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Disorders of Consciousness

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Disorders of Consciousness DISORDERS OF CONSCIOUSNESS Rebecca John MBBS Graduate, Kannur Medical College, Kerala, India Introduction Pathophysiology Etiology Spectrum of consciousness Definitions Impairment of conscious states Management Consciousness State of full awareness of the self and one’s relationship to the environment. Two elements Arousal – wakefulness/alertness (Ascending reticular activating system at pons, midbrain, thalamus, hypothalamus) Content-affective and cognitive functions such as attention, memory, motivation and executive function ( higher level structures of cerebral cortex and connections to subcortical white matter ) Pathophysiology Integral Consciousness requires an intact - 1) Ascending reticular activating system, 2) Cerebral cortex, 3) Healthy projections between the two systems. • Begins in the lower brainstem and extends upward through pons, midbrain, thalamus • Finally project throughout cerebral cortex into two pathways a) through subthalamus b) through thalamus The state of wakefulness is mediated by neurons of the ascending reticular activating system(ARAS). • Neural pathways from these locations project throughout the cortex , which is responsible for awareness. Loss of consciousness will result if • The function of ARAS neurons compromised or • Both cerebral hemisphere are sufficiently affected by disease. Proper function of ARAS and both cerebral hemisphere depends on: • Presence of substrate for energy production • Adequate blood flow • Absence of abnormal metabolic wastes or toxins • Normal body temperature • Absence of abnormal neuronal excitation or irritation from seizure activity • Absence of CNS infections • Normal intracranial pressure Etiologies of impaired consciousne ss Infectious Inflammatory Structural Metabolic Toxins Psychogenic Heavy Hyper/hyoglyc metal Bacterial emia Catatonia meningitis Demyelinatio poisonin n g Rikettsial Hyponatremia Conversion infection Disorder Vasculitis Alcohol Hypercalcemia Viral Sepsis Malingering encephalitis associated Hyperbilirubine Carbon encephalopathy mia Monoxide Acute disseminated Acute uremia encephalopmyel itis Supratentorial Infratentorial Brainste Traumatic Vascular Focal Neoplastic Cerebellum m Abscess Pontine Hematoma Concussion Anoxic- hemorrhage Ischemic Brain encephalopath mets y Cerebritis Abscess Epidural/int Basilar racerebral Multiple artery Tumor hematoma cortical thrombosis infarctions Lymphoma Diffuse axonal Bilateral Central injury Thalamic pontine infarction myelinosi s Definitions • Sleep - Biologically active state with identifiable behavioral and EEG stages, with appropriate stimulus intensity and duration sleeping person can be aroused to a normal state of consciousness. • IRS - Unpredictable, transient and spontaneous unresponsiveness lasting from hours to days, with a frequency of three to seven attacks per year, in the absence of readily discernible toxic, metabolic or structural causes. • Catatonia is marked by a significant decrease in someone's reactivity to their environment. This can involve stupor, mutism, negativism, or motor rigidity, and even purposeless excitement. • Non-Convulsive Status Epilepticus (NCSE) is a persistent change in the level of consciousness, behavior, autonomic function, and sensorium from baseline associated with continuous epileptiform EEG changes, but without major motor signs Impairment of consciousness states Impairment of consciousness Impairment of consciousness Impairment of consciousness along the continuum of with activated mental state with reduced mental state coma–vegetative state– minimally conscious state Delirium : Activated mental state that may include disorientation, irritability, Drowsiness fearful- responses, and sensory misperception. Delusion : Incorrect thoughts or beliefs that do not change when challenged by Obtundation contradictory evidence or logical reason. Illusion : Misinterpretation of Stupor actual sensory stimuli. Hallucination : Perception of sensory input that are not present. Impairment of consciousness with reduced mental state • Drowsiness • Obtundation arousal is present to stimuli • Stupor State Stimulus needed for arousal Drowsiness Verbal and light touch Obtundation Deep touch Stupor Vigorous, painful, or noxious stimulation Vegetative state • Complete unawareness of self & environment accompanied by sleep-wake cycles with complete/partial preservation of hypothalamic and brainstem autonomic function. • Persistent Vegetative state - > 1month • Permanent Vegetative state (Poor prognosis) - > 3 months after non-traumatic injury, >12 months after traumatic injury Minimally conscious state • Severely alterered consciousness, demonstrates minimal evidence of self / environmental