CEN Neurological Emergencies: Stroke, Seizures, ICP and Spinal Cord Injury in 17 Items

The 9 topics in the CEN neurological area

The July 2026 CEN outline gives Neurological Emergencies 17 scored items, 11.3% of the 150 in Passy's arithmetic, with 9 topics:

The July 2026 outline gives no examples for "neurological disorders." The January 2022 outline named multiple sclerosis, myasthenia gravis and Guillain-Barré syndrome, and the last two appear below because both can threaten breathing. The clinical statements come from Merck Manual Professional Edition chapters, cited with their review dates; they are not BCEN statements.

Suspected stroke on the CEN: rule out first, then treat

Merck's ischemic stroke chapter says the diagnosis is clinical but that "neuroimaging and bedside glucose testing are mandatory." The order matters:

• Glucose at the bedside. Hypoglycemia is on Merck's list of stroke mimics, with seizures followed by postictal weakness, CNS infections, migraine and functional disorders
• Imaging first. CT or MRI is performed first to exclude intracerebral hemorrhage and other bleeding. Early CT changes of an ischemic stroke can be subtle in the first hours
• Hemorrhage clues. Headache, coma or stupor, and vomiting are more likely with hemorrhagic than ischemic stroke
• Before anything by mouth. Merck says dysphagia screening before eating, drinking or oral medications helps identify patients at risk of aspiration
• The next 72 hours. Deterioration in the first 48 to 72 hours, especially worsening consciousness, results more often from cerebral edema than from extension of the infarct

Thrombolysis has its own eligibility rules, including blood pressure thresholds. This guide doesn't restate those numbers; Passy's CCRN neuro review lays out the 2026 AHA/ASA blood pressure targets.

TIA and the sudden severe headache

Transient ischemic attack. Merck's TIA chapter says TIA symptoms usually last less than an hour, most less than 5 minutes, and resolve completely; TIA is diagnosed in hindsight. Because TIAs "markedly increase risk of stroke, beginning in the first 24 hours," evaluation proceeds rapidly, and neuroimaging is still required. Resolved symptoms are not a reason to relax.

Subarachnoid hemorrhage. The outline doesn't say whether it counts this bleed under stroke or headache, so learn it with both. Merck's SAH chapter describes a severe headache peaking within seconds, often called "the worst headache" of the patient's life, sometimes followed by loss of consciousness. Noncontrast CT comes first; lumbar puncture follows if CT is negative or unavailable, but lumbar puncture is contraindicated if increased intracranial pressure is suspected.

Meningitis on the CEN: antibiotics don't wait for the scan

Merck's acute bacterial meningitis chapter lists the typical findings as headache, fever and nuchal rigidity, often with changes in mental status, and warns that these signs may be absent or mild in infants, older adults, immunocompromised patients and people with alcohol use disorder. In an older patient, new confusion may be the only sign.

The timing rule is the one most worth remembering: if bacterial meningitis is suspected and lumbar puncture will be delayed for CT or MRI, antibiotics and glucocorticoids are started after blood cultures are drawn but before the imaging. "The need for confirmation should not delay treatment." For infection control, the chapter says droplet precautions for the first 24 hours of therapy help prevent spread.

Seizures and status epilepticus

Merck's seizure disorders chapter defines generalized convulsive status epilepticus as tonic-clonic activity lasting more than 5 minutes, or two or more seizures without full recovery of consciousness between them. The older 30-minute definition was revised to encourage prompt treatment.

• During a tonic-clonic seizure: prevent injury by loosening clothing around the neck and placing a pillow under the head; trying to protect the tongue is futile and can injure teeth or fingers; roll the patient onto the side to prevent aspiration
• For status epilepticus: monitor breathing, obtain IV access quickly, and expect an IV benzodiazepine first, followed by a second, longer-acting antiseizure medication; intubate if there is any sign of airway compromise
• Why speed matters: Merck says untreated generalized seizures lasting more than 60 minutes may cause permanent brain damage

To drill these first-step decisions in exam-style stems, 192 Neurological questions are planned for full CEN prep.

