“Should be read by those who decide initial management of neurological emergencies.” Postgraduate Medical Journal Since its birth as a series of articles in the Journal of Neurology, Neurosurgery and Psychiatry this book has moved into four editions, attesting to its lasting quality as an authoritative introduction to the major neurological emergencies. It is not just a basic reference for physicians, neurologists, neurosurgeons and psychiatrists in training. It has also become a standard text for emergency departments, with its N comprehensive yet concise discussions of immediate management. The conditions eurological covered are: ■ Medical coma ■ Cerebral infection ■ Traumatic brain injury ■ Acute spinal cord compression ■ Acute stroke ■ Acute neuromuscular respiratory ■ Delirium paralysis Neurological ■ Acute behaviour disturbances ■ Acute visual loss E ■ Tonic-clonic status epilepticus ■ Criteria for diagnosing brain mergencies ■ Raised intracranial pressure stem death Emergencies ■ Subarachnoid haemorrhage This edition has brought the book right up to date with emphasis on the evidence base for management, including reference to the relevant systematic reviews. With Fourth Edition the use of helpful summary boxes, this information – contributed by internationally respected leaders in their specialties – is quick to access in the clinical situation. Related titles from BMJ Books F The Epidemiology of Neurological Disorders ourth Edition Hughes Management of Neurological Disorders Neurological Investigations Edited by RAC Hughes Neurology and Medicine Stroke Units: an evidence based approach Neurology & Clinical Neurophysiology www.bmjbooks.com Neurological Emergencies Fourth edition Neurological Emergencies Fourth edition Edited by RAC Hughes Head, Department of Clinical Neurosciences, Guy’s, King’s and St Thomas’ School of Medicine, London, UK © BMJ Publishing Group 2003 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 1994 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com First edition 1994 Second edition 1997 Third edition 2000 Fourth edition 2003 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1774 9 Typeset by SIVA Math Setters, Chennai, India Printed and bound in Spain by GraphyCems, Ltd Contents Contributors vii Preface xi 1 Medical coma 1 David Bates 2 Traumatic brain injury 34 Peter JD Andrews 3 Acute stroke 67 R Davenport, M Dennis 4 Delirium 101 S Turner, S Lewis 5 Acute behaviour disturbances and their management 130 GG Lloyd, J Pimm 6 Tonic-clonic status epilepticus 155 Simon Shorvon, Matthew Walker 7 Raised intracranial pressure 188 JD Pickard, M Czosnyka, LA Steiner 8 Management of subarachnoid haemorrhage 247 Thomas A Kopitnik, Carol Croft, Shawn Moore, Jonathan A White 9 Cerebral infection 296 J Greig, MJ Wood 10 Acute spinal cord compression 345 J Brown, RA Johnston 11 Acute neuromuscular respiratory paralysis 377 RAC Hughes, A McLuckie v NEUROLOGICAL EMERGENCIES 12 Acute visual loss 408 Shirley H Wray 13 Criteria for diagnosing brain stem death 437 MD O’Brien Index 442 vi Contributors Peter JD Andrews Reader in Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Clinical and Surgical Sciences (Anaesthetics) and Western General Hospital, Edinburgh, UK David Bates Professor of Clinical Neurology, Department of Neurology, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK J Brown Consultant Neurosurgeon, Institute of Neurosurgical Sciences, Southern General Hospital, Glasgow, UK Carol Croft Associate Professor of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA M Czosnyka Director of Neurophysics, Academic Neurosurgery Unit, Addenbrooke’s Hospital, Cambridge, UK R Davenport Consultant Neurologist, Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK M Dennis Consultant Physician, Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK J Greig Specialist Registrar, Department of Infection and Tropical Medicine, Birmingham Heartlands Hospital, UK RAC Hughes Head, Department of Clinical Neurosciences, Guy’s, King’s and St Thomas’ School of Medicine, London, UK vii NEUROLOGICAL EMERGENCIES RA Johnston Consultant Neurosurgeon, Institute of Neurosurgical Sciences, Queen Elizabeth National Spinal Injuries Unit, Southern General Hospital, Glasgow, UK Thomas A Kopitnik Professor of Neurological Surgery, Director of Cerebrovascular Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA S Lewis Professor of Adult Psychiatry, University of Manchester, Withington Hospital, Manchester, UK GG Lloyd