# Clinical Cases: Neurological Emergencies

## Case 1: Acute Ischemic Stroke - Time is Brain

### Patient Demographics
- **Age:** 67 years
- **Sex:** Male
- **Occupation:** Retired accountant

### Chief Complaint
"My husband's face looks droopy and he can't lift his right arm."

### History of Present Illness
Wife called 911 after noticing her husband suddenly developed right-sided weakness and facial droop while eating breakfast. She reports he was "last seen normal" 45 minutes ago when he went to use the bathroom. On EMS arrival, patient unable to speak clearly and had right arm drift. EMS activated stroke alert en route.

### Initial Assessment (Triage and First Impression)

**ESI Level:** 1 - Immediate life-saving intervention required (stroke alert)

**First Impression (Across the Room):**
- Appearance: Alert but frustrated, right facial droop
- Work of breathing: Normal respiratory effort
- Circulation: Skin color normal

**Vital Signs:**
- Heart rate: 88 bpm, irregularly irregular
- Blood pressure: 178/96 mmHg
- Respiratory rate: 16 breaths/min
- SpO2: 97% on room air
- Temperature: 37.0C
- GCS: 14 (E4V4M6)
- Glucose: 142 mg/dL

### Primary Survey (ABCDE)

**Airway:**
- Patent, no stridor or obstruction
- Mild dysarthria noted

**Breathing:**
- Normal respiratory effort
- Clear bilateral breath sounds
- No accessory muscle use

**Circulation:**
- Irregular pulse (atrial fibrillation)
- Strong peripheral pulses
- No signs of heart failure

**Disability:**
- GCS 14 (E4V4M6 - confused speech)
- Right facial droop (lower face)
- Right arm weakness (no antigravity movement)
- Right leg weakness (drift against gravity)
- Pupils: 3mm, reactive bilaterally

**Exposure:**
- No trauma
- No rashes

### Neurological Assessment

**NIH Stroke Scale (NIHSS):**
- 1a. Level of consciousness: 0
- 1b. LOC questions: 1 (month wrong)
- 1c. LOC commands: 0
- 2. Best gaze: 1 (partial gaze palsy)
- 3. Visual fields: 0
- 4. Facial palsy: 2 (partial paralysis)
- 5a. Left arm motor: 0
- 5b. Right arm motor: 3 (no effort against gravity)
- 6a. Left leg motor: 0
- 6b. Right leg motor: 2 (some effort against gravity)
- 7. Limb ataxia: 0
- 8. Sensory: 1 (mild-moderate loss)
- 9. Best language: 1 (mild aphasia)
- 10. Dysarthria: 2 (severe)
- 11. Extinction/inattention: 1

**Total NIHSS: 14** (moderate stroke)

**Last Known Well:** 45 minutes ago

### Secondary Survey

**SAMPLE History:**
- Symptoms: Sudden right-sided weakness, facial droop, slurred speech
- Allergies: None known
- Medications: Lisinopril (not taking consistently)
- PMH: Hypertension, "irregular heartbeat" (never followed up)
- Last Meal: Eating breakfast when symptoms started
- Events: Sudden onset while seated

### Diagnostic Testing

**Immediate:**
- Fingerstick glucose: 142 mg/dL
- ECG: Atrial fibrillation with RVR (rate 112)

**CT Head (door-to-CT: 8 minutes):**
- No hemorrhage
- No early ischemic changes
- ASPECTS score: 10

**CT Angiography:**
- Left MCA M1 segment occlusion
- Good collateral circulation

**Labs:**
- INR: 1.0
- Platelets: 234,000
- Creatinine: 1.1

### Management

**Time-Critical Interventions:**
1. Door-to-needle time goal: <45 minutes
2. IV alteplase 0.9 mg/kg (max 90 mg): 10% bolus, remainder over 60 minutes
3. Blood pressure management: Allow permissive hypertension <185/110 pre-tPA
4. Neurology and interventional radiology consulted
5. NPO for swallow evaluation

**Thrombectomy Decision:**
- Large vessel occlusion (LVO) confirmed
- NIHSS 14, good ASPECTS
- Within time window
- Emergent mechanical thrombectomy performed

