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Current Clinical Approach to Patients with Disorders of Consciousness

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Current Clinical Approach to Patients with Disorders of Consciousness CURRENTREVIEW CLINICAL APPROA CARTICLEH TO PATIENTS WITH DISORDERS OF CONSCIOUSNESS Current clinical approach to patients with disorders of consciousness ROBSON LUIS OLIVEIRA DE AMORIM1, MARCIA MITIE NAGUMO2*, WELLINGSON SILVA PAIVA3, ALMIR FERREIRA DE ANDRADE3, MANOEL JACOBSEN TEIXEIRA4 1PhD – Assistant Physician of the Neurosurgical Emergency Unit, Division of Neurosurgery, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil 2Nurse – MSc Student at the Neurosurgical Emergency Unit, Division of Neurosurgery, Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil 3Habilitation (BR: Livre-docência) – Professor of the Neurosurgical Emergency Unit, Division of Neurosurgery, Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil 4Habilitation (BR: Livre-docência) – Full Professor of the Division of Neurosurgery, Hospital das Clínicas, FMUSP, São Paulo, SP, Brazil SUMMARY Study conducted at Hospital das Clínicas, In clinical practice, hospital admission of patients with altered level of conscious- Faculdade de Medicina, Universidade de ness, sleepy or in a non-responsive state is extremely common. This clinical con- São Paulo (FMUSP), São Paulo, SP, Brazil dition requires an effective investigation and early treatment. Performing a fo- Article received: 1/28/2015 cused and objective evaluation is critical, with quality history taking and Accepted for publication: 5/4/2015 physical examination capable to locate the lesion and define conducts. Imaging *Correspondence: and laboratory exams have played an increasingly important role in supporting Address: Av. Dr. Enéas de Carvalho Aguiar, 255, Cerqueira César clinical research. In this review, the main types of changes in consciousness are São Paulo, SP – Brazil discussed as well as the essential points that should be evaluated in the clinical Postal code: 05403-000 [email protected] management of these patients. http://dx.doi.org/10.1590/1806-9282.62.04.377 Keywords: coma, neurology, emergency medicine, state of consciousness. INTRODUCTION The different stages that may precede coma will be Consciousness is the individual’s ability to have perception described below. Drowsiness or lethargy is considered a of themselves and their surrounding environment. It is im- state of decreased level of consciousness in which the pa- portant to distinguish the level and the content of con- tient can be woken up with mild stimuli and obey com- sciousness. The first refers to the degree of alertness and the mands. In the state of torpor, the patient wakes up after second is related to the quality and coherence of the indi- mechanical stimulation, responds to simple requests, has vidual’s thought, cognition and attitude. To be conscious self-psychic orientation, while generally suffering allo- one must be awake; however, being awake does not neces- psychic disorientation.4 A patient with clouding of con- sarily mean that one is conscious. Anatomically and func- sciousness oscillates between states of drowsiness and ag- tionally, consciousness depends on the interaction and ac- itation. Stupor is considered a deeper state of drowsiness tivity of the cerebral cortex, brainstem and thalamus.¹ The in that the individual needs to receive vigorous and re- activity of these three brain regions has fundamental im- peated stimuli to be awakened. portance on an individual’s capacity to open their eyes, re- Coma can then be defined as a sustained state (>1 spond to verbal and motor commands and also be aware of hour) of loss of perception of oneself and of the surround- themselves and the environment through the interrelation ing environment, characterized by a reduction in the lev- of the five senses (sight, smell, touch, taste, and hearing). el of alertness to such an extent that one cannot be awak- The most common causes of brain injury are trau- ened after maximum internal or external stimulus. matic, ischemic/hemorrhagic and metabolic (drugs, ex- Classically, coma is considered in patients scoring less cess insulin, diabetes, alcohol)2 in nature. than nine points on the Glasgow Coma Scale (GCS). In Altered levels of conscience can range from temporo- a coma, the central nervous system is compromised, char- spatial disorientation to a state of deep coma.3 Therefore, acterized by ascending reticular activator system injury know how to correctly classify the patient’s type of alter- (ARAS) and/or extensive injury to the cerebral hemispheres. ation is as important as defining appropriate medical This may be due to a structural injury or metabolic dis- conduct for the clinical symptoms. order, and information such as previous symptoms, his- REV ASSOC Med BRAS 2016; 62(4):377-384 