Consultant Liaison Psychiatrist, Royal Free Hospital, London, UK A McLuckie Consultant Intensive Care Physician, Intensive Care Unit, St Thomas’ Hospital, London, UK Shawn Moore Resident in Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA MD O’Brien Consultant Neurologist, Department of Neurology, Guy’s Hospital, London, UK JD Pickard Professor of Neurosurgery, Academic Neurosurgery Unit, Addenbrooke’s Hospital, Cambridge, UK J Pimm Lecturer in Psychiatry, Royal Free and University College Medical School, London, UK Simon Shorvon Professor in Clinical Neurology, Institute of Neurology, University College London, London, UK viii CONTRIBUTORS LA Steiner Department of Anaesthesia, Kantonsspital, Basel, Switzerland S Turner Consultant in Old Age Psychiatry, Carleton Clinic, Carlisle, UK Matthew Walker Honorary Consultant and Senior Lecturer in Neurology, Department of Clinical and Experimental Epilepsy, Institute of Neurology, London, UK Jonathan A White Assistant Proffessor of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA MJ Wood Late Consultant Physician, Department of Infection and Tropical Medicine, Birmingham Heartlands Hospital, Birmingham, UK Shirley H Wray Professor of Neurology, Department of Neurology, Harvard Medical School and Director, Unit for Neurovisual Disorders, Massachusetts Hospital, Boston, Massachusetts, USA ix Preface This popular book is designed for every doctor who deals with neurological emergencies. Each chapter reviews current management and the evidence for its efficacy, and concludes with a brief summary of recommendations that should be a useful aide-mémoire in an emergency. The fourth edition of the book, which was first published as a series in 1993 in the Journal of Neurology, Neurosurgery and Psychiatry, has been thoroughly revised and based on the latest evidence. The first-time reader will find succinct reviews of the pathogenesis and especially management of all the common neurological emergencies. “Neurological” is used in the broadest sense to include neurosurgery (head injury, compression, subarachnoid haemorrhage, raised intracranial pressure), psychiatry (delirium, acute behaviour disturbances), neuro-ophthalmology (acute visual failure), infectious disease (cerebral infections), and intensive care (acute neuromuscular respiratory paralysis). Old lags can quickly bring themselves up to date because each chapter has taken advantage of the increasing collection of relevant Cochrane reviews to provide the best evidence on which to base practice. Are you confident that you know the latest guidelines for head injury, raised intracranial pressure and acute spinal cord compression, the best antibiotics for meningitis, and the best antiepileptic drug regimen for status epilepticus? Although a book like this is inevitably targeted at the doctor in training, especially residents in internal medicine, accident and emergency medicine, and neurology (including neurosurgery and psychiatry), we are all perpetual students of medicine. We hope therefore that this work will help the whole profession improve the care of neurological patients when they most need it, in an emergency. We regret to report the death of Dr Martin Wood shortly after submitting the fine chapter on cerebral infections, of which he was co-author. RAC HUGHES xi 1: Medical coma DAVID BATES The patient in coma who is brought to the hospital casualty department, or seen on the intensive care unit, though not having been exposed to evident trauma, may be harbouring delayed effects of head injury such as a subdural haematoma or meningitis arising from a basal skull fracture. The possibilities of raised intracranial pressure following a parenchymal haematoma in a hypertensive patient, the decompensation of a cerebral tumour, or the collection of pus means that all possible causes of loss of consciousness must be considered in coma. In the diagnosis of medical coma it is not easy to exclude the possibility of head injury. If patients with a transient loss of consciousness following seizure, syncope, cardiac dysrhythmia or hypoglycaemia, and those unresponsive due to impending death are excluded, then, once a patient has been unconscious for 5–6 hours, about 40% of such patients seen in medical practice will have taken some form of sedative drug with or without alcohol.1 Of the remainder just over 40% will have suffered a hypoxic-ischaemic insult as a result of cardiac arrest or anaesthetic accident, a third will be unconscious as