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Evaluation of Patients in
Coma
Definitions

„ Coma: “Unarousable unresponsiveness in
  which the subjects lie with eyes closed”
Consciousness

„ Two components of conscious behavior
  ƒ content- the sum of cognitive and affective
    function
  ƒ arousal- appearance of wakefulness
„ Content depends on arousal but normal
  arousal does not guarantee normal
  content
Really Simple
Neuroanatomy

„ Arousal: where is it localized?
  ƒ Ascending Reticular Activating System (ARAS)
    ‘core of the brainstem’
  ƒ receives input from numerous somatic
    afferents
  ƒ projects to midline thalamic nuclei (which are
    in a circuit with cortical structures) and the
    limbic system
ARAS

„ ARAS acts as a gating system, increasing
  or decreasing thalamic inhibitory influence
  on the cortex
  ƒ alters effect of sensory stimuli ascending
  ƒ alters descending cortical stimulation
Demands of Arousal

„ Function of ARAS-Thalamic-Cortical
  system depends on:
  ƒ anatomic integrity of structures
  ƒ metabolic integrity (circulatory integrity)
  ƒ communicative integrity (neurotransmitter
    function)
Coma Fact Number One

„ Coma implies dysfunction of:
  ƒ ARAS or
  ƒ Both hemi-cortices
„ Anatomically, this means
  ƒ central brainstem structures (bilaterally) from
    caudal medulla to rostral midbrain
  ƒ both hemispheres
Clues from History

„ Onset of symptoms
  ƒ sudden onset
  ƒ fluctuations
„ Associated neurologic symptoms
„ Medications
Breathing

„ Abnormalities of respiration can help
  localize but almost always in the context
  of other signs
  ƒ Central-reflex Hyperpnea (midbrain-
    hypothalamus)
  ƒ Apneustic, cluster, Ataxic (Lower pons)
  ƒ Loss of automatic breathing (medulla)
Cranial Nerve Exam

„ Systematic assessment of brainstem
  function via reflexes
„ Cranial Nerve Exam
  ƒ   Pupillary light response (CN 2-3)
  ƒ   Occulocephalic/calorics (CN 3,4,6,8)
  ƒ   Corneal reflex (CN 5,7)
  ƒ   Gag refelx (CN 9,10)
.Pupillary Light Responses

„ Afferent Limb: Optic Nerve
„ Efferent Limb: Parasympathetics via
  occulomotor
„ Midbrain integrity/ tectum
„ Uncal Herniation (3rd nerve dysfunction)
„ Pupillary resistance to insult
Pupillary Light Responses

„ Be aware of drug effects
  ƒ Systemic and Local
„ Avoid ‘PERLA’
  ƒ State size, before and after light stimulation
  ƒ Specify right and left
Pupils: Localizing Value

„ Pons-pinpoint pupils
  ƒ Symp. Dysfinction plus parasymp.irritation
„ Midbrain-Large fixed pupils unresponsive
  to light, hippus
„ Horner’s- symp.dysfunction
„ Unilateral dilation- parasymp. Dysfunction
  usually due to 3rd nerve lesion
Ciliospinal Reflex

„ 1-2 mm pupillary dilatation evoked by
  noxious cutaneous stimulation
„ More prominent in sleep or coma than
  during wakefulness
„ Test integrity of symp.pathways in
  comatose patients
„ Not particularly useful in evaluating
  brainstem function
Corneal Reflex

„ Afferent: Trigeminal Nerve
„ Efferent: Third Nerve (Bell’s Phenomenon
 and Facial Nerve (Eye closure)
„ Tests dorsal midbrain (Bell’s) and pontine
  integrity (Eye closure)
Eye Movements

„ Before maneuvers attempted note resting
  position
  ƒ Midline
    ‚ Deviation suggests frontal/pontine damage
  ƒ Conjugate
    ‚ Dysconjugance suggests CN abn.
  ƒ Moving
    ‚ Roving, dipping, bobbing
Occulocephalic/ Calorics

„   Same reflex elicited differently
„   Afferent: Eighth nerve
„   Efferent: 3,4,6 via MLF and PPRF
„   Occulocephalics may also involve
    proprioceptive afferents from the neck
Occulcephalic Reflex

„ Brisk rotation of head with eyes held open
„ Watch for contraversive movements
„ Next:
  ƒ Flexion: eyes deviate up and eyelids open
    (doll’s head phenomenon)
  ƒ Extension:eyes deviate downward
Caloric reflex

„ Ensure TM integrity
„ Elevation of head to 30 degrees (so that
  lateral semicircular canal is vertical)
„ Instillation of up to 120 ml of ice water
  ƒ Awake: deviation toward,nystagmus away
  ƒ Comatose: deviation toward
„ Wait 5 minutes, do other ear
Calorics

