Decision Algorithms for Emergency Neurology

Foreword
Preface
Contents
1.: Transient Loss of Consciousness
	Introduction
	Definition
	Etiology and Pathophysiology
	Diagnosis
		Anamnesis
	Patient Management with TLoC in the Context of Emergency [1, 12, 13]
	References
2.: Coma
	Definition
	Signs and Symptoms for Differential Diagnosis
	History
	General Physical Examination
	Neurological Examination
		State of Consciousness
		Cranial Nerves
	Brain Herniation Syndromes
	Diagnostic Procedures
		Arterial Blood Gas Analysis
		Serum Chemistries
		Neuroimages
		CSF Examination
		Electroencephalogram
		Electromyography
	Therapeutic Approach
	Appendix
	References
3.: Delirium/Acute Confusional State
	Definition
		Diagnostic Criteria for Delirium According to DSM-V
	Classification
	Epidemiology and Pathophysiology
	Prognosis
	Rating Scales
	Identification of Predisposing and Precipitating Factors
	Differential Diagnosis
		History
			The Most Important Questions
			Age
			Life Habits Age
			Medical History
			Medications History
		Neurological Evaluation
		General Clinical Evaluation
		Criteria for Identifying the Causes of Delirium
			Medication-Induced Delirium
			Infective Delirium
			Hydroelectrolytic Imbalance
			Endocrine Metabolic Disorders (Uremia, Liver Encephalopathy, Hypoglycemia, Hyperthyroidism, and Adrenal Insufficiency)
			Intracranial Disorders
			Cardiopulmonary Impairment and/or Hypoxia
			Alcohol and Withdrawal Syndrome
			Preexisting Dementia, Whether or Not Associated with Visual and Auditory Impairment
	Differential Diagnosis
	Diagnostic (Laboratory, Radiology, and Neuropathophysiology) Procedures
		Laboratory and Blood Gases
		Instrumental Investigations
		Indications to Urgent CT Scan
		EEG Features
	Pharmacological and Non-pharmacological Treatments
		Non-pharmacological Interventions
			Protocol of Preventive Interventions [40]
			Environmental Prevention Measures
		Pharmacological Interventions
			Typical Antipsychotics
			Atypical Antipsychotics
			Benzodiazepines
			Other Drugs
			Quality Indicators
	Appendix
	References
4.: Motor and Nonmotor Epileptic Seizures
	Introduction
	Definitions
		Differential Diagnosis
	Etiology of Epileptic Seizures
		Triggering Factors
	Laboratory and Instrumental Investigations
		Laboratory Investigations
		Neuroimaging
			Computed Tomography Imaging
			Magnetic Resonance Imaging
		Other Tests
			Electrocardiogram
			Lumbar Puncture
		Electroencephalogram
			Status Epilepticus
			Single Seizures
	Therapy
		General Criteria
		Patient Management
		Antiepileptic Drugs in Emergency Care [17–19]
			Initial SE
			Defined SE
			Other Drugs [28]
			Nonconvulsive Refractory SE
			Refractory Convulsive SE
	Setting Up Chronic Drug Therapy
	Further Patient Care
	Further Issues
		Advice to the Patient
	Special Situations
	References
5.: Headache
	Definition
	Diagnosis
	Signs and Symptoms: Differential Diagnoses
	Scenario 1: ‘A Sudden Headache’
	Scenario 2: ‘Headache with Fever or Neck Stiffness’
	Scenario 3: ‘New Onset Headache in Non-headache Adults’
	Scenario 4: ‘The Headache Attack in Known Headache Patient’
	Rating Scales
	Treatment
	References
6.: Fever and Neurological Signs
	Submission Methods
		Fever and Headache
		Fever, Delirium and Agitation
	Diagnostic Framework
		Diagnosis in ED: Priority Goals
		Synthetic Anamnestic Sheet: Main Questions to Ask
		History: Broad Spectrum of Initial Stage Variability
		CSF Examination
	Diagnostic and Therapeutic Priorities
