Neurological disorders account for at least 20% of the world’s burden of disease. Neurological disorders account for nearly a quarter of all the years of life spent disabled. In 2005, neurologic emergencies resulted in 92 million disability-adjusted life years, with a potential increase to 103 million by 2030. In a developing country, where 85 percent of the world's population lives, the burden of these diseases is higher [3, 18]. A significant portion of patients in the emergency room (ER) may have life-threatening neurological diseases that would quickly deteriorate if not diagnosed and treated rapidly. However, the vast majority of these patients are not evaluated by neurologists [7]. Neurological emergencies are defined by certain features, including rapid onset, the need for immediate assessment, diagnosis, and intervention, and the propensity to cause immediate life-threatening situations or long term disability [15, 17]. Because of the shortage of neurology specialists in our country, the majority of patients with neurological emergencies do not have access to neurological evaluation by neurologists. As a result, these patients are assessed by generalists or internists in the ER. In addition, the proportion of neurologic patients in the emergency department and their diagnosis and disease patterns had never been studied in the country before.
As demonstrated by a cross sectional study conducted in Turkey, the mean age of neurologic patients evaluated in the ER was 63.14 ± 18.61 years. The male patients accounted for 50.7% of the subjects, while female subjects accounted for 49.3% [4]. As per Marcos C. Lange, Vera L. Braatz, Carolina Tomiyo shiet el, the mean age of neurologic patients in the ER was 58 years of age. 60% of the subjects were female, while 40% were male subjects [5]. In our study, the majority of the patients were 50 years of age or older (59%).The male subjects in the study population accounted for 180 (56%), while females accounted for 141 (44%). The gender distribution of the study population showed no significant differences, which is consistent with previous studies.
Comorbidities are common in patients with neurological presentations because of the fact that common neurological disorders are prevalent with increasing age [19]. Our study showed that 76% of subjects had associated comorbidities. Hypertension was the most common associated comorbidity seen in 38% of the patients, followed by diabetes mellitus, previous history of stroke, heart disease, epilepsy, cancer, respiratory disease, and other metabolic conditions. The findings were almost similar to another study by Ufuk Emre and his colleagues, which showed hypertension, previous stroke, diabetes mellitus, chronic obstructive pulmonary disease, epilepsy, and cancer were the most common comorbidities in their study [11].
As shown by previous studies, neurological complaints were observed in 2% to 10% of patients admitted to the emergency room. In one study conducted in Brazil, 10% of cases admitted to the emergency room had neurologic presentations [10]. Another study in Turkey found 6% of emergency admissions were due to neurologic disorders [11]. As per study in Ethiopia 10.8% of ER admissions had neurologic emergencies [17]. In our study, 3.7% of emergency admissions had neurologic presentations. 78% of these patients with neurological disorders were admitted to the hospital. This high proportion should be taken into account during emergency medicine and neurology training programs, with the goal of increasing hospital staff's capacity to diagnose and treat these common neurological disorders. Our study also showed that 85% of the cases had at least one cranial or spinal diagnostic imaging. Tomography was the most common imaging modality used for evaluating these patients. This indicates the importance of imaging in the diagnosis of neurological diseases.
A study in the UK by Carroll and Zajicek demonstrated that the main neurological presentations in the ER requiring neurologic consultation were weakness (40%), headache (24%), and seizures (15%). Stroke, headaches, and seizures were the three most common ER admissions and accounted for 53% of cases [8]. Another study conducted in a referral hospital in Bangladesh showed that stroke was the most common condition (47.5%) followed by seizure ( 9.3%), disease of the spinal cord (7.8%) and encephalopathy ( 6.3%) [9]. In our study, the main reason for neurology consultations was impaired consciousness 141 (43.9%) followed by motor weakness 102 (31.8%), seizure 33 (10.3%) and headache 17 (5.3%). This is consistent with the findings that the most common neurologic disorders diagnosed in the emergency room are strokes, seizures, and headache disorders.
The study found the most common neurologic examination findings were motor deficit, conscious impairment, speech impairment, cranial nerve palsy, cerebellar system dysfunction, abnormal movement disorder, and autonomic dysfunction. These findings are consistent with the fact that cerebrovascular diseases are the most common reason for neurologic consultation. This is similar to another study by Sevilay Vural and her colleagues which also showed motor deficit, speech disorder, conscious impairment, facial asymmetry, and sensory system dysfunction were the major neurologic examination findings in those subjects [14].
In our study the neurologic diagnosis among evaluated patients, ischemic and hemorrhagic stroke were the most common neurologic diagnoses, representing 38.9% and 20.2%, respectively. Other common diagnoses among these patients included epilepsy (8.7%), cerebral venous thrombosis (3.7%), metabolic encephalopathy (4%), and acute spinal cord disease (3.1%). The distribution of diagnoses among the patients in the ER requiring neurologic consultation varies from one study to another. In one study in Ethiopia cerebrovascular diseases, meningitis, seizure disorders were the most common neurologic disorders in the ER [17].
In another study in Nigeria, the main neurologic diagnoses were stroke, central nervous system (CNS) infections, and myelopathies [12]. In another study conducted in Cameron, Malaria and other related central nervous system infections, which are endemic to sub-Saharan African countries, were the most common non-traumatic neurological causes in the ER [13]. Nevertheless, CNS infections account for a smaller number of patients in emergency admissions in developed countries [14]. Although Somalia is a sub-Saharan African nation, CNS infections were only 0.6% of the cases in our study.
According to our study, stroke, movement disorders, CNS neoplasm, hypertensive and metabolic encephalopathies, delirium, subarachnoid hemorrhage, and motor neuron diseases were more common in patients over 60 years old. In patients under 60 years old, epilepsy, BPPV, headache disorders, demyelinating disorders, CVT, CNS infections, and psychogenic disorders were the most common diseases. Our study also showed that the most common neurologic findings in patients evaluated due to conscious impairment were ischemic stroke, hemorrhagic stroke, epilepsy, metabolic encephalopathy, cerebral venous thrombosis, delirium, and drug intoxication. These are a group of patients who are mostly consulted with neurology department in the ER. This is almost similar to a study by Ufuk Emre and his colleagues which demonstrated that ischemic stroke, hemorrhagic stroke, hypoxic and metabolic encephalopathy were the most common neurologic diagnoses in patients evaluated due to conscious impairment [11].
This study emphasizes the significance of neurologists in the assessment of patients in the emergency room who present with neurological symptoms as well as their contribution to the early diagnosis and management of disease. Knowing the profile of neurological emergencies can help in the formulation of strategies for better management of patients with neurological symptoms in the ER in our country, where there is a shortage of neurologists.
Limitation: This study has some limitations, such as the absence of assessment of the outcome and related factors, the shorter duration of the study, and the fact that it is a single-center cross-sectional that does not necessarily cover the country's epidemiology. However, it provides an overview assessment of common neurologic emergencies in the country (which was missing data), which is why we consider it to be a valuable study.