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June 8, 1999

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Emergency or Not? A Tipsheet For The Undecided

Most people are alert to symptoms of a heart attack -- a little shortness of breath, pain radiating down an arm -- and know to rush to an emergency room. But few recognize signs of other medical crises, especially ones that may begin in the brain. Even physicians are sometimes unaware that certain signs call for prompt action. Yet recent research shows that, as in heart attacks, knowing obvious symptoms of a variety of brain emergencies can also save lives.

On June 25-26 Johns Hopkins will co-sponsor a symposium for non-neurospecialist health professionals titled "Neurological and Neurosurgical Emergencies: How to Recognize Early Symptoms and Begin Appropriate Workup and Therapy." Below are selected speakers' take-home messages -- advice that could make a vast difference if victims or their families know to act quickly. The speakers are available for interviews and can, in many cases, provide patients who've experienced these problems.

A middle-aged man kneels on the ground, bending over his veggie garden. Within minutes, he develops a miserable, whole-head headache. He totters into the house and lies down. He's alert, his speech is normal; all he's got is headache and a touch of nausea and then, perhaps, a slight stiff neck. If the man's family suspected an aneurysm in his brain had ruptured, they'd have rushed him to the hospital.

Each year, approximately 30,000 people in this country suffer from a brain hemorrhage as a blood vessel wall balloons out and ruptures. Fifty percent of them die immediately. For those who get to a hospital, though, the odds are much better: five in six survive.

But recognizing people with a ruptured aneurysm isn't always intuitive. Victims aren't aware they carry a congenitally abnormal blood vessel. And the rupture doesn't typically follow exercise, unless you count gardening or sex -- the only activities consistently associated with the condition. Even the headache, touted as "the worst you've ever had" may be hard to associate with a brain bleed. How do you know if a bad headache ranks as your worst?

A study quoted by Hopkins neurosurgeon Rafael Tamargo says 25 percent of people with this problem who see a physician are misdiagnosed because both patient and doctor may be looking for a more catastrophic picture. Tamargo discusses the onset of the three tipoff signs -- headache, sore neck and nausea -- and their importance compared with other common symptoms.

When you've got the flu, says Hopkins neurologist Justin McArthur, the high fever, stiff neck and headache you experience may really be a mild case of meningitis the influenza virus confers as it invades membranes surrounding the brain. The flu, however, goes away and there's no need for the hospital. But bacterial meningitis, a far more dangerous infection, begins with the same symptoms. Then, getting to a doctor quickly becomes a classic life-or-death situation. So how do you tell the difference between the common illness and the life-threatening one?

McArthur says it's largely a matter of what happens after the first 12 hours. "With some forms of bacterial meningitis," he says, "you can be apparently well one day and at death's door the next." So a rapid change in condition is a red flag. Another sign is often the appearance of a measles-like rash following the headache. (Meningococcus-caused meningitis causes a rash; the other common bacteria, Hemophilus, does not.)

Because meningitis is airborne -- it travels on a cough or sneeze -- students, soldiers or others gathered in large groups are most at risk. A substantial fever, headache, stiff neck and rapid decline signal a need for prompt evaluation. When patients reach the hospital, neurologists do a spinal tap, a procedure McArthur assures is low-risk and painless. Knowing which organism is involved lets physicians tailor subsequent antibiotic treatment. McArthur can explain the fine points of the diagnosis and treatment for this and other infectious disease emergencies.

Epidural abscess is relatively rare -- only about 10,000 people suffer from it each year, usually following something as simple as a sinus or urinary tract infection. Bacteria break away to form a pocket of infection beneath the membrane covering the spinal cord. Rare or not, epidural abscess warrants attention because of potentially serious effects. Untreated, it can cause paraplegia "in just a few hours," according to Hopkins neurosurgeon Daniele Rigamonti.

The key symptom in the disease is intense and excruciating pain localized in a specific spot along the back, somewhere between neck and tailbone. Pain may come on over a period of days or merely hours. Unlike pain from a pinched nerve, the misery remains localized and doesn't extend to an arm or leg. Diabetics, IV drug users or the obese are, for various reasons, most at risk.

"It's far better to chance an unnecessary trip to the ER if you have this sort of pain," Rigamonti says, "than risk paralysis."

Few medical situations carry more drama than an epileptic seizure that won't quit. Called status epilepticus, the condition differs from typical epileptic or fever-associated seizures in that the latter usually last at most a few minutes. Status epilepticus, however, can continue for hours or days, resulting in brain damage and/or death. Recognizing the situation and getting emergency care are extremely important, says Hopkins neurologist Ron Lesser, who specializes in epilepsy.

People assume that someone with status epilepticus has had previous seizures or has been diagnosed with epilepsy, but, says Lesser, "sometimes it's the first seizure a patient's ever had." Patients also may never experience another seizure, especially if the underlying cause proves to be trauma or infection and has disappeared.

Lesser is expert in classifying seizures as well as in treating status epilepticus. He also can discuss myths in the proper handling of patients in the midst of a seizure.

No one doubts that seeing double -- diplopia, in medical terms -- warrants a visit to the doctor. But sometimes double vision signals a medical emergency. "The most important question is whether the abnormal vision stems from a clear-cut abnormality in the eye itself, like a cataract, or whether it's from an overall eye misalignment," says neuro-ophthalmologist Neil Miller. The latter case, where one eye comes to look in a different direction from the other, means people should seek medical help quickly," he says.

"With misalignment, the brain is getting two distinct images of what you are trying to see," Miller adds, whereas a problem within the eye brings about more of a distortion or blurring of existing vision.

While misalignment can stem from something serious but not critical, such as diabetes or ocular muscle inflammation, it occasionally results from a more threatening problem. Double vision can occur, for example, when the third cranial nerve is pinched by an arterial aneurysm on the verge of rupture. Or it can come from a brain hemorrhage or excessive brain pressure.

Miller describes a simple way a person with diplopia can distinguish the two: Have both eyes open. Then close one eye and open it; then close the other. If the double image goes away with either of the eyes closed, it signals an ocular misalignment and a quick trip to the emergency room or an ophthalmologist is in order.

"Most people don't know that the source of their double vision makes a difference in urgency," says Miller, "and simple eye-closing could tell them how to respond."

Like adults, some children are more prone to headaches than others. Most headaches in children are associated with a fever, and can be remedied with over-the-counter medications. Parents should be concerned, however, when a child experiences worsening, chronic headaches or those accompanied by changes in mood, behavior, gait, and cognitive abilities. Pediatricians assessing such children should combine careful histories of both the headaches and the family with a complete general and neurologic examination, says Harvey Singer, M.D., director of pediatric neurology at the Johns Hopkins Children's Center.
For this story, contact Wendy Mullins at 410-223-1741 or email wmullins@jhmi.edu

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