awareness. • Neurologic recovery-better. • Life expectancy- longer than vegetative state. Locked-In Syndrome • Retain consciousness & cognition but unable to move or communicate because of paralysis. • Involvement – Descending corticospinal & corticobulbar pathways at or below Pons/ Peripheral nervous system. • Communication – using eye movements. Akinetic Mutism • Akinetic mutism is “a state of limited responsiveness to the environment in the absence of gross alteration of sensorimotor mechanisms operating at a more peripheral level.” Neither paralysis nor coma accounts for the symptoms. Patients may open their eyes and seem alert, and brief movement, speech, or even agitation may follow powerful stimuli; however, patients are otherwise “indifferent, detached, frozen, and apathetic.” • Pathologically slowed or nearly absent bodily movement accompanied by loss of speech. • Wakefulness and Self awareness - Preserved. • Mental function- Reduced. • Area Involved – damage to paramedian mesencephalon, basal diencephalon, inferior frontal lobes. Coma • State of deep, unarousable, sustained pathologic unconsciousness with the eyes closed that results from dysfunction of the ascending reticular-activating system in the brainstem or in both cerebral hemispheres. • Patients in coma lack both wakefulness and awareness. Brain Death • Brain death is defined as the irreversible loss of all functions of the brain, including the brainstem. • The three essential findings in brain death are coma, absence of brainstem reflexes, and apnoea test. Ancillary neurodiagnostic studies • Electroencephalography- Absence cerebral activity over 30 min recording. • Radionuclide imaging – Absence of radionuclide detection in brain parenchyma and large vessels. • Cerebral angiography – Absence of intracranial filling of large cerebral arteries & branches. • Transcranial Doppler ultrasound- loss of diastolic flow, systolic flow,flow reversal. Condition Self- Pain and Sleep– Motor Function Respiratory Awareness Suffering Wake Function Cycles Coma Absent No Absent No purposeful Variably movement depressed Vegetative Absent No Intact No purposeful Normal State movement Minimaly Very Yes Intact Severe limitation Variably conscious limited of movement depressed State Locked-in- Present Yes Intact Quadriplegia, Normal to syndrome Eye movements variably + depressed. Brain Absent No Absent None Absent Death Management • Rapid assessment and stabilization – ABCDE • Assess vital signs Temp: Fever – Sepsis, pneumonia, meningitis, encephalitis, intracranial abscess, empyema. Hypothermia - Sepsis, shock, alcohol, barbiturate poisoning, hypoglycemia. Very high fever and dry skin – Heat stroke. HR: Bradycardia -↑ ICT, myocardial injury due to hypoxia, sepsis Tachycardia - Shock, Infections, Fever, Heart failure Irregular –Arrhythmia RR: Bradypnea/ Apnea - Drug intoxication, septicemia Tachypnea - Metabolic Acidosis, Pneumonia, Asthma, Pulmonary embolism, Brainstem lesion. BP: HTN - ↑ICP or stroke, HTN encephalopathy Hypotension -Shock, sepsis, myocardial injury / failure, drug ingestion , adrenal insufficiency. Clues to etiology of coma in general examination Look for if present ,think of Pallor Cerebral malaria, intracranial bleed, hemolytic uremic syndrome Icterus Hepatic encephalopathy, leptospirosis, complicated malaria Rashes Meningococcemia, dengue , measles, rickettsial diseases, arboviral diseases Petechiae Dengue, meningococcemia , hemorrhagic fevers Head and scalp Traumatic/ non accidental injury hematomas Dysmorphism, Possibility of seizures neurocutaneusmarkers Abnormal odour DKA, hepatic coma Cyanosis Cyanotic congenital heart disease, Hypoxia Oedema CHF, Renal failure Dehydration Hypovolemic shock, HUS Respiratory Patterns ,, Cheyne-Stokes respiration - Denotes a cyclic pattern of alternating hyperpnea and apnea. - A bilateral hemispheric or diencephalic insult may indicate incipient transtentorial herniation - CHF,COPD,OSA,Uremia. Hyperventilation - Injury in the pontine or midbrain tegmentum; - respiratory failure, hemodynamic shock, fever, sepsis, metabolic disarray, and psychiatric disease. Apneustic breathing - prolonged pause at the end of inspiration - lateral tegmentum of the lower half of the pons. Cluster breathing - Periodic respirations that are irregular in frequency and amplitude with variablepauses between clusters of breaths - lower pontine tegmental lesion Ataxic breathing - Is irregular in both rate and tidal volume - Suggests damage to the medulla. Neurological Assesment Level of consciousness Pupillary responses Brainstem function Motor response Other neurological findings Herniation syndrome A. Level of conciousness • The level of conciousness must be recorded in the form of an objective scale. • The Glasgow coma scale is a useful tool for the grading of the degree of altered
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