APPROACH TO PATIENTS

WITH ALTERED
CONSCIOUSNESS

Consciousness
Two components of conscious
behavior
content- the sum of cognitive and
affective function
arousal- appearance of wakefulness

Content depends on arousal but

normal arousal does not guarantee
normal content

Neuroanatomy
Arousal: where is it localized?
Ascending Reticular Activating System
(ARAS) CENTRAL core of the brainstem
from caudal medulla to rostral midbrain
receives input from numerous somatic
afferents and special sensory pathway
projects to midline thalamic nuclei (which
are in a circuit with cortical structures)
and the limbic system

ARAS
Ascending pathway from ARAS
1. THALAMUSCORTEX
2. HYPOTHALAMUSBASAL
FOREBRAIN, LIMBIC CORTEX
3. RAPHE N.(MDBs) & LOCUS
CERULEUS(ne)CORTEX
ARAS THEREFORE GATING MECHANISM
TO CORTEX

Demands of Arousal
Function of ARAS-Thalamic-Cortical
system depends on:
anatomic integrity of structures
metabolic integrity (circulatory
integrity)
communicative integrity
(neurotransmitter function)

NEUROANATOMY
Coma implies dysfunction of:
ARAS or
Both hemi-cortices

Anatomically, this means

central brainstem structures (bilaterally)
from caudal medulla to rostral midbrain
both hemispheres

DEFINITION

DEFINITION

DEFINITION

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

Akinetic Mutism
Silent, immobile but alert appearing
Usually due to lesion in bilateral
mesial frontal lobes, bilateral
thalamic lesions or lesions in periaqueductal grey (brainstem)

Definition
Coma: Unarousable
unresponsiveness in which the
subjects lie with eyes closed
Plum and Posner- Diagnosis of Stupor
and Coma
Absence of arousal and awareness,
must last for at least an hour.

Causes of Altered
Consciousnes
Structural- brain lesions that destroy
tissue or occupy space normally
occupied by the brain
Cardiovascular- temporary or
permanent interruption to the blood
supply to the brain
Metabolic- abnormally high or low
levels of circulating metabolites

MNEMONICS
A-Alcohol,acid-base
E- epilepsy,electrolyte,
encephalopathy
I- insulin(diabetes)
O- opiates, oxygen
U-uremia , underdose

Mnemonics

T- Trauma,temperature, tumors
iI- infection( sepsis)
P- psychiatric disorders, poisons
S-stroke, shock

Clues from History

Onset of symptoms
sudden onset
fluctuations

Associated neurologic symptoms

Medications

Cranial Nerve Exam

Systematic assessment of brainstem
function via reflexes
Cranial Nerve Exam

Pupillary light response (CN 2-3)

Occulocephalic/calorics (CN 3,4,6,8)
Corneal reflex (CN 5,7)
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

Oculocephalic Reflex
Brisk rotation of head with eyes held
open
Watch for contraversive movements
Next:
Flexion: eyes deviate up and eyelids
open (dolls head phenomenon)
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
Awake: deviation toward,nystagmus away
Comatose: deviation toward

Wait 5 minutes, do other ear

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

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

CHEYNE - STOKES
HYPERPNEA ALTERNATING
REGULARLY WITH APNEA:H>A
BILATERAL CEREBRAL DYSFUNCTION

CENTRAL NEUROGENIC
HPVN
AT LEAST 25 DEEP RAPID BREATHS/
MIN.
LOWER MIDBRAIN-UPPER PONS
?KUSSMAUL BREATHING

APNEUSTIC BREATHING
END EXPIRATORY PAUSES OF 2 TO 3
SECONDS USU. ALTERNATE WITH
END- EXPIRATORY PAUSES;
BASILAR ARTERY OCCLUSION

CLUSTER BREATHING

ATAXIC BREATHING
IRREGULAR BREATHING WITH
IRREGULAR PAUSES AND
UNPREDICTABLE PERIODS OF APNEA
LESION OF DORSOMEDIAL MEDULLA

Epidemiology of Coma
Plum and Posner 1982
500 consecutive cases of coma
101 supratentorial (44/101 ICH)
65 subtentorial lesions (40/65 brainstem
infarcts)
326 diffuse or metabolic brain dysfunction
149 drug intoxication

GOOD

DAY