**Post-Procedure:**
- Successful recanalization (TICI 2b/3)
- NIHSS improved to 4
- Admitted to Neuro ICU
- Started on anticoagulation for atrial fibrillation (after 24-hour imaging)

### Disposition
- Neuro ICU admission
- 24-hour follow-up CT
- Transition to stroke unit
- Comprehensive stroke workup
- Anticoagulation planning

### Teaching Points

1. **Time is brain:** Each minute of untreated large vessel occlusion results in loss of ~1.9 million neurons
2. **Last known well:** Document precisely - determines treatment eligibility
3. **NIHSS standardization:** Consistent scoring enables treatment decisions and prognostication
4. **Stroke mimics:** Always check glucose; consider seizure with Todd's paralysis, complex migraine
5. **Door-to-needle goals:** <45 minutes for tPA; door-to-groin <90 minutes for thrombectomy
6. **Atrial fibrillation:** Common cause of cardioembolic stroke; often undiagnosed

### Clinical Image
![CT Angiography showing MCA Occlusion](case_01_image.jpg)

**Image Description:** CT angiography of the brain demonstrating left middle cerebral artery M1 segment occlusion (arrow), with absent flow in the distal MCA territory, consistent with acute large vessel occlusion stroke.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/middle-cerebral-artery-occlusion

---

## Case 2: Bacterial Meningitis - The Febrile Patient with Headache

### Patient Demographics
- **Age:** 22 years
- **Sex:** Female
- **Occupation:** College student

### Chief Complaint
"Worst headache of my life and I can't stand the light."

### History of Present Illness
A 22-year-old college student presents with severe headache for 12 hours, progressively worsening. She reports fever, neck stiffness, and photophobia. Roommate states patient has been "out of it" for the past few hours. Patient lives in dormitory; two other students on her floor recently had "bad colds."

### Initial Assessment

**ESI Level:** 1 - Immediate intervention required

**First Impression:**
- Appearance: Toxic-appearing, lying still with eyes closed
- Work of breathing: Mildly tachypneic
- Circulation: Flushed appearance

**Vital Signs:**
- Heart rate: 118 bpm
- Blood pressure: 102/68 mmHg
- Respiratory rate: 22 breaths/min
- SpO2: 96% on room air
- Temperature: 39.8C (103.6F)
- GCS: 13 (E3V4M6)

### Primary Survey

**Airway:** Patent, speaking in short sentences
**Breathing:** Tachypneic, clear lungs
**Circulation:** Tachycardic, warm peripheries, capillary refill 2 seconds
**Disability:** Lethargic, oriented to person only; photophobic
**Exposure:** Petechial rash on trunk and lower extremities

### Neurological Assessment

**Mental Status:**
- Lethargic but arousable
- Oriented to person only
- Following simple commands

**Meningeal Signs:**
- Nuchal rigidity: Present
- Kernig sign: Positive
- Brudzinski sign: Positive

**Cranial Nerves:** Intact
**Motor:** Moving all extremities, withdraws to pain
**Pupils:** 3mm, reactive, photophobic

### Secondary Survey

**SAMPLE History:**
- Symptoms: Headache, fever, neck stiffness, photophobia, nausea/vomiting
- Allergies: None
- Medications: Oral contraceptives
- PMH: Healthy, immunizations up to date (including MenACWY but not MenB)
- Last Meal: Yesterday evening
- Events: Gradual onset headache, progressive lethargy

### Clinical Decision - Lumbar Puncture Timing

**CT Before LP?**
Risk factors for herniation (need CT first):
- Immunocompromised: No
- History of CNS disease: No
- New-onset seizure: No
- Papilledema: Unable to assess (photophobia)
- Altered consciousness: YES
- Focal neurologic deficit: No

**Decision:** CT head before LP due to altered mental status, BUT antibiotics given BEFORE CT

### Diagnostic Testing

**Point-of-Care:**
- Glucose: 98 mg/dL
- Lactate: 3.8 mmol/L

**CT Head:** No mass effect, no herniation risk

**Lumbar Puncture Results:**
- Opening pressure: 32 cm H2O (elevated)
- WBC: 2,400 cells/μL (95% neutrophils)
- RBC: 12 cells/μL
- Glucose: 28 mg/dL (serum 98) - ratio 0.29
- Protein: 280 mg/dL
- Gram stain: Gram-positive diplococci

