ACUTE NEUROLOGICAL CONDITIONS

General Medical Emergencies 95

2 Deciding who to admit can be difficult. Refer the patient for immediate
medical admission if:
(i) High-risk patient with an ABCD^2 score of ≥4 points.
(ii) The ECG is abnormal, and a cardiac embolic source is suspected
particularly new or untreated atrial fibrillation.
(iii) TIAs are recurring over a period of hours or are progressing in
severity and intensity (known as crescendo TIAs).
(iv) There are residual neurological findings.
(v) The patient has new or poorly controlled diabetes.
(vi) The patient has poorly controlled hypertension with systolic BP
≥180 mmHg, or diastolic BP ≥100 mmHg.
(vii) Carotid territory disease, particularly in an otherwise healthy
patient with an audible carotid bruit and possible high-grade
stenosis, or a history of known carotid stenosis.

3 Refer the remaining patients to medical or neurology outpatients within
7 days, if complete recovery has occurred, and the patient is low-risk with an
ABCD^2 score of 0–3 points.
(i) Arrange an echocardiogram (if cardiac cause suspected) as an
outpatient.
(ii) Inform the GP by fax and by letter.

Stroke

These are due to a vascular disturbance producing a focal neurological deficit for
over 24 h.

DIAGNOSIS

1 The causes include:
(i) Cerebral ischaemia or infarction (80%)
(a) cerebral thrombosis from atherosclerosis, hypertension or
rarely arteritis, etc.
(b) cerebral embolism from atheromatous plaques in a neck
vessel, AF, post-myocardial infarction or mitral stenosis
(c) hypotension causing cerebral hypoperfusion.
(ii) Cerebral haemorrhage (20%)
(a) intracerebral haemorrhage associated with hypertension or
rarely intracranial tumour and bleeding disorders including
anticoagulation

Warning: remember that patients can present with the consequences

of their TIA, e.g. a head injury, Colles’ fracture, or fracture of the neck

of femur. Do not fail to investigate for these, or to look for the true

precipitating event (i.e. the TIA).

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