Contents
1. PATHOPHYSIOLOGY OF SIGNS AND SYMPTOMS OF COMA 3
ALTERED STATES OF CONSCIOUSNESS 3
DEFINITIONS 5
Consciousness
Acutely Altered States of Consciousness
Subacute or Chronic
Alterations of Consciousness
APPROACH TO THE DIAGNOSIS OF THE COMATOSE PATIENT 9
PHYSIOLOGY AND PATHOPHYSIOLOGY OF CONSCIOUSNESS
AND COMA 11
The Ascending Arousal System
Behavioral State Switching
Relationship of
Coma to Sleep
The Cerebral Hemispheres and Conscious Behavior
Structural
Lesions That Cause Altered Consciousness in Humans
2. EXAMINATION OF THE COMATOSE PATIENT 38
OVERVIEW 38
HISTORY 39
GENERAL PHYSICAL EXAMINATION 40
LEVEL OF CONSCIOUSNESS 40
ABC: AIRWAY, BREATHING, CIRCULATION 42
Circulation
Respiration
PUPILLARY RESPONSES 54
Examine the Pupils and Their Responses
Pathophysiology of Pupillary Responses:
Peripheral Anatomy of the Pupillomotor System
Pharmacology of the Peripheral
Pupillomotor System
Localizing Value of Abnormal Pupillary Responses
in Patients in Coma
Metabolic and Pharmacologic Causes of Abnormal
Pupillary Response
OCULOMOTOR RESPONSES 60
Functional Anatomy of the Peripheral Oculomotor System
Functional Anatomy of the
Central Oculomotor System
The Ocular Motor Examination
Interpretation of
Abnormal Ocular Movements
MOTOR RESPONSES 72
Motor Tone
Motor Reflexes
Motor Responses
FALSE LOCALIZING SIGNS IN PATIENTS WITH
METABOLIC COMA 75
Respiratory Responses
Pupillary Responses
Ocular Motor Responses
Motor
Responses
ix
MAJOR LABORATORY DIAGNOSTIC AIDS 77
Blood and Urine Testing
Computed Tomography Imaging and
Angiography
Magnetic Resonance Imaging and Angiography
Magnetic
Resonance Spectroscopy
Neurosonography
Lumbar
Puncture
Electroencephalography and Evoked Potentials
3. STRUCTURAL CAUSES OF STUPOR AND COMA 88
COMPRESSIVE LESIONS AS A CAUSE OF COMA 89
COMPRESSIVE LESIONS MAY DIRECTLY DISTORT
THE AROUSAL SYSTEM 90
Compression at Different Levels of the Central Nervous System Presents in Distinct
Ways
The Role of Increased Intracranial Pressure in Coma
The Role of Vascular
Factors and Cerebral Edema in Mass Lesions
HERNIATION SYNDROMES: INTRACRANIAL SHIFTS IN
THE PATHOGENESIS OF COMA 95
Anatomy of the Intracranial Compartments
Patterns of Brain Shifts That Contribute to
Coma
Clinical Findings in Uncal Herniation Syndrome
Clinical Findings in Central
Herniation Syndrome
Clinical Findings in Dorsal Midbrain Syndrome
Safety of
Lumbar Puncture in Comatose Patients
False Localizing Signs in the Diagnosis
of Structural Coma
DESTRUCTIVE LESIONS AS A CAUSE OF COMA 114
DIFFUSE, BILATERAL CORTICAL DESTRUCTION 114
DESTRUCTIVE DISEASE OF THE DIENCEPHALON 114
DESTRUCTIVE LESIONS OF THE BRAINSTEM 115
4. SPECIFIC CAUSES OF STRUCTURAL COMA 119
INTRODUCTION 120
SUPRATENTORIAL COMPRESSIVE LESIONS 120
EPIDURAL, DURAL, AND SUBDURAL MASSES 120
Epidural Hematoma
Subdural Hematoma
Epidural Abscess/Empyema
Dural and
Subdural Tumors
SUBARACHNOID LESIONS 129
Subarachnoid Hemorrhage
Subarachnoid Tumors
Subarachnoid Infection
INTRACEREBRAL MASSES 135
Intracerebral Hemorrhage
Intracerebral Tumors
Brain Abscess and Granuloma
INFRATENTORIAL COMPRESSIVE LESIONS 142
EPIDURAL AND DURAL MASSES 143
Epidural Hematoma
Epidural Abscess
Dural
and Epidural Tumors
SUBDURAL POSTERIOR FOSSA COMPRESSIVE LESIONS 144
Subdural Empyema
Subdural Tumors
x
Contents
SUBARACHNOID POSTERIOR FOSSA LESIONS 145
INTRAPARENCHYMAL POSTERIOR FOSSA MASS LESIONS 145
Cerebellar Hemorrhage
Cerebellar Infarction
Cerebellar Abscess
Cerebellar
Tumor
Pontine Hemorrhage
SUPRATENTORIAL DESTRUCTIVE LESIONS CAUSING COMA 151
VASCULAR CAUSES OF SUPRATENTORIAL
DESTRUCTIVE LESIONS 152
Carotid Ischemic Lesions
Distal Basilar Occlusion
Venous Sinus
Thrombosis
Vasculitis
INFECTIONS AND INFLAMMATORY CAUSES OF SUPRATENTORIAL
DESTRUCTIVE LESIONS 156
Viral Encephalitis
Acute Disseminated Encephalomyelitis
CONCUSSION AND OTHER TRAUMATIC BRAIN INJURIES 159
Mechanism of Brain Injury During Closed Head Trauma
Mechanism of Loss of
Consciousness in Concussion
Delayed Encephalopathy After Head Injury
INFRATENTORIAL DESTRUCTIVE LESIONS 162
BRAINSTEM VASCULAR DESTRUCTIVE DISORDERS 163
Brainstem Hemorrhage
Basilar Migraine
Posterior Reversible
Leukoencephalopathy Syndrome
INFRATENTORIAL INFLAMMATORY DISORDERS 169
INFRATENTORIAL TUMORS 170
CENTRAL PONTINE MYELINOLYSIS 171
5. MULTIFOCAL, DIFFUSE, AND METABOLIC BRAIN DISEASES
CAUSING DELIRIUM, STUPOR, OR COMA 179
CLINICAL SIGNS OF METABOLIC ENCEPHALOPATHY 181
CONSCIOUSNESS: CLINICAL ASPECTS 181
Tests of Mental Status
Pathogenesis of the Mental Changes
RESPIRATION 187
Neurologic Respiratory Changes Accompanying Metabolic Encephalopathy
Acid-Base
Changes Accompanying Hyperventilation During Metabolic Encephalopathy
Acid-Base
Changes Accompanying Hypoventilation During Metabolic Encephalopathy
PUPILS 192
OCULAR MOTILITY 193
MOTOR ACTIVITY 194
‘‘Nonspecific’’ Motor Abnormalities
Motor Abnormalities Characteristic
of Metabolic Coma
DIFFERENTIAL DIAGNOSIS 197
Distinction Between Metabolic and Psychogenic Unresponsiveness
Distinction
Between Coma of Metabolic and Structural Origin
Contents
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