„ Watch for conjugance of deviation
„ To test vertical eye movements
  ƒ Both ears, cold water-downward gaze
  ƒ Both ears, warm water-upward gaze
Gag Reflex

„ Afferent: Glossopharyngeal
„ Efferent: Vagus
„ Taken in context of other findings
Motor Exam

„ Assess tone, presence of asterixis
„ Response to painful stimuli
  ƒ   none
  ƒ   abnormal flexor
  ƒ   abnormal extensor
  ƒ   normal localization/withdrawal
„ Avoid use of decerebrate/ decorticate
Reflexes

„ Brainstem
„ Deep tendon
  ƒ Biceps, brachioradialis, triceps
  ƒ Patellar, Achilles
  ƒ Plantar Responses
„ Superficial skin
  ƒ Abdominal, cresmasteric
Uncal herniaiton

„ Expanding lesions in lateral middle fossa
„ Compression of hippocampal gyrus over
  free edge of tentorium
„ Three stages described
  ƒ Early third nerve
  ƒ Late third nerve
  ƒ Midbrain-Upper pons stage
Goals in Emergency

„ Primary Neurological Process?
  ƒ evidence of raised ICP
  ƒ focal findings, especially that implicate
    brainstem structures
„ Secondary Processes
  ƒ signs of infection, toxic/metabolic processes
  ƒ relative lack of focality
Coma Mimics

„   Akinetic mutism
„   ‘Locked-in’ syndrome
„   Catatonia
„   Conversion reactions
Akinetic Mutism

„ Silent, immobile but alert appearing
„ Usually due to lesion in bilateral mesial
  frontal lobes, bilateral thalamic lesions or
  lesions in peri-aqueductal grey
  (brainstem)
“Locked-In’ Syndrome

„ Infarction of basis pontis (all descending
  motor fibers to body and face)
„ May spare eye-movements
„ Often spares eye-opening
„ EEG is normal or shows alpha activity
Catatonia

„ Symptom complex associated with severe
  psychiatric disease with:
  ƒ stupor, excitement, mutism, posturing
  ƒ can also be seen in organic brain diease:
    encephalitis, toxic and drug-induced
    psychosis
Conversion reactions

„ Fairly rare
„ Occulocephalics may or may not be
  present
„ The presence of nystagmus with cold
  water calorics indicates the patient is
  physiologically awake
„ EEG used to confirm normal activity

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medicine.Coma.(dr.muhamad tahir)

  • 2. Definitions „ Coma: “Unarousable unresponsiveness in which the subjects lie with eyes closed”
  • 3. Consciousness „ Two components of conscious behavior ƒ content- the sum of cognitive and affective function ƒ arousal- appearance of wakefulness „ Content depends on arousal but normal arousal does not guarantee normal content
  • 4. Really Simple Neuroanatomy „ Arousal: where is it localized? ƒ Ascending Reticular Activating System (ARAS) ‘core of the brainstem’ ƒ receives input from numerous somatic afferents ƒ projects to midline thalamic nuclei (which are in a circuit with cortical structures) and the limbic system
  • 5. ARAS „ ARAS acts as a gating system, increasing or decreasing thalamic inhibitory influence on the cortex ƒ alters effect of sensory stimuli ascending ƒ alters descending cortical stimulation
  • 6. Demands of Arousal „ Function of ARAS-Thalamic-Cortical system depends on: ƒ anatomic integrity of structures ƒ metabolic integrity (circulatory integrity) ƒ communicative integrity (neurotransmitter function)
  • 7. Coma Fact Number One „ Coma implies dysfunction of: ƒ ARAS or ƒ Both hemi-cortices „ Anatomically, this means ƒ central brainstem structures (bilaterally) from caudal medulla to rostral midbrain ƒ both hemispheres
  • 8. Clues from History „ Onset of symptoms ƒ sudden onset ƒ fluctuations „ Associated neurologic symptoms „ Medications
  • 9. Breathing „ Abnormalities of respiration can help localize but almost always in the context of other signs ƒ Central-reflex Hyperpnea (midbrain- hypothalamus) ƒ Apneustic, cluster, Ataxic (Lower pons) ƒ Loss of automatic breathing (medulla)
  • 10. Cranial Nerve Exam „ Systematic assessment of brainstem function via reflexes „ Cranial Nerve Exam ƒ Pupillary light response (CN 2-3) ƒ Occulocephalic/calorics (CN 3,4,6,8) ƒ Corneal reflex (CN 5,7) ƒ Gag refelx (CN 9,10)
  • 11. .Pupillary Light Responses „ Afferent Limb: Optic Nerve „ Efferent Limb: Parasympathetics via occulomotor „ Midbrain integrity/ tectum „ Uncal Herniation (3rd nerve dysfunction) „ Pupillary resistance to insult
  • 12. Pupillary Light Responses „ Be aware of drug effects ƒ Systemic and Local „ Avoid ‘PERLA’ ƒ State size, before and after light stimulation ƒ Specify right and left
  • 13. Pupils: Localizing Value „ Pons-pinpoint pupils ƒ Symp. Dysfinction plus parasymp.irritation „ Midbrain-Large fixed pupils unresponsive to light, hippus „ Horner’s- symp.dysfunction „ Unilateral dilation- parasymp. Dysfunction usually due to 3rd nerve lesion
  • 14. Ciliospinal Reflex „ 1-2 mm pupillary dilatation evoked by noxious cutaneous stimulation „ More prominent in sleep or coma than during wakefulness „ Test integrity of symp.pathways in comatose patients „ Not particularly useful in evaluating brainstem function
  • 15. Corneal Reflex „ Afferent: Trigeminal Nerve „ Efferent: Third Nerve (Bell’s Phenomenon and Facial Nerve (Eye closure) „ Tests dorsal midbrain (Bell’s) and pontine integrity (Eye closure)
  • 16. Eye Movements „ Before maneuvers attempted note resting position ƒ Midline ‚ Deviation suggests frontal/pontine damage ƒ Conjugate ‚ Dysconjugance suggests CN abn. ƒ Moving ‚ Roving, dipping, bobbing
  • 17. Occulocephalic/ Calorics „ Same reflex elicited differently „ Afferent: Eighth nerve „ Efferent: 3,4,6 via MLF and PPRF „ Occulocephalics may also involve proprioceptive afferents from the neck
  • 18. Occulcephalic Reflex „ Brisk rotation of head with eyes held open „ Watch for contraversive movements „ Next: ƒ Flexion: eyes deviate up and eyelids open (doll’s head phenomenon) ƒ Extension:eyes deviate downward
  • 19. Caloric reflex „ Ensure TM integrity „ Elevation of head to 30 degrees (so that lateral semicircular canal is vertical) „ Instillation of up to 120 ml of ice water ƒ Awake: deviation toward,nystagmus away ƒ Comatose: deviation toward „ Wait 5 minutes, do other ear
  • 20. Calorics „ Watch for conjugance of deviation „ To test vertical eye movements ƒ Both ears, cold water-downward gaze ƒ Both ears, warm water-upward gaze
  • 21. Gag Reflex „ Afferent: Glossopharyngeal „ Efferent: Vagus „ Taken in context of other findings
  • 22. Motor Exam „ Assess tone, presence of asterixis „ Response to painful stimuli ƒ none ƒ abnormal flexor ƒ abnormal extensor ƒ normal localization/withdrawal „ Avoid use of decerebrate/ decorticate
  • 23. Reflexes „ Brainstem „ Deep tendon ƒ Biceps, brachioradialis, triceps ƒ Patellar, Achilles ƒ Plantar Responses „ Superficial skin ƒ Abdominal, cresmasteric
  • 24. Uncal herniaiton „ Expanding lesions in lateral middle fossa „ Compression of hippocampal gyrus over free edge of tentorium „ Three stages described ƒ Early third nerve ƒ Late third nerve ƒ Midbrain-Upper pons stage
  • 25. Goals in Emergency „ Primary Neurological Process? ƒ evidence of raised ICP ƒ focal findings, especially that implicate brainstem structures „ Secondary Processes ƒ signs of infection, toxic/metabolic processes ƒ relative lack of focality
  • 26. Coma Mimics „ Akinetic mutism „ ‘Locked-in’ syndrome „ Catatonia „ Conversion reactions
  • 27. Akinetic Mutism „ Silent, immobile but alert appearing „ Usually due to lesion in bilateral mesial frontal lobes, bilateral thalamic lesions or lesions in peri-aqueductal grey (brainstem)
  • 28. “Locked-In’ Syndrome „ Infarction of basis pontis (all descending motor fibers to body and face) „ May spare eye-movements „ Often spares eye-opening „ EEG is normal or shows alpha activity
  • 29. Catatonia „ Symptom complex associated with severe psychiatric disease with: ƒ stupor, excitement, mutism, posturing ƒ can also be seen in organic brain diease: encephalitis, toxic and drug-induced psychosis
  • 30. Conversion reactions „ Fairly rare „ Occulocephalics may or may not be present „ The presence of nystagmus with cold water calorics indicates the patient is physiologically awake „ EEG used to confirm normal activity