Urgent considerations
See Differentials for more details
Guillain-Barré syndrome, acute inflammatory demyelinating polyradiculoneuropathic (AIDP) form
This condition has an abrupt onset, typically with paresthesias starting in the toes and progressing proximally over hours or days. The ascending paralysis can affect respiratory muscle function and lead to respiratory failure or arrest if the condition is not recognized and treated. Patients may also develop acute dysautonomia with potentially life-threatening fluctuations in blood pressure and heart rate. The diagnosis depends on recognition of the clinical features, including the rapid onset and progression of the symptoms, and is confirmed by the finding of albuminocytologic dissociation on cerebrospinal fluid (CSF) exam and characteristic findings on electromyogram (EMG). Suspected AIDP requires close monitoring of neurologic and respiratory function and early institution of treatment with emergent plasma exchange or intravenous immune globulin.
How to perform a diagnostic lumbar puncture in adults. Includes a discussion of patient positioning, choice of needle, and measurement of opening and closing pressure.
Stroke
Ischemic or hemorrhagic strokes present with acute onset of neurologic symptoms, which may include paresthesias. The location and extent of the stroke determines the severity of the neurologic deficit, associated neurologic symptoms and findings, and the risk of damage to adjacent brain tissue from swelling of the infarcted brain tissue. Large strokes in the cerebral hemispheres or hemorrhagic strokes in the brainstem pose an immediate risk of brainstem compression or herniation. The diagnosis is based on clinical history and neurologic exam, with supporting evidence from neuroimaging such as head computed tomography (CT) or brain magnetic resonance imaging (MRI).
Spinal cord compression
Spinal cord compression, either acutely from traumatic injury or a spinal cord infarct, or subacutely from a metastatic or primary mass lesion compressing the spinal cord, requires urgent diagnosis and treatment. Patients may develop irreversible loss of neurologic function and, in some cases, respiratory function. A spinal cord compression syndrome is suspected based on the history and exam findings, and confirmed using neuroimaging (MRI) of the suspected segments of the spinal cord. Surgical decompression or treatment with high-dose steroids is required to reduce edema of the spinal cord tissue and prevent further loss of neurologic function.
Transverse myelitis
Transverse myelitis is an acute inflammatory lesion in the spinal cord that usually involves one or two spinal segments. Patients may present with a spinal cord syndrome of weakness and numbness and bowel/bladder incontinence. Depending on the location of the lesion, respiratory muscle control may be affected and become life-threatening. The diagnosis depends on clinical history and exam, followed by neuroimaging (MRI) of the spinal cord and lumbar puncture with CSF exam. If recognized early, treatment with high-dose intravenous corticosteroids may reduce edema and prevent further loss of function.
Acute disseminated encephalomyelitis
Acute disseminated encephalomyelitis is a central demyelinating disease that appears following infection (usually viral) or vaccination, or sometimes spontaneously. Patients present with an acute encephalitis, and may develop rapid neurologic decline with coma and seizures. Brain and spinal cord MRI reveal characteristic lesions. Patients require intravenous corticosteroid therapy such as methylprednisolone. If the response to steroids is inadequate, plasma exchange or intravenous immune globulin may be used.[62][63]
Vasculitic neuropathy
Patients who present with a clinical syndrome of mononeuritis multiplex (pain, followed by paresthesias and weakness in multiple single peripheral nerve distributions) should be suspected to have vasculitis and need urgent evaluation to confirm the diagnosis. Initial tests for specific disease markers should be sent. Immunosuppressive therapy should be initiated as soon as possible. If left untreated, patients are likely to experience further loss of neurologic function and devastating multi-organ damage. Definitive diagnosis requires a tissue biopsy.
Focal seizures
Focal seizures (formerly known as partial seizures) involving the somatosensory cortex may cause stereotyped episodes of hemifacial and/or hemibody sensory symptoms such as transient paresthesias. These may be isolated events or part of the aura initiating a complex focal seizure. An electroencephalogram (EEG) may identify epileptiform activity or a focal, localizing abnormality. Neuroimaging may reveal evidence of a structural lesion or other process that has caused the seizure. It is important to identify this subset of patients as they can be effectively treated with anticonvulsant medications.
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