		Diagnostic Priorities [10–12]
		Therapeutic Priorities [13, 14]
	Diagnostic Procedures Based on the Clinical Scenario
	Interpretation of Brain MRI patterns
	References
7.: Acute Vision Disorders
	Introduction
	Vision Loss [2]
		Definition
		Etiology
		Diagnosis
	Visual Drop from Prechiasmatic Cause
		Visual Loss from Prechiasmatic Neurological Cause on Inflammatory Basis (Optic Neuritis) [4]
		Visual Loss from Prechiasmatic Neurological Cause on Vascular Basis
			Retinal TIA (Amaurosis Fugax: Transient Visual Darkening) [8]
			Retinal Infarction
			Ischemic Optic Neuropathies
		Diagnostic Workflow for Acute Visual Impairment of Pre-chiasmatic Nature
	Visual Loss Due to Chiasmatic/Retro-Chiasmatic Causes (Fig. 7.2) [17, 18]
		Diagnostic Workup for Acute Visual Loss of a Chiasmatic/Retro-Chiasmatic Nature
		Therapy for Acute Visual Impairment of a Chiasmatic/Retro-Chiasmatic Nature
		Differential Diagnosis of Acute Visual Impairment (Figs. 7.3, 7.4, 7.5, and 7.6)
	Extraocular Muscle Palsies [21]
		Definition
		Causes of Extraocular Muscle Palsies
		Semeiology of Acute Ophthalmoplegia
			Diagnostic Procedures for Acute Ophthalmoplegia (Figs. 7.7 and 7.8)
		Differential Diagnosis
			Causes of Diplopia Usually Without Strabismus
			Causes of Strabismus with Ptosis
			Causes of Ptosis Without Strabismus and Isolated Muscle Paresis [23–25]
			Causes of Strabismus Without Ptosis and Multiple Muscle Palsy [27]
			Causes of Internuclear Ophthalmoplegia [27]
			Causes of Vertical Diplopia (Skew Deviation)
	Neuro-Ophthalmological Changes in the Patient with Disorders of Consciousness
	References
8.: Dizziness and Vertigo
	Introduction
	Clinical Criteria for Differential Diagnosis Between Vertigo of Peripheral or Central Origin
	Proposal for a Diagnostic Algorithm for Vertigo in the Emergency Room
		Definitions
		History Taking and First Evaluation of Vertigo
		Neurological Examination in the Patient with Vertigo
		Nystagmus (Table 8.2)
			Peripheral Vestibular Nystagmus
			Gaze Evoked Nystagmus
			Vertical Nystagmus (Directed Upwards or Downwards)
			Pendular Nystagmus
	Head Impulse Test (HIT)
		Cover Test (or Test of Skew)
	HINTS Evaluation
	Positioning Maneuvers
		Dix-Hallpike Manoeuver
	Appendix 1. Migraine with Brainstem Aura [21, 22]
		Diagnostic Criteria
		Notes
		Comments
	Appendix 2. Vestibular Migraine [23]
		Diagnostic Criteria
		Notes
		Other Symptoms
		Relation to Migraine Aura and Migraine with Brainstem Aura
	Appendix 3. Diagnostic Algorithm
		Diagnostic Algorithm A
		Diagnostic Algorithm B
		Diagnostic Algorithm C
		Diagnostic Algorithm D
		Diagnostic Algorithm E
		Diagnostic Algorithm F
		Diagnostic Algorithm G
	References
9.: Diagnostic Algorithm for Patients Presenting with Acute Dizziness: The ATTEST Method
	Introduction
	Misdiagnosis
	Diagnostic Algorithm
	History
		AVS
		s-EVS
		t-EVS
	Physical Examination
		AVS
		s-EVS
		t-EVS
	Testing
	References
10.: Focal Neurological Deficits
	Introduction
		From What Point of View Are We Observing the Phenomenon
		Pathway Organization According to the Level of Complexity of the Hospital
	Clinical Pictures
		Focal Neurological Deficits
		Patient with Altered State of Consciousness: Stupor/Coma
	Diagnostic Pathway of Ischaemic Stroke and Revascularization Treatments
		Revascularization treatments (Fig. 10.2)
		Patient Eligibility to Intravenous Thrombolytic Treatment
		Acute Complications of Intravenous Thrombolysis
		Eligibility of the Patient to Endovascular Treatment