377 AMORIM RLO DE ET al. tory of recent trauma, personal history, life habits and Abulia is a behavior in which there is serious indiffer- medications in use are valuable for clinical management.3 ence with a reduction or absence of emotional or mental Among the states that are characterized by altered behavior, in which the patient does not speak or move content of consciousness are delirium and dementia. De- spontaneously, although alert and recognizing stimuli lirium is characterized by disorientation, attention defi- from the environment.3 This usually occurs in patients cit, a feeling of fear, irritability and changes in the per- with bilateral frontal lesions. Akinetic mutism presents ception of sensory stimuli, such as visual hallucinations.2 symptoms similar to those of abulia but less severe; the pa- In dementia, there is the progressive and permanent loss tient shows an unwillingness/extreme difficulty to move of cognitive function over months or years, without chang- or speak, with the level and content of consciousness pre- es in alertness or level of consciousness. served, and eyes following the observer or sound although The following behavioral states can be commonly the patient does not obey commands. Muscle tone and re- confused with coma: persistent vegetative state, minimal- flexes are usually intact. In the case of locked-in syndrome, ly conscious state, abulia, catatonia, locked-in syndrome, the patient also has the level and content of consciousness akinetic mutism and psychogenic passivity (Table 1). The preserved; however, the patient presents complete paraly- first two can be states subsequent to coma. sis, preventing any type of movement or verbal communi- cation. In some cases, eye movement may be present. This TABLE 1 Types of consciousness disorder; -(absent), syndrome usually occurs in patients with basilar artery +(present); UWS: unresponsive wakefulness syndrome. thrombosis and ischemic infarction of the base of the pons State Alert Consciousness and must be differentiated from coma and persistent veg- etative state. This condition may show symptoms similar Coma - - to those of acute polyneuropathies, myasthenia gravis and Persistent vegetative state/UWS +++ - acute use of neuromuscular blockers. Advances in the field Minimally conscious state +++ + of neuroimaging suggest a new diagnosis: Functional Delirium ++ ++ locked-in syndrome. In this condition, patients do not Abulia ++ ++ show any behavioral signs of consciousness and differ from Catatonia ++ + patients who are in a vegetative state as only examinations Akinetic mutism +++ + such as functional magnetic resonance imaging, positron Locked in syndrome +++ +++ emission tomography or evoked potential tests are able to Psychogenic passivity +++ +++ identify responses that suggest some degree of conscious- ness.10 Catatonia is a state in which the individual may re- The clinical definition of the vegetative state, most recent- main mute and with a marked decrease of motor activity, ly described as unresponsive wakefulness syndrome usually associated with psychiatric symptoms, but it can (UWS)5,8,10 the clinical condition of complete unconscious- also occur due to metabolic disorders or induced by drugs.3 ness of self and the environment. However, the sleep-wake The patient exhibits bizarre and repetitive behavior, pos- cycle is maintained and the autonomic functions of the ture disturbances and rigidity. hypothalamus and brainstem are completely or partially Psychogenic passivity is also associated with psychi- preserved.6,8 The patient usually presents reflexes, eye atric conditions and includes preserved muscular tone, opening and spontaneous breathing and may perform resistance to passive movement of the limbs, resistance spontaneous movements like chewing and swallowing, to opening of the eyelids or forcibly closed eye, eyes fo- emitting unintelligible sounds, and demonstrating cer- cused on the ground regardless of the side on which they tain spontaneous reactions such as smiling and crying. are lying, or the presence of non-epileptic seizures. The main causes are TBI and cardiorespiratory arrest. So, how can we differentiate a patient in a coma from These symptoms must be present for more than 4 weeks a brain dead patient? In brain death, brain damage is so after the event that led to brain injury.6 extensive that there is no potential for structural and In a minimally conscious state, the patient may pos- functional recovery of the brain and internal homeosta- sess some degree of consciousness, obey verbal commands sis cannot be maintained. What separates the state of sporadically, and try to communicate; however, this is coma from a diagnosis of brain death is the irreversible most often unintelligible, and they may cry or smile in nature of the latter, with systemic repercussions on the
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