Neurological Emergencies in Incarcerated Patients: Clinical Characteristics, Severity, and Outcomes in an Emergency Department with an Embedded Neuro-Emergency Expert Model

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Abstract
Background: Incarcerated patients with neurological complaints present substantial diagnostic and care-delivery challenges in emergency departments (EDs). We delineate the clinical spectrum, severity, and outcomes among incarcerated patients managed in an ED with an embedded neuro-emergency expert model. Methods: A retrospective observational study of adult ED visits for neurological symptoms was conducted from September 2018 to June 2025 at a government-designated regional emergency center serving multiple correctional facilities. Incarceration was confirmed in the electronic medical record. Extracted variables included demographics, chief complaint, comorbidities, triage and acuity scale, Glasgow Coma Scale (GCS), neuroimaging, ED diagnoses, and outcomes (hospital admission, ICU care, ED/in-hospital mortality). Results: Sixty-five patients were included (median age 57.0 years [IQR 47.0–64.5]; 95% male). Chief complaints were altered mental status (36.9%), hemiparesis (21.5%), and seizures (13.8%). On arrival, 40.0% had GCS ≤ 12, including 23.1% with severe impairment (GCS 3–8). Non-contrast head CT was obtained in 95.4% and diffusion-weighted MRI in 38.5%. Frequent diagnoses were psychiatric/functional neurological disorder (16.9%), metabolic encephalopathy (15.4%), and acute ischemic stroke (12.3%). Serious conditions (stroke, hypoxic brain injury, central nervous system infection, status epilepticus, and neuroleptic malignant syndrome) were diagnosed in 41.5%. Hospital admission occurred in 63.1% (ICU care in 47.7%); in-hospital mortality was 10.8%. Conclusions: ED visits by incarcerated individuals with neurological complaints were often linked to serious diagnoses, ICU use, and mortality, challenging assumptions of exaggeration. Over two in five had stroke, hypoxic brain injury, central nervous system infection, or status epilepticus. The findings support rapid, systematic, bias-aware evaluation with early neurological involvement, clear imaging triggers, safety protocol, and expedited transfers from correctional facilities.

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