##PaoloPart ##Approach to Stupor

and Coma OS ###

Lecturer’s Name Exam 01
Date of lecture in 01 Jan 2018 format Trans 01

MIGS, PAKI-AYOS NALANG YUNG FIGURE NUMBERS.  Uncus and parahippocampal gyrus shift across the tentorial
THANKS! notch or free edge of tentorium cerebelli, leads to
→ Compressed midbrain
IV. TYPES OF BRAIN HERNIATION → Displaced posterior cerebral artery (PCA)
→ Compressed CN III (from the displaced PCA over it)
 Compressed ipsilateral cerebral peduncle -> contralateral
hemiparesis
 In some cases, Kernohan’s syndrome (a false localizing sign),
an ipsilateral hemiparesis, is caused by contralateral cerebral
peduncle over Kernohan’s notch.
 Decreased sensorium due to distortion of ARAS in midbrain
 Compressed ipsilateral PCA -> ischemia of ipsilateral primary
visual cortex and contralateral visual field deficit.
 CN III compression -> ipsilateral pupillary dilation followed by
oculomotor nerve palsy wherein patient’s eye deviates in a down
and out position.
 Progressive uncal herniation -> brainstem distortion -> duret
hemorrhage in median and paramedian zones of midbrain and
Figure #. Diagram of Brain Herniations. A. Subfalcine = 3, B Uncal = 1, C. pons -> decorticate posturing, Cushing’s triad (hypertension +
Central = 2, D. Tonsillar = 6. Other herniations = Transcalvarial and bradycardia + bradyapnea), respiratory arrest, and death
Upward.
C. CENTRAL HERNIATION
A. SUBFALCINE HERNIATION

Figure 2. Central Herniation Diagram.

Figure ##. Subfalcine Herniation Diagram.
 MOST COMMON TYPE
 “Under” + “falx”
 Cingulate gyrus shifts under falx cerebri -> Compressed anterior
cerebral artery (ACA) under free edge of falx -> Infarction of the
medial hemispheric wall dorsal to corpus callosum
 NEUROIMAGING: Shift of septum pellucidum, effacement of
anterior horn of lateral ventricles, and compression of ACA
 SYMPTOMS: Headache and contralateral lower extremity
weakness
B. TRANSTENTORIAL OR UNCAL HERNIATION
Figure 2. ...Or Uncal Herniation. Note that the other herniation in the
diagram is of tonsillar type
TG 01: Surname 1, Surname 2, Surname 3, Surname 4 [Editor’s Surname]
 Diencephalon and parts of temporal lobe of both hemispheres
are squeezed through the notch in the tentorium cerebelli
 Has 3 stages
 Early diencephalic stage = Reversible stage
 Decreasing level of consciousness
 Small (1-3 mm) pupils that are reactive and May be used
immediately after Heading 1 or 2
 Intact doll’s eye maneuver
 Flexor plantar response
 Respiration contain deep sigh, yawns, and occasional
pauses that may progress to Cheyne-Stoke respiration
→ Late diencephalic stage
 Stretching of the penetrating vessels of PCA and PCOM
that supply the thalamus and hypothalamus
 Sensorium further decreases and there is difficulty in
arousing patient
 Localization to pain disappears and patient presents with
decorticate/flexed posturing with eventual progression to
decerebration
→ Midbrain stage (irreversible stage)
 Signs of oculomotor failure appear
 Pupils become irregular, fixed at midposition, and
nonreactive
 Occulocephalic reflex cannot be elicited
 Decerebrate/extended posturing appears
 Increase in motor tone with bilateral Babinski (extensor
plantar response)
D. TONSILLAR OR TRANSFORAMINAL HERNIATION
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OS ###: ##PaoloPart ##Approach to Stupor and Coma Exam 01 - Trans 01

5. The Pt has no significant level of depressant or

neuroparalytic (synaptic-blocking) medications.
Determine by history, chart review, and toxicology screen
6. The Pt shows no brainstem function whatsoever
a. Absolute coma
b. Midposition or dilated pupils, nonreactive to light, and
not paralyzed by neuroactive drugs
c. Absolutely no spontaneous or induced eye movements
d. Absolutely no spontaneous to 5th nerve stimulation: no
glabellar wink, no corneal reflex
e. Absolutely no spontaneous or reflex facial movements
f. Absolutely no oropharyngeal responses: no gag reflex,
sucking, chewing, sucking, or rooting and no tongue
Figure 2. ...Or Transforaminal Herniation. movements
g. Absolutely no auditopalpebral or vestibulo-ocular
reflexes
h. Complete apnea on adequate testing by temporary
stoppage of respirator
7. A second complete neuro exam done 6-24h after the first
demonstrates absolutely no responses
B. ANCILLARY DIAGNOSTIC TESTS
8. Isoelectric EEG
9. Absence of cerebral blood flow by radionuclide or
Doppler studies or direct angiography

END OF TRANS

Figure 2. Radiograph of Tonsillar Herniation.

 Cerebellar tonsils shift down into the foramen magnum,
compressing the medulla and upper cervical cord
 Compression of upper cervical cord causes respiratory
distress/apnea and quadriplegia
 Sudden and very rapid
 Intractable headache, head tilt and neck stiffness due to tonsillar
impaction
 The apnea is due to the quadriplegia that affects volitional
breathing and compression of the reticulospinal tracts that stop
the automatic breathing
 Typically, rapidly fatal
V. BRAIN DEATH
 “Death” as irreversible cessation of all brain function
 If the neurological examination discloses no evidence of function
after two times of examination separated by 6 to 24 hours or
most conservatively 72 hours, some physicians will diagnose
brain death.
 Ancillary procedures may be done to conclude brain death after
one neuro exam to facilitate organ transplantation rather than
waiting for a prolonged period for a second clinical examination
 Time of death is recorded as the time at which the examiner
reaches a diagnosis of brain death
 Involvement of 2-3 different physicians, the attending physician
and another doctor, preferably a neurologist or neurosurgeon,
for 2nd determination
A. PRIMARY CLINICAL CRITERIA
1. The Pt has suffered a clinical disaster that could cause
brain death and is completely comatose, with no
respiration or other behavior that could arise in the brain
2. The Pt is receiving artificial respiration and is adequately
oxygenated
3. The Pt has a minimum core body temperature of 36.1°C
for a child or 32.2°C for an adult
4. The Pt is normotensive (but may require dopamine, etc.,
for support) and is in good a metabolic balance as the
circumstances allow.

TG 01: Surname 1, Surname 2, Surname 3, Surname 4 [Editor’s Surname] 2 of 2