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1.01A DIAGNOSIS OF STUPOR AND COMA (PART 1)
Dr. Maria Socorro Sarfati/ January 16, 2018
PRELIMS; QUIZ NO. 1
Red bold- emphasized during lecture, Blue italic- Audio, Green-OT/ book
ORIENTATION
MEDICINE 328 – NEUROSCIENCES 3: NEUROLOGY
- Diagnosis and management of common neurological and
neurosurgical diseases
- 52 hours (Monday, Tuesday, Thursday)
- Case dissection – case discussion in class/quiz
- 3 quizzes (and case dissections)
- 3 long examinations
- Quiz – minimum of 15 questions per one hour lecture
- Long examination – 15 questions per one hour lecture
if not yet included in the quiz; 5-10 questions if included
in the quiz per 1 hour lecture
GRADING SYSTEM
- 40% quiz, 60% long exam
- 75% passing grade
Lecture Proper:
STUPOR and COMA
- aka Disorders of Consciousness (full awareness of self
and one’s relation to the environment)
- even if you’re seated but your mind is in your boyfriend
then you are not conscious. It’s not just about oneself but
also the relationship to the environment.
Consciousness: (components)
 Arousal
 Attention
 Intention
 Memory
 Awareness
- Better definition of consciousness is divided into two:
arousal and content (attention, intention, memory and
awareness)
ANATOMIC SUBSTRATES OF CONSCIOUSNESS
- You don’t need your cerebellum and caudal medulla for
consciousness
- You need your bilateral cerebral hemispheres and
diencephalon (thalamus and hypothalamus)
- If only one is affected, then sensorium may be intact. It
has to be BILATERAL. You have to affect both cerebral
hemispheres and both diencephalon to cause altered
sensorium
- You should understand this anatomy for you to
understand why a patient with ruptured aneurysm
presents with stupor and coma, or how an alcoholic
patient goes into hepatic encephalopathy, or recognize a
malingering patient with psychogenic coma.
BRAIN AROUSAL SYSTEM
- ARAS: Ascending Reticular Activating System
- You have a very long reticular formation from caudal
medulla to midbrain, but the one responsible for
wakefulness is from your rostral pons to the
midbrain (connected to the diencephalon up to your
cerebral hemispheres)
- Lesions in medulla: breathing problems, labile blood
pressure but you can be awake
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NEUROLOGY 2
Here’s the projection:
WHY IS THE BRAIN VULNERABLE?
- One of highest rates of metabolism with high
requirement for ATP
- Constant rate of maintaining membrane potentials,
synthesis/storage of neurotransmitters
- No reserves of O2 and critical nutrients and substrates
particularly glucose. Unlike the tummy or liver, your
brain has no reserve, it depends on the actual flow at a
point in time
- If you deprive your brain of circulation for 5
minutes, expect for irreversible damage.
Cerebral Blood Flow (CBF)
- 55ml/100gm/minute (20% of Cardiac Output)
- <20ml – loss of consciousness (damage is still reversible)
- <10ml – irreversible damage
- Glucose – predominant blood-derived substrate:
5.5mg(.31mol/100gm/minute)
- Just remember the magic number “5”
NEUROTRANSMITTERS THAT MEDIATE CONSCIOUSNESS
 Acetylcholine – Nicotinic A4B2 receptor important for
consciousness; anticholinergics cause memory loss and
delirium
 Dopamine – D2 receptor for arousal; D2 agonists cause
delirium, increased in hypoxia (hypoxic encephalopathy)
 GABA – inhibitory neurotransmitter;
- GABA-A receptor binds to anesthetics; chronic use of
valium causes memory loss; increased GABA agonists in
hepatic encephalopathy
- GABA-B agonists cause delirium and memory loss (date
rape drug)
 Histamine – needed for wakefulness, H1 antagonist causes
sleepiness
 Glutamate - excitotoxic neurotransmitter
- upregulation seen in alcohol withdrawal delirium
 Norepinephrine – elevated in alcohol and opiate
withdrawal and in cocaine use
ACUTE ALTERED STATES OF CONSCIOUSNESS
- Divided into acute, subacute and chronic
- Patients who have been comatose for a month is not
labeled as comatose anymore, they are VEGETATIVE
 Clouding of consciousness
 Delirium
 Obtundation
 Stupor
 Coma
CLOUDING OF CONSCIOUSNESS
- reduced wakefulness/awareness (basta hindi ka
normally awake)
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- hyperexcitability/agitation at night and drowsiness
during the day
- inattention and poor memory (cannot register new
information)
- it’s a very broad term, it just tells you that sensorium is
not normal
DELIRIUM
- literally “to go out of the furrow”
- misperception, visual hallucination (very important
feature, visual not auditory which is more common
among psychiatric patients)
o Hallucination vs. illusion (illusion: with
stimulus; hallucination without stimulus)
- fluctuating during the day
OBTUNDATION
- literally “to beat against or blunt”
- mental blunting
- reduced alertness and reduced interest in the
environment
- slow response to stimulation with increased sleep
time(sleeping most of the time)
STUPOR
- literally “to be stunned”
- unresponsiveness
- aroused only by vigorous stimulation
- once stimulus ceases, person lapses back to
unresponsiveness
- impaired cognitive function (patient does not follow
command)
COMA
- literally “deep sleep or trance”
- no elements of consciousness beyond 24 hours
- state of unresponsiveness even with noxious stimulus
(even if you apply the most noxious stimulus, patient
remains unresponsive)
- Some use the term light coma or deep coma which are
vague. In reporting, it’s better to describe the patient’s
response to a particular stimulus.
o e.g. “On tactile stimulation, patient opens eyes
but no verbal output.”
o avoid terms such as semiconscious without
descriptions
LOCKED IN SYNDROME
- aka deefferented syndrome
- lesion in basis pontis affecting pyramidal tract so
patient is quadriplegic (facial and bulbar muscles are
also paralyzed) and can only communicate using his
eyes (such as blinking) but the patient is awake.
GULLAIN BARRE SYNDROME
- demyelinating motor neuropathy (there are some
variants affecting cranial nerves so the patient cannot
move and respond but they are actually awake)
SUBACUTE and CHRONIC ALTERED
STATES OF CONSCIOUSNESS
- Subacute – more than 48hrs; Chronic – more than 2
weeks
 Dementia
 Hypersomnia
 Abulia
 Akinetic mutism
 Minimal consciousness (a relatively new concept; better form
than vegetative state and brain death)
 Vegetative
 Brain death
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NEUROLOGY 2
DEMENTIA
- chronic progressive cognitive decline
- worsening leads to involvement of arousal
- later on lesion in cerebral hemispheres leads to
altered sensorium
- you will have to perform the mini-mental state exam
(patient should be fully awake when testing)
- during severe form of dementia, patient’s awareness is
affected, patient is bedridden and does not follow
instructions, patient is sleeping most of the time
HYPERSOMNIA
- patient with excessive sleep
- lesion is usually in the hypothalamus
ABULIA
- “lack of will”
- apathetic state, patient responds slowly if at all when
sufficiently stimulated
- cognitive functions may be normal (can carry out
commands)
- lesion in the bifrontal lobes (it should be bifrontal)
AKINETIC MUTISM
- silent, alert-appearing immobility
- no evidence of mental activity, no spontaneous motor
movement
- lesion in hypothalamus and basal forebrain
VEGETATIVE STATE
- after 10 days of coma, patient has “open eye
periods” in an unresponsive state
- brainstem regulation of cardiopulmonary and visceral
functions retained (VS are okay, there are tears in the
patient’s eye)
- Coma vigil, apallic state
- PERSISTENT VEGETATIVE STATE – at least 1
month in vegetative state
o very important especially in US and Europe
because if patient is in this status, you can
remove life support and you are legally
protected
MINIMAL CONSCIOUSNESS
- severely impaired consciousness but with minimal
awareness (it depends on the perception of the carers:
patient smiles when hearing familiar voices or twitch a
little)
- lighter wakefulness than in vegetative state, minimal
awareness of self
BRAIN DEATH
- No cerebral function, vital signs are very labile and
patient is on respirator
- Irreversible loss of function of cerebral
hemispheres and the brainstem arousal system
APPROACH
- any altered form of sensorium is considered as
MEDICAL EMERGENCY and history is very difficult
to elicit since it does not come from the patient
- You have to look at the place where you see the patient,
talk to the one who brought the patient, do quick physical
and neuro exam at the same time you are instituting
emergency management(ABC)
- History does not come from the patient
- Onset (abrupt: both hemispheres or brainstem like in
poisoning; or gradual: brain tumor initially causing
hemiparesis then with IICP, patient dozes off and goes
into coma)
- Age group: young (usually drug poisoning), elderly
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- Previous medical illness (renal, hepatic, diabetic) (itutulak niya yung arm mo) or is posturing? Again,
- Previous premorbid personality – especially in the describe.
young, very common in depression, they commit suicide - Comatose – unresponsiveness
- Access to drugs
- Airway and breathing DECEREBRATE
- Vital signs, circulation – MAP >60mmHg (for you to
maintain CBF of 55)
o MAP = 2/3 diastolic BP + 1/3 systolic BP
- Clues (such as needle marks, breath)
- Evidence of chronic diseases
- Evidence of trauma
DECORTICATE

Battle’s sign – hematoma behind your ear - decorticate posturing has a better prognosis

Raccoon eye – over the eye
- Both battle’s sign and raccoon eye indicate basal skull
fracture, request for head CT Scan.
NEURO EXAM
 Level of consciousness/Sensorium
 Pupillary reaction/fundoscopy
 Eye movement (oculocephalic/oculovestibular)
PUPILLARY RESPONSE
- Reflex afferent (subserved by CN II), efferent (CN III)
- Balance between the sympathetic (pupil dilator) and
parasympathetic (pupil constrictor) pathways
- Single most important physical sign in
differentiating metabolic from structural coma,
vs. a malingering patient
- Anisocoria (0.4mm difference) – more common in
neurologic disorders
- Pupils equal in size (asymmetry in 8-18% of normal
individuals so look at the reaction, if briskly responsive
then the patient must be having a normal anisocoric
variant)

 Respiratory pattern
 Motor responses/muscle tone/DTR
Remember SPERM!
LEVEL OF CONSCIOUSNESS
- intensity of stimulation and quality of response
- stimulation – verbal/tactile, deep nail bed pressure,
supraorbital ridge, temporomandibular joint, deep
sternal pressure, deep sternal rub (can be very painful,
least preferred)
- For stimulation do not do sternal rub right away, start
with verbal and check if patient will open his eyes, if no
response, tap them on the shoulder or do deep nailbed
pressure

Supraorbital pressure TMJ pressure

- Your CNIII is very close to the uncus, medial portion of
- Sufficiently painful stimulus but not causing tissue
the temporal lobe, very close to the posterior
damage
communicating artery
- Nailbed pinch, supraorbital pressure: Lateralized
- If you have increased pressure in the supratentorial
- Sternal rub: midline – very painful assessing response of
area, uncus can compress CN3 causing dilated pupil
right half and left half of the body
- Pupilloconstrictors are in the superficial part of the nerve
RESPONSE
(in the outermost part of the CN3) while levator
- Drowsy, lethargic or obtunded – responds to verbal or
palpebrae fibers are close to the blood vessel (vasa
tactile stimulation
nervorum)
- If patient requires noxious stimulation, patient is
stuporous. More than that, can the patient localize

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- If there’s uncal herniation, first thing to see is anisocoria,
then later on, patient presents with ptosis, at this time,
pangit na ang sensorium ng patient
- If patient has ptosis and reactive pupil, there should be a
problem with the circulation kasi siya pinakamalapit sa
vasa nervorum (e.g. diabetic patients with atherosclerotic
blood vessel)
- There are certain levels of the brain giving you a
characteristic pupillary size and reaction
- If metabolic (spared sympathetic and parasympathetic
pathways), still briskly reactive
- In diencephalic lesions, sometimes there’s sluggish
reaction, if uncus would compress on CN3, your
ipsilateral pupil will be dilated.
- Midbrain – pupils are in midposition and fixed
- Pontine – pupils are very small and you could hardly see
reaction
- Medulla (terminal stage) – fixed and dilated pupils
NEUROLOGY 2
o 30 degrees inclination to make semicircular
canals vertical thus more sensitive
- Normal response:
o nystagmus(rapid saccadic movement): slow
and fast pace (nystagmus is identified by its
fast component)
o Remember COWS: Cold Opposite, Warm
Same
o Cold infusion (<20oC)–fast component to the
opposite side
o Warm infusion (>40oC)–fast component to the
same side
- May be absent in coma due to
phenytoin/aminoglycoside/TCA toxicity causing
vestibular failure
- Video:
https://www.youtube.com/watch?v=H4iQkFUgG6k

PRACTICE QUIZ:
1-2. Part of the reticular formation responsible for
wakefulness is from (1)____________ to (2) ____________.
3. Normal CBF: ______________.
4. Upregulation of this neurotransmitter is seen in alcohol
withdrawal delirium?
5. What form of hallucination common in patients with
delirium?
6. Literally means "to be stunned".
7. Any altered form of sensorium is considered as
_______________.
8. Persistent vegetative state is defined as vegetative state
for _____________.
9. Caloric vestibulo-ocular response is done to check if
________________ is intact.
HORNER’S SYNDROME
10. Meaning of SPERM.
- ptosis, miosis and anhydrosis (on the ipsilateral side)
- involvement of the sympathetic pathway
CILIOSPINAL REFLEX
- if pupillary test cannot be done
- pinch the neck, if the pupils constrict, it means the
midbrain, up is still intact
- If no reaction, brainstem is involved (very impt
maneuver to differentiate brainstem from non-brainstem
lesions)
- sympathetic reflex causing pupillary dilation after
pinching the neck --end of trans---
- (+): midbrain lesion
- (-): brain death
OCULOMOTOR RESPONSE
- asymmetry in oculomotor function favors structural
coma rather than metabolic coma
- oculomotor pathways are very close to ARAS (if you
have problems with the brainstem, you may have eye
signs)
2 responses to check:
OCULOCEPHALIC REFLEX
- aka Doll’s Eye
- r/o fracture or dislocation of the cervical
spine(contraindication)
CALORIC VESTIBULO-OCULAR RESPONSE
- positive if brainstem intact (expected in patients with
metabolic encephalopathy)
- if brainstem affected, it’s negative
- Requirements:
o tympanic membrane should be intact
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