my presentation may reflect more focus on that disciplines
2. A lot of the audiences might have competence or understanding more than me on another topics, so feel free to make correction(s) ☺
 Stroke and Neurovascular Emergency
• Stroke: “Rapidly developing clinical signs of focal (or global) disturbance of
cerebral function, lasting more than 24 hours or leading to death, with no
apparent cause other than that of vascular origin” →Not changed
• Transient Ischemic Attack (TIA): “a transient episode of neurological
dysfunction caused by focal brain, spinal cord or retinal ischemia without
acute infarction→ Changed in 2013
• Why the changing → Paradigm of stroke management itself has changed
through the years.
Sacco RL, Kasner SE, Broderick JP, Caplan LR, Connors JJ, Culebras A, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals
from the American Heart Association/American Stroke Association. Stroke. 2013;44:2064-2089).
 Stroke and Neurovascular Emergency
• Most common deficits: balance problem, loss ef visiom, face drop, hemiplegia (arm
deviation), slurred speech (or abbreviated BE- FAST)
• Could be brain ischemia or hemorragic stroke
• Brain ischemia→ could be thrombosis origins or embolic (from proximal thrombus or
cardiac problems, i.e: Atrial fibrillation)
• Hemorrage stroke could be intracerebral / intraparenchymal hemorrhage, or subarachnoid
hemorrhage (spontaneous or aneurysmal)
• Gold standard→ Head CT OR Brain MRI to treat ASAP (COR/LOE: 1A)
• In imminent condition in past years: Siriraj Stroke Score, Algoritma Gadjah Mada,
Djoenaidi Stroke Score, Syiah Kuala Stroke Score etc
SSS and ASGM
 Stroke and Neurovascular Emergency
ACUTE ISCHEMIC STROKE (AIS)
• First Hyperacute Period (Up to 4.5 hs from ictus):
rTPA (recombinant tissue plasminogen activators) / Alteplase dosage 0.9 mg/
kgBB (or 0.6 mg/kgBB according to J-ACT study) (COR/LOE : 1A)
• Aspirin dosage 160 mg – 300 mg is recommended within 24- 48 hs of onset
(COR/LOE : 1A)→ but no single antiplatelets is comparable to IV alteplase.
• Urgent anticoagulation, with the goal of preventing early recurrent stroke,
halting neurological worsening, or improving outcomes after AIS, is not
recommended for treatment of patients with AIS. (COR/LOE : IIIA – No
benefit)
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K et al. Guidelines for the early management of patients with acute ischemic stroke: 2019
update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American
Stroke Association. Stroke. 2019;50:e344–e418 doi: 10.1161/STR.0000000000000211.
Cerebral Digital Substraction Angiography
(Cerebral DSA)
- A Minimal invasive technique
for DIAGNOSTIC
APPROACH

- Comparable to CT-Angio

- Measurement of lumen
vasculature and along with CTA,
as a gold standard for cerebral
vascular DIAGNOSIS
approaches
Emerging Neuroimaging and Neurintervention
Procedure in the Near Future
• CT and/ or MR Perfusion
• Mechanical Thrombectomy using Stent Retriever or Suction Device
Mechanical Thrombectomy using Stent
Retriever and/ or Suction Device
AHA /ASA 2019 AIS Reccomendation:

1. Patients eligible for IV alteplase should receive IV

alteplase even if mechanical thrombectomy is being
considered. (COR /LOE IA)

2. Patients should receive mechanical thrombectomy with a

stent retriever if they meet all the following criteria: (1)
prestroke mRS score of 0 to 1; (2) causative occlusion of
the internal carotid artery or MCA segment 1 (M1); (3)
age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of
≥6; and (6) treatment can be initiated (groin puncture)
within 6 hours of symptom onset. (COR /LOE IA)
Mechanical Thrombectomy using Stent
Retriever and/ or Suction Device
1. In selected patients with AIS within 6 to 16
hours of last known normal who have LVO
in the anterior circulation and meet other
DAWN or DEFUSE 3 eligibility criteria,
mechanical thrombectomy is recommended.
(COR /LOE IA)
2. In selected patients with AIS within 16 to 24
hours of last known normal who have LVO
in the anterior circulation and meet other
DAWN eligibility criteria, mechanical
thrombectomy is reasonable. (COR /LOE II
aB-R)
 Stroke and Neurovascular Emergency
SPONTANEOUS INTRACEREBRAL STROKE
• For ICH patients presenting with SBP between 150 and 220 mmHg and
without contraindication to acute BP treatment, acute lowering of SBP to
140 mmHg is safe (COR/LOE : 1A)

• Patients with cerebellar hemorrhage who are deteriorating neurologically or

who have brainstem compression and/or hydrocephalus from ventricular
obstruction should undergo surgical removal of the hemorrhage as soon as
possible (COR/LOE : 1B)
Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a
guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–2060.
 Stroke and Neurovascular Emergency
• SUBARACHNOID HEMORRHAGE (SAH)
• Treatment of high blood pressure with antihypertensive medication is recommended to
prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ
injury (COR / LOE 1A)

• CTA may be considered in the workup of aSAH. If an aneurysm is detected by CTA, this
study may help guide the decision for type of aneurysm repair, but if CTA is inconclusive,
DSA is still recommended (except possibly in the instance of classic perimesencephalic
aSAH).

Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline
for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012;43:1711–1737.
NCCT Head – Cerebral DSA – CTA (r)
 Neuroinfection Emergency
Most common neuroinfection emergencies
• Meningitis and/or encephalitis: remember the triad
M: fever, neck stiffness, headache – E: fever, loss of concioussness, seizure
• Clostridium Tetanii infection
Trismus, Opistotonus, Rhisus Sardonicus
• Rabies Virus infection
Photophobia, Hydrophobia, Hypersalivation
Neuroinfection Emergency ME
 Neuroinfection Emergency ME

David F. Gaieski1 • Nicole F. O’Brien2 • Ricardo Hernandez. Emergency Neurologic Life Support: Meningitis and Encephalitis. Neurocrit Care
DOI 10.1007/s12028-017-0455-y.
 Neuroinfection Emergency : Tetanus
• Infection of C. tetanii, a gram + coccus commonly found in soil and faeces
• Incubations from 1 day to months, approximately 8 days.
• Releasing endotoxins of Tetanolysin and Tetanospasmin, preventing release of
inhibitory neurotransmitters such Glycin, GABA, NA and dopamines
Management of Tetanus infection:
• ABC
• Source control of suspected infection (port d’entree) – DoC: Metronidazole or Penicillin G
• Eradication of tetanus toxins : HTIG 500 IU or EquineTIG 1500-3000 IU
• Muscle spasm control : benzodiazepines, muscle relaxant (beware of respiratory depression)
• Sympatetic and Autonomic dysfunction stabilization.

I K A Somia 2018 IOP Conf. Ser.: Earth Environ. Sci. 125 012086
 Neuroinfection Emergency: Rabies
• Lyssavirus of Rhabdoviridae family with bulletshaped single-stranded RNA
Genome. Saliva entrance through biting, wounds or unwrapped cuts.
• 3 Stages: Prodromal, Furious and Paralytic Stage
• The treatment is generally supportive since Lyssavirus could be inactivated I
vitro with soap, sunshine and aeration. Post exposure prophylacyic (PEP)
ONCE neurological warning sign developed.

Bano I,Sajjad H, Shah AM, Leghari A, Mirbahar KH, Shams S, Soomro M (2017). A review of rabies disease, its transmission and
treatment. J. Anim. Health Prod. 4(4): 140-144.
 Head Injury Classification (VA / DoD of US)

The Management of Concussion-mild Traumatic Brain Injury Working Group With support from: The Office of Quality, Safety and Value,
VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command
 Head Injury
• Epidural hemorrhage (EDH), Subdural hemorrhage (SDH) and traumatic
subarachnoid hemorrhage (SAH) , Diffuse Axonal injury (DAI)
 Spinal Cord Injury
• Sudden, traumatic impact on the spine that fractures or dislocates vertebrae,
displaced bone fragments, disc materials, and/or ligaments bruise or tear into the
spinal cord tissue.
• Transections, Contusive or Compressive models of injury
• Diagnosis using ASIA scoring system
• No exact medications, some studies say methylprednisolone IV in time might be
helpful.
• Future research on lazaroids and stem cell transplant onto injury site

Alizadeh A, Dyck SM and Karimi-Abdolrezaee S (2019) Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury
Mechanisms. Front. Neurol. 10:282. doi: 10.3389/fneur.2019.00282
 Secondary Insults of Injury

Alizadeh A, Dyck SM and Karimi-Abdolrezaee S (2019) Traumatic Spinal Cord Injury: An Overview of Pathophysiology, Models and Acute Injury
Mechanisms. Front. Neurol. 10:282. doi: 10.3389/fneur.2019.00282
The Canadian Recommendations on Head and Spine
 Status Epilepticus
• Seizure that last more than 30 minutes or 2 seizure that happened sequentially without
recovery of consciousness.
• Treatment algorithm starts on 5 minutes
• 18% – 28 % considered non convulsive status epilepticus
• EEG is important, but diagnosis is based on clinical appearences

Hiba Arif, M.D.,1 and Lawrence J. Hirsch, M.D. Treatment of Status Epilepticus. Seminars in neurology/volume 28, number 3 2008
 Status Epilepticus Algorithm (1)

Proposed Algorithm for Convulsive Status Epilepticus From “Treatment of Convulsive Status Epilepticus in Children and Adults,”
Epilepsy Currents 16.1 - Jan/Feb 2016
 Status Epilepticus Algorithm (2)

Proposed Algorithm for Convulsive Status Epilepticus From “Treatment of Convulsive Status Epilepticus in Children and Adults,”
Epilepsy Currents 16.1 - Jan/Feb 2016
 Reminding and Refreshing as IASP said
• IASP Definition of Pain (1979)
“An unpleasent sensory or emotional experience associated with actual or
potential tissue damage or described in terms of such damages”

• Proposed revised definition by Cohen, Quintner and Rysewyk (2018):

“Pain is mutually recognizeable somatic experience that reflects a person’s
apprehension of threat to their bodily or existensial integrity”

Cohen M, Quintner J, van Rysewyk S. Reconsidering the IASP definition of pain. PAIN Reports 2018:e634.
Is the definition changed now? Slightly Yes

Cohen M, Quintner J, van Rysewyk S. Reconsidering the IASP definition of pain. PAIN Reports
2018:e634.
 2020 Update on Pain Definition

DESCRIBED (--yang dideskripsikan sebagai nyeri)

→ RESEMBLED (--yang menunjukkan / menyerupai kondisi nyeri--)

 Causalgia Hyperpathia
• Also known as CRPS Type II • Pain produced by
• Burning pain in the extrimities subthreshold stimuli
with sympatetic component

Dysesthesia
• Unpleasent abnormal
sensation
Pain Perceived By Talamus, Projected
into Somatosensory and Association
Cortices
Pain Pathways
Persepsi Pain Inhibition Mechanism Through Midbrain
and Spinal Cord: Gate Control Mechanism and
Opioid Endogen System

Modulasi
Primary Afferent Nociceptor To Dorsal
Horn of Spinal Cord

Transmisi
Transduksi

Noxious Stim of Free Nerve

Endings and Receptors
 Purpose of
Pain Assesment and PainMeasurement
• “All Patients Have The Right To Have Their Pain Treated”
Patients Pain Manifesto CPS 2001
• Pengendalian Nyeri bergantung pada keakuratan:
• Assesment (Penilaian)
• Measurement (Pengukuran)
• Documentation (Pencatatan)
 VISUAL ANALOG SCALE (VAS)

NUMERIC PAIN RATING SCALE (NPRS)

Wong-Baker Faces Pain Rating Scale (untuk anak)

Emergency Pain Syndrome
Emergency in Low Back Pain
Emergency in Headache and Vertigo
SNOOP Mnemonics to exclude emergency
headache:
• Systemic or Secondary sign and symptoms
• Neurologic Symptoms
• Onset of time (New, Changed)
• Older (> 50 y.o)
• Papilledema, Provocation, Progressive
 Point of Care in End-of-Life Settings
• 1. QUICK-CHECK
• ABC, Nyeri Dada, Nyeri Abdominal, Nyeri Leher, Nyeri Kepala, Demam
• 2. CHECK-IN-ALL-PATIENTS
• Batuk, Under-nutrisi anemia, mulut dan tenggorokan, nyeri di tempat lainnya
• 3. RESPONDS TO VOLUNTEERED PROBLEMS
 Nyeri pada Setting Paliatif
• “By the Mouth”
• Melalui mulut→ bila tidak bisa, rektal→ hindari IM
• “By the Clock”
• Fixed Time Intervals, Next dose should be happen before last dose wear-off
• Hubungkan dosis dengan waktu bangun-tidur
• Untuk breakthrough pain, ekstra 1 dosis reguler
• “By the Individuals”
• Ajari pasien dan kelg penggunaan obat
• Pastikan nyeri tidak muncul– namun pasien dalam kondisi sadar penuh
WHO’s Essentials Drug For Palliative Care
From 1st Level Facility
 Metode kontrol nyeri lainnya
• Dukungan Emosional
• Metode Fisis (Pijat, Kompres Panas/Dingin,Deep bathing)
• Metode Kognitif (Distraksi Musik, Pemandangan)
• Ibadah sesuai Agama dan Kepercayaan
• Kebiasaan Tradisional/Lokal yang tidak membahayakan (Moxibustion,
Kerokan etc)
 Terima Kasih Atas Perhatiannya

“Yang kulakukan hanyalah merangkai karangan bunga milik orang lain dan tak ada setangkai pun
bunga kumiliki, melainkan hanya seutas tali yang mengikatnya,hanya itu saja milikku”
(Alm) Prof.DR.Dr. Priguna Sidharta, Sp.S(K)