		Admission to Stroke Unit
	Transient Ischaemic Attack
	Patient with Suspected Cerebral Venous Thrombosis
	Patient with Intraparenchymal Haemorrhage
	Subarachnoid Haemorrhage
	Other Causes of Focal Neurological Deficit
	References
11.: Para- and Tetraplegia in the Emergency Room and in the Intensive Care Unit
	Introduction
	Injury Level: Clinical Implications and Assessment Scales
		Level Diagnosis in Spinal Cord Syndromes
		Assessment Scales
		Systemic Effects of Spinal Cord Injury
		Respiratory Dysfunction
		Perineal Dysfunction
	Causes of Acute Paraplegia and Tetraplegia
		Vascular Myelopathy
			Ischemic Myelopathy
			Spinal Hemorrhage and Vascular Malformations
		Inflammatory and/or Infectious Myelopathies
		Noninflammatory Expansive Diseases
	Para- and Tetraplegia in Intensive Care Unit
	References
12.: Head Injuries
	Definition and Epidemiology
	Diagnosis and Evaluation Scales
	Moderate to Severe Head Injury
		Management of Severe Head Trauma
	References
13: Muscle Pain, Weakness and/or Sensory Disorders
	Introduction
	Patient with Acute Onset of Diffuse Muscle Pain
	Patient with Generalized Acute Muscle Weakness (Myogenic)
	Patient with Acute Muscle Weakness (Neurogenic and Non-traumatic)
	Patient with Acute Sensitivity Disorder (Peripheral Type)
	References
14.: Movement Disorders Emergencies
	Introduction
	Hypokinetic Disorders
		Patient Without Parkinson’s Disease
			Signs and Symptoms for Differential Diagnosis
			Clinical Evaluation
			Diagnostic Procedures
			Treatment
		Patients with Parkinson’s Disease
			Treatment
	Hyperkinetic Disorders
		Mimics
			Clinical Evaluation
			Neurological Examination
			Diagnostic Procedures
			Treatment
	References
15.: Respiratory Emergencies in Neurological Diseases
	Introduction
	Pathogenesis of ARF
	Pathogenesis of Respiratory Complications
	Clinical Management and Treatment
		Acute Respiratory Failure in Chronic Progressive Neurological Diseases (Acute on Chronic Respiratory Failure)
			Movement Disorders
			Chronic Neuromuscular Diseases with Slow Progression
		Rapidly Progressive Acute Respiratory Failure
			Stroke
			Convulsive Status Epilepticus
			Severe Head Injury
			Spinal Cord Injuries
			Diaphragmatic Paralysis
			Rapidly Evolving Neuromuscular Diseases
	References
16.: Neurological Emergencies in Pregnancy and Puerperium
	Introduction
	Pathophysiology
	Neurological Syndromes
		Other Rare Causes of Acute Neurological Deficit
	Diagnostic Algorithms
	Seizure Algorithm
		Therapeutic Approach
	Headache Algorithm
		Therapeutic Approach
	Acute Neurological-Deficit Algorithm
		Therapeutic Approach
			Anti-Platelet Therapy
				Acetylsalicylic Acid
				Clopidogrel and Association of Several Anti-Platelets
			Anticoagulant Therapy
				Vitamin K Antagonists (Warfarin and Acenocoumarol)
				Fractional Heparin and Low Molecular Weight Heparins
				Direct Opponents of Factor II and X (DOACs: Dabigatran, Rivaroxaban, Apixaban and Edoxaban)
		Recanalization Therapy in Acute Ischemic Stroke
			Fibrinolytic Treatment IV (t-PA)
			Mechanical Thrombectomy
	Fever Algorithm and Neurological Signs
		Therapeutic Approach
	Multiple Sclerosis Algorithm
		Disease Progression and Relapse Management
		Therapeutic Approach
	Algorithm of Delirium and Pregnancy Psychosis
		Therapeutic Approach [29]
			Therapy of Psychotic Disorders
			Pharmacological Therapy in Pregnancy [29]
			Drug Therapy During Breastfeeding
	Neuromuscular Diseases Algorithm
		Acquired Compressive Nerve and Root Disorders During Pregnancy and Puerperium
			Carpal Tunnel Syndrome
			Lower-Limb Neuropathies and Lumbosacral Radiculopathies
		Other Neuropathies
			Bell’s Palsy
			Intercostal Neuralgia and Radial Neuropathy
		Inflammatory Neuropathies
			Guillain-Barré Syndrome
			Chronic Inflammatory Demyelinating Polyneuropathy and Multifocal Motor Neuropathy
		Neuromuscular Junction Disorders
			Myasthenia Gravis
		Botulism
		Tetanus
		Respiratory Failure in Pregnancy (Fig. 16.8)
		Therapeutic Approach
			Carpal Tunnel Syndrome
			Lower-Limb Neuropathies and Lumbosacral Radiculopathies
			Paralysis of Bell
			Guillain-Barré Syndrome
			Chronic Inflammatory Demyelinating Polyneuropathy and Multifocal Motor Neuropathy
			Myasthenia Gravis
				Treatment of MG in Pregnancy
				Treatment of MG During Breastfeeding
			Botulism
			Tetanus
	Algorithm on Dizzying Syndromes
		Therapeutic Approach
	Diagnostic Tests and Radiation Protection During Pregnancy
		Ionizing Radiation
		Fluoroscopy
		Nuclear Medicine
		Nuclear Magnetic Resonance Imaging [63–67]
		Contrast Medium [63–67]
	References
17.: Functional Disorders in Emergency
	Epidemiology
	History and Clinical Overview
	Neurological Examination
		Non-organic Paralysis
	Instrumental Investigations
	Therapy
	References
18.: Neurotoxicological Emergencies
	Introduction
		The Neurological Diagnosis in Intoxications/Poisonings
	Toxidromes
		Diagnosis and Treatment of Acute Opioid Syndrome
		Diagnosis and Treatment of Acute Cholinergic Syndrome
		Diagnosis and Treatment of Acute Anticholinergic Syndrome
		Diagnosis and Treatment of Acute Sedative-Hypnotic Syndrome
		Diagnosis and Treatment of Acute Sympathomimetic Syndrome.
		Toxic Coma and Stupor
		Toxic Seizures
		Toxic Agitation, Delirium and Psychosis
		Toxic Dystonia, Dyskinesia and Rigidity
	Frequent and/or Severe Neurotoxic Syndromes
		Carbon Monoxide Poisoning
			Clinical Manifestations and Neurotoxicity
		Fire Smoke Inhalation and Mixed Carbon Monoxide-Cyanide Poisoning
		Sodium thiosulfate (12.5 g i.v. over 10 min in adults and 400 mg/kg, up to a maximum of 12.5 g, in children) determines an enhancement of the transformation of cyanide in the less toxic thiocyanate. This mechanism is slower than that of cobalt compound
			Diagnosis
			Laboratory Diagnosis Confirmation
			Differential Diagnosis
			Treatment
		NPS: New Psychoactive Substances
			Synthetic Cannabinoids/Synthetic Cannabinoid Receptor Agonists/CB1R “Super Agonists”
			Synthetic Cathinones (β-Keto Amphetamines)
			Ketamine and Ketamine Derivatives (Arycyclohexylamines)
			NPS Psychostimulants
			New Hallucinogen Phenethylamine- and Tryptamine-Derived Drugs
	Peripheral Neurotoxic Syndromes
		Thallium
		Tetanus
		Ciguatoxin
	Neurotoxic Adverse Drug Reactions
		Serotonin Toxicity
			Clinical Picture and Diagnostic Criteria
		Neuroleptic Malignant Syndrome
		Lithium Toxicity due to Chronic Overmedication
	The Role of the Poison Control Centre and the Toxicological Analyses
		Toxicological Analysis on Blood/Urine
	Selected Antidotes Useful for the Treatment of Neurotoxic Effects
	References
19.: Neurological Emergency Services: A Case for Change to the Model of Care?
	Background
		Shortage of Neurologists at a Global Level
		Limited Number/Access to Neurology Training Programs Between Countries of Various Income Groups
		Suboptimal Organization of Neurology Emergency Care
			Models of Care
	Unmet Needs: A Case for Change
	References