Rising intracranial pressure and herniation

Merck's brain herniation chapter describes the Cushing reflex: systolic hypertension with a widening pulse pressure, irregular respirations and bradycardia. Its nursing-relevant measures for increased ICP:

• Head of the bed at 30 degrees, with the head above the heart, as long as cerebral perfusion pressure stays in range
• Head midline, with neck rotation and flexion minimized, to help venous outflow
• Limit tracheal suctioning, which can raise ICP
• Blood pressure high enough to keep the brain perfused even when ICP rises

Merck's traumatic brain injury chapter adds that transtentorial herniation can cause coma, one or both pupils dilated and unreactive, and hemiplegia, usually opposite a single dilated pupil. If neuro items keep costing you points, planned CEN prep tracks your accuracy in Neurological Emergencies separately.

Head and spinal cord trauma, and neurogenic shock

Head injury. The TBI chapter uses the Glasgow Coma Scale and pupil checks for the initial assessment, repeated every 15 to 30 minutes at first and then hourly after stabilization. Hypotension and hypoxia are "secondary brain insults," and both, along with sedatives and paralytics, can lower the GCS, so the score is more meaningful after resuscitation.

Spinal cord injury. Merck's spinal trauma chapter says possible spinal injuries are immobilized immediately, with inline stabilization during intubation, and care is aimed at avoiding hypotension and hypoxia, both of which further stress the injured cord. Injuries at or above C5 affect the respiratory muscles.

Neurogenic shock. Cervical cord injury can cause bradycardia and hypotension from autonomic dysfunction. "Unlike in other forms of shock, the skin remains warm and dry." A hypotensive trauma patient with a slow heart rate and warm skin is a different picture from hemorrhagic shock, where Merck's shock chapter describes a compensatory rise in heart rate and cool, clammy skin; the CEN medical emergencies guide compares the shock states.

Neurological disorders that threaten breathing

Guillain-Barré syndrome. Merck's GBS chapter describes relatively symmetric flaccid weakness that usually begins in the legs and rises, with lost deep tendon reflexes. Forced vital capacity is measured every 6 to 8 hours; below 15 mL/kg, intubation is indicated. Being unable to lift the head off the pillow is another danger sign, often appearing with diaphragm weakness.

Myasthenic crisis. Merck's myasthenia gravis chapter describes life-threatening respiratory muscle weakness, often triggered by infection, and notes that respiratory failure can follow rapidly once insufficiency begins. Bedside forced vital capacity helps detect it.

A Passy-written CEN neurological practice item

This is an original practice item, not a BCEN question.

A 24-year-old has fever, a severe headache, neck stiffness and new confusion. The provider orders a head CT before lumbar puncture, and the scanner is 45 minutes away. Which should the nurse anticipate before the CT?

• A. Drawing blood cultures, then giving the ordered antibiotics and glucocorticoid
• B. Holding antibiotics until cerebrospinal fluid has been collected
• C. Giving an antipyretic and reassessing after the CT
• D. Performing the lumbar puncture now so the CT isn't needed

Preferred response: A. Merck's meningitis chapter says that when lumbar puncture is delayed for imaging, antibiotics and glucocorticoids start after blood cultures and before neuroimaging, because "the need for confirmation should not delay treatment." Holding antibiotics (B) or treating only the fever (C) delays the treatment that matters. The CT was ordered to check for raised ICP or a mass before lumbar puncture, which Merck says can otherwise risk herniation (D). The CEN priority questions guide has more items built on "what can't wait."

How to review the 17 CEN neurological items

A practical plan, not a BCEN rule:

1. Learn each topic's "first" rule. Glucose and imaging in stroke, 5 minutes for status epilepticus, antibiotics before a delayed CT in meningitis, inline stabilization in spinal injury.
2. Learn each topic's "worse" sign. Cushing reflex, a newly dilated pupil, falling vital capacity, new confusion in an older adult.
3. Pair it with musculoskeletal review. The CEN study plan pairs Neurological with Musculoskeletal and Wound in week 3, which keeps spinal and head trauma together with other injuries.
4. Use mixed items. The free CEN practice questions include neurological items alongside the other areas.

For quick recall of the numbers in this guide, 61 Neurological flashcards are planned for full CEN prep; checkout isn't open yet.