Plum and posner’s diagnosis of stupor and coma fourth Edition series editor sid Gilman, md, frcp
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conjugate lateral deviation, 69–70 conjugate vertical deviation, 70 nonconjugate eye deviation, 70 oculocephalic stimulation of, 65 pathways for, 60f periodic alternating, 71 resting, 69 roving, 70–71 skew deviation, 70 spontaneous, 69, 69t Eyelids, 64 Falcine herniation, 100 Falx cerebri, 95–96, 96f–97f Families
considerations for, 379–380 functional communication with, 380 Fat embolism, 217–218 Fatal familial insomnia, 115, 277–278 Fever, 260–261, 282–283 Flumazenil, 316 Flunitrazepam, 248 Focal continuous epilepsy, 315 Focal ischemia, 207–208 Foramen magnum, 100 Forced duction of globe, 68 Forebrain arousal of, 14 mesopontine tegmentum, 14 Foster-Kennedy syndrome, 92 FOUR Score, 41b, 311 14–3–3, 277 Fourth ventricle compression, 148 Fractional loss of consciousness, 5, 27 Frontal eye fields, 62 Frontoparietal hemorrhage, 138b GABA
A receptors, 18b, 209, 246 Gag reflex, 334 Galvanic stimulation, 65 Gamma-aminobutyric acid, 209 Gamma-aminobutyric acid-ergic neurons, 205 Gamma-hydroxybutyrate, 209 Gastric lavage, 326 General anesthesia description of, 205–206 malignant hyperthermia associated with, 262 Gerstmann-Strau¨ssler disease, 277 GHB, 248
Glasgow Coma Scale description of, 42b in traumatic brain injury prognosis, 345, 345t Glasgow Outcome Scale, 344, 344t Glia, 198 Glial fibrillary acidic protein, 347 Gliomas, 140–141 Gliomatosis cerebri, 278–279 Global ischemia, 206–207 Globe forced duction of, 68 lateral movement of, 60–61 Globