Neurological

Emergencies in
Peripheral Nervous System
dr. Yetty Hutahaean, Sp.S

Kuliah Modul-2 Blok 19

Fakultas Kedokteran Universitas Mulawarman
Rabu, 14 September 2016
Establishing correct diagnosis
on neurological complaints:
 Rate of onset & time course
 Anatomical localization

Based on detailed history & examination

Neurological Emergencies
 Acute presentation
 Cannot-missed diagnoses

Good treatment

if missed  BAD OUTCOME

Peripheral motor & sensory unit
Acute General Weakness
Occur as a result of injury to:
1. Central nervous system
- cerebral
- brain stem
- spinal cord
2. Peripheral nervous system
- peripheral nerve
- neuromuscular junction
- muscles
General Consideration
 Subtypes:
1. Acute inflammatory
demyelinating
polyradikuloneuropathy (AIDP)
2. Acute motor axonal neuropathy
(AMAN)
3. Acute motor sensory axonal
neuropathy (AMSAN)
4. Miller fisher syndorme
Emergencies Clinical
Findings
 Respiratory paralysis may rapidly
appear (± ¼ AIDP)  necessitating
intubation & mechanical ventilation
 Autonomic nervous system
involvement: dangerous fluctuation
od blood pressure or cardiac
arrythmia
Factors suggesting need
for ETT
 Force vital capacity <15 cc/kg
 Negative inspiratory force < -20
 Inability to clear secretion (concern
for aspiration)
 Use of accesory muscles for
breathing
Diagnostic Studies
 Lumbal puncture:
- CSF protein ↑ few days after
onset, peak in 4-6 weaks
- cell count normal/ mild
lymphocytic pleocytosis
 cyto-albumin dissociation
 Nerve conduction studies
 EMG : ↓ motor unit recruitment
Treatment
 Intravenous immunoglobulin: IVIG
0,4 g/kg/day for 5 days
 Plasmapheresis: 5-6 exchanges
over 1-2 weeks
 Combination of both gives no
additional benefit
 Randomized trials of oral &
intravenous corticosteroid: failed to
show benefit
Prognosis
 20-25% require mechanical
ventilation  5% die
 Poor prognostic factors: Older age,
ventilatory support, rapid
progression (<7 days), low motor
amplitude  < 20% probability of
walkin independently at 6 months
Clinical Findings
 Respiratory symptoms in
conjunction with severe bulbar
symptom (15-20% patients) 
mechanical ventilation

occur by either
myasthenic or
cholinergic crisis
Diagnostic Studies
 Tensilon (edrophonium) test: 1mg
iv  3mg iv (3x)  Observe respon
in 30-60’’ (negative if no response
until 2’)
 Laboratory studies:
- AChR binding antibody
- AChR modulating antibody
 Electrodiagnostic studies
 Asses the present of tymoma by
chest CT-Scan/MRI
Treatment
 Symptomatic treatment
- Acetycholinesterase inhibitor
(pyridostigmin, at least 3-4x daily)
 Immunosupressive treatment
- Thymectomy
- Medical therapy: corticosteroid
- Plasmapheresis
- IVIG
Prognosis
 80%  general myasthenic
 Cholinesterase inhibitor, low-
dosecorticosteroid may control
symptom
 Patients w/ thymoma  more
aggressive disease course