Neurological aspects of chemical and biological terrorism:
guidelines for neurologists
Harald De Cauwer
Francis J. M. P. Somville
Received: 10 February 2017 / Accepted: 15 March 2017 / Published online: 25 March 2017
Ó Belgian Neurological Society 2017
Abstract This statement paper deals with the key role an
neurologist plays in the management of victims of chemi-
cal warfare/terrorist attacks. Because terrorist factions have
expanded the war zone creating a worldwide risk of ter-
rorist attacks, not only limited to some conﬂict zones in the
Middle East, neurologists in all countries/regions have to
be prepared for disaster response. The scope of this paper is
to provide guidelines for the neurological management of
victims of chemical and biological terrorist attacks.
Keywords Neurology Á Biological warfare Á Chemical
warfare Á Terrorism
In recent years, the world has been repeatedly rocked by
terrorist attacks. After a long series of worldwide attacks,
mostly by Al Qaeda or Islamic State or other jihadist ter-
rorist factions, Belgium was hit by terrorism . Belgium
mourned 32 casualties and more than 300 wounded after a
series of bombing attacks on Brussels International Airport
and the Brussels Metro, March 22, 2016. This was the most
deadly attack in Belgium thus far .
Thus far, the so-called dirty bombs have not been used,
though a terrorist attack with an improvised nuclear device
would create political, economic, social, psychological,
and environmental havoc around the world. As the threat is
global, Nuclear Security Summits have been held (the ﬁrst
summit in April 2010, Washington, D.C., USA) in order to
prevent nuclear terrorism and counter nuclear smuggling.
The third summit was held in 2016 .
On the contrary, both chemical and biological weapons
have already been used in acts of terror. The radical reli-
gious group Aum Shinrikyo, founded in Japan in the 1980s,
used sarin in 1994 as a chemical weapon to poison
approximately 600 civilians in Matsumoto city releasing
12 l of sarin, killing seven people. On March 20, 1995,
Aum deployed sarin in an even larger terrorist attack on the
Tokyo Subway System, which poisoned some 6000 people
of which 12 did not survive [4, 5].
In 1984, the Rajneesh movement spreaded salmonella in
salad bars at ten restaurants in Oregon to inﬂuence a local
election, in what is believed to be the ﬁrst incident of
bioterrorism in the United States .
Although there is some reasonable risk for terrorist
attacks or accidental chemical, biological, radiation, and
nuclear incidents, hospitals are not sufﬁciently prepared to
deal with these incidents. Moreover, hospitals themselves
are at risk becoming soft targets for terrorist actions [1, 7].
Therefore, awareness among neurologists is essential.
The management of victims of attacks with chemical
and biological weapons of mass destruction with neuro-
logical symptoms is the focus of this review paper.
& Harald De Cauwer
Department of Neurology, Dimpna Regional Hospital, AZ St
Dimpna, JB Stessenstraat 2, 2440 Geel, Belgium
Department of Emergency Medicine, Dimpna Regional
Hospital, Geel, Belgium
Department of Health Psychology, University of Leiden,
Leiden, The Netherlands
Clerkships Ofﬁce, Faculty of Medicine, University of
Leuven, Louvain, Belgium
Faculty of Medicine, University of Maastricht, Maastricht,
Acta Neurol Belg (2017) 117:603–611