**Labs:**
- WBC: 18,500 with 88% neutrophils, 8% bands
- Procalcitonin: 8.4 ng/mL
- Blood cultures: Pending

### Diagnosis

**Acute Bacterial Meningitis** - presumed *Streptococcus pneumoniae* based on Gram stain

### Management

**Immediate Treatment (given BEFORE CT):**
1. Dexamethasone 0.15 mg/kg IV (before or with first antibiotic dose)
2. Ceftriaxone 2g IV
3. Vancomycin 25 mg/kg IV (for possible resistant pneumococcus)
4. IV fluid resuscitation

**Timing:**
- Door-to-antibiotic: 18 minutes (goal <60 minutes)
- Steroids given with antibiotics

**Additional Measures:**
- Droplet precautions until N. meningitidis ruled out
- Close contact prophylaxis notification to public health
- ICU admission for monitoring

### Disposition
- ICU admission
- Continued antibiotics (narrowed based on culture)
- Dexamethasone x 4 days
- Hearing evaluation prior to discharge
- Public health notification

### Teaching Points

1. **Classic triad rarely complete:** Fever, neck stiffness, and altered mental status all present in only 44% of cases
2. **Don't delay antibiotics:** If LP will be delayed for CT, give antibiotics first
3. **Dexamethasone timing:** Must be given before or with first antibiotic dose; reduces mortality in pneumococcal meningitis
4. **Petechial rash:** Suggests meningococcemia - requires immediate isolation and treatment
5. **CSF interpretation:** Low glucose ratio (<0.4), elevated protein, neutrophilic pleocytosis suggest bacterial etiology
6. **Chemoprophylaxis:** Close contacts of meningococcal meningitis need rifampin, ciprofloxacin, or ceftriaxone

### Clinical Image
![Petechial Rash in Meningococcemia](case_02_image.jpg)

**Image Description:** Photograph showing petechial and purpuric rash on the lower extremities, characteristic of meningococcal septicemia. The rash is non-blanching and can rapidly progress to purpura fulminans.

**Attribution:** Image from Wikimedia Commons, Meningococcal rash. Public domain. Source: https://commons.wikimedia.org/wiki/File:Meningococcemia.jpg

---

## Case 3: Status Epilepticus - Seizure That Won't Stop

### Patient Demographics
- **Age:** 34 years
- **Sex:** Male
- **Occupation:** Construction worker

### Chief Complaint
"He's been seizing for 10 minutes and won't stop."

### History of Present Illness
EMS called to construction site for a 34-year-old male found having generalized tonic-clonic seizure. Coworkers report seizure began approximately 15 minutes ago with brief pauses but continuous activity. Patient has no known seizure history. EMS administered midazolam 10mg IM en route with no response.

### Initial Assessment

**ESI Level:** 1 - Active seizure, life-threatening

**First Impression:**
- Appearance: Ongoing tonic-clonic activity
- Work of breathing: Compromised during seizure
- Circulation: Cyanotic during tonic phase

**Vital Signs (between seizure activity):**
- Heart rate: 132 bpm
- Blood pressure: 168/102 mmHg
- Respiratory rate: Unable to assess (seizing)
- SpO2: 84% (during seizure) improving to 94% (post-ictal)
- Temperature: 38.2C
- GCS: 3 (during seizure)

### Primary Survey During Active Seizure

**Airway:**
- Compromised during tonic phase
- Secretions present
- Positioned on side, suction available
- No airway adjunct placed during active seizure

**Breathing:**
- Apneic during tonic phase
- Irregular during clonic phase
- Oxygen via non-rebreather when possible

**Circulation:**
- Tachycardic
- IV access attempted (difficult during seizure)
- IO access placed in right tibia

**Disability:**
- GCS 3 during seizure
- Bilateral tonic-clonic activity
- No lateralizing features

**Exposure:**
- No obvious trauma
- Incontinent of urine

### Status Epilepticus Management Protocol

**Definition:** Seizure >5 minutes OR recurrent seizures without return to baseline

**Timeline:**
- T=0 (ED arrival, ~15 min into seizure): Lorazepam 4mg IV
- T=5 min: Continued seizure - Lorazepam 4mg IV repeat
- T=10 min: Continued seizure - Fosphenytoin 20 mg PE/kg IV loading
- T=25 min: Breakthrough seizure - Levetiracetam 60 mg/kg IV
- T=35 min: Refractory status - Propofol infusion, intubation

### Secondary Survey (Post-Intubation)

**SAMPLE History (from coworkers):**
- Symptoms: Sudden collapse, generalized seizure
- Allergies: Unknown
- Medications: Unknown, coworkers unaware of any
- PMH: Unknown
- Last Meal: Lunch 2 hours ago
- Events: Working normally, then collapsed

**Physical Examination:**
- Head: No obvious trauma, no Battle sign or raccoon eyes
- Pupils: 4mm, reactive
- Tongue: Lateral tongue laceration (bite)
- Neck: No rigidity (after paralysis for intubation)
- Cardiac: Tachycardic, regular
- Lungs: Coarse breath sounds bilaterally (aspiration risk)
- Extremities: No track marks, no medic alert bracelet

### Diagnostic Testing

**Point-of-Care:**
- Glucose: 68 mg/dL (give D50)
- VBG: pH 7.18, pCO2 52, lactate 8.2

**Labs:**
- Sodium: 118 mEq/L (CRITICAL - severe hyponatremia)
- Potassium: 3.2 mEq/L
- BUN/Cr: 8/0.9
- Calcium: 9.2 mg/dL
- Magnesium: 1.6 mg/dL
- Ammonia: Normal
- Urine drug screen: Negative

**CT Head:** No acute intracranial abnormality

**Additional History (obtained from wife by phone):**
- Patient is a heavy beer drinker
- Has been trying to "cut back" this week
- No prior seizure history
- No psychiatric history

### Diagnosis

**Status Epilepticus** secondary to:
1. Severe hyponatremia (beer potomania with recent decreased intake)
2. Possible alcohol withdrawal contributing

### Management

**Seizure Control:**
- Propofol infusion for burst suppression
- Continuous EEG monitoring

**Hyponatremia Correction:**
- 3% hypertonic saline 100 mL bolus
- Goal: Raise sodium 4-6 mEq/L in first few hours
- Maximum correction: 8-10 mEq/L in 24 hours (avoid osmotic demyelination)
- Serial sodium levels every 2-4 hours

**Supportive Care:**
- Mechanical ventilation
- Thiamine 500mg IV (before glucose, given alcohol history)
- Magnesium repletion
- Aspiration pneumonia prophylaxis monitoring

### Disposition
- ICU admission
- Continuous EEG
- Slow sodium correction
- Wean sedation after 24 hours seizure-free
- Neurology consultation
- Social work/addiction services

### Teaching Points

1. **Status epilepticus is time-critical:** Mortality increases with duration; aggressive early treatment essential
2. **Benzodiazepines first:** Lorazepam or midazolam are first-line; can repeat once
3. **Second-line agents:** Fosphenytoin, levetiracetam, or valproate if benzos fail
4. **Refractory status:** Requires anesthetic agents (propofol, midazolam infusion, or pentobarbital) and intubation
5. **Always check sodium:** Hyponatremia is common, treatable cause of seizures
6. **Hyponatremia correction:** Too rapid correction risks osmotic demyelination syndrome; document sodium carefully
7. **Beer potomania:** Chronic low-solute intake leads to impaired free water excretion

### Clinical Image
![EEG showing Status Epilepticus](case_03_image.jpg)

**Image Description:** Continuous EEG tracing demonstrating generalized rhythmic epileptiform discharges consistent with electrographic status epilepticus, with high-amplitude spike-and-wave complexes occurring at approximately 2-3 Hz.

**Attribution:** Image from Wikimedia Commons, EEG in status epilepticus. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:Spike-waves.png