Category: Neurology

The American Headache Society recently published updated guidelines for the acute treatment of migraine in adult patients presenting to the emergency department. Based on the strength of available evidence, intravenous prochlorperazine was classified as highly likely to be effective, supported by multiple Class I studies. Intravenous metoclopramide and intravenous ketorolac (personal opinion: we have to […]

JAMA recently published a randomized controlled trial evaluating the treatment of peripheral vertigo using three arms: sodium bicarbonate, diphenhydramine, and their combination. The study concluded that combination therapy provided superior outcomes compared to either agent alone. Exclusion Criteria were: Refusal to participate, Pregnancy, Prior use of antivertigo medication, Symptom duration > 24 hours, Heart failure, […]

A recent research question on the relationship between head-of-bed positioning and clinical deterioration in patients with large vessel occlusion (LVO) stroke was addressed in the June edition of JAMA. Only a small number of studies have examined this topic in recent years. The current study demonstrated that a 0° head position was superior to a […]

A Systematic Review and Meta-analysis published in JAMA focusing on choice of medication for patient with vertigo. They reviewed 27 trials and they found that there is a moderately strong evidence to suggest that “single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines”. Link to article

My last post discussed the magnitude of blood pressure reduction specifically within first 6 hours of ICH! Now the current study really questioned the impact of aggressively lowering BP on outcome of patients with ICH! I believe our practice guideline should be based on sustained high quality studies, and persistent EBM, and not based on […]

We have learned that BP control in paints with ICH can help with their outcome. Neurocritcal care in a multi-center study showed that this may not direct us to a better outcome. Link to study

A very great review regarding new onset seizure and systematic approach. Unfortunately, lacking ED setting, but worthwhile reading it. Interestingly, from 8% to 10% of the population will experience a seizure, 2-3% may develop epilepsy. Link      

Large Vessel Occlusion Stroke (LVOS) is  an indication for activating stroke team. IR will be on board and this is level IA recommendation from 2015 AHA/ASA Guideline. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) extracted from NIHSS. LVOS were defined by total occlusions involving the intracranial ICA, MCA-M1, MCA-2, or basilar arteries. FAST-ED scoring […]

Expert panel from American Headache Society Published a guideline! to manage Migraine Headache in ED in Headache June 2016. They searched and found 68 randomized controlled trials. I am very happy to see our routine practice to treat headache in ED, now after years is coming to Neurology Guideline! Metoclopramide and prochlorperazine offered as level […]

PATCH is a European based study that published in Lancet in May 2016. PATCH is trying to investigate the effects of platelet transfusion on acute intracranial bleed  after using anti-platelet therapy. Study had 2 arms with 95 patients in each arm randomized to standard of care versus platelet transfusion in patient with intracranial bleed on anti […]

There are a lot of controversies around this topic, but It sounds like lowering blood pressure is safe, the following Stroke link recommend SBP 140 is safe, I am not sure the exact number or acceptable number to drop BP but obviously, we should not be worried to drop SBP in hypertensive hemorrhagic stroke as […]

I am fan of Metoclopramide + Diphenhydramine  or Prochlorperazine + Diphenhydramine for Migraine Headache, and I see a lot of good outcome among patients with headache. Annals of EM published “Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department–Based Randomized Clinical Trial”. I am not sure that I am ready to start practicing this […]

Dizziness! one of the most complex and ambiguous term in ED. The first response: what do you mean? But sounds like we need to have more critical thinking than just a vertigo, or lightheartedness. Neurology in Nov.2015 Publishes an article regarding: Stroke risk stratification in acute dizziness presentations! There were 272 patients, 10.7% acute stroke […]

There are several methods to orally load Anti Epileptic drugs (AED) in ED. Tintinalli’s has 2 approaches: 1.patient with active seizure 2. patient with history of seizure. Patient who had active seizure should receive Phenytoin 15- 25 mg/kg no more than 50 mg/min. For patient in no active seizure: Without a loading dose, phentoin may […]

Neurologic clinics has a very nice article regarding BPPV. It explains not only the epidemiology and Etiology , it also discusses the diagnosis maneuver and also treatment options. Link to article          

Recent post in NY Times,  Stroke of Fate , offended many ED physicians. I was not! It was very simple to me. A 78 years old neurologist said “I’m afraid to go to the emergency room,” he added. “I think it’s dangerous.” I agree that this is not a good comment for general population to […]

The BMJ study was a shocking news in 2011 regarding Sensitivity of Modern CT scan in diagnosis of SAH within 6 hours of presentation, Click here for more Then, Storke in 2012 reported another study that showed there is “no added value of CSF analysis to detect SAH within 6 hours of patient presentation with […]

​Pediatrics published an article regarding Migraine treatment in children. This is a retrospective study that has shown us non opioid medication has pretty significant effects in the treatment of Migraine.

As much as I read the literature, I really don’t know the BP is my friend or enemy. If you look at the Stroke guideline published in 2013, their recommendation for lowering  BP is”not to lower the blood pressure during the initial 24 hours of acute ischemic stroke unless the blood pressure is >220/120 mm […]

American Headache Society (AHS) published in Headache Journal list of 5 things physicians and patients should question in Nov 2013. This is a quick review and you can find full text here.

I was working on LP study that we did, and found this article from JAMA, very informative. http://jama.jamanetwork.com/article.aspx?articleid=203808  

There are different approaches to Migraine HA, Narcotics, Triptans, NSAIDS, Steroids, … but my approach is combination of Metoclopramide and Diphenhydramine. Headache “The Journal of Head and Face Pain” Published a Systematic Review regarding Toradol and Migraine headache in Jan, and the conclusion is:

TIA is a huge dilemma in ED. It could be challenging from definition to workup to disposition, but recent article in clinics of north America, reviewed the pitfalls in diagnosis and disposition of patients with TIA. TIA is important because there is a chance of Stroke within 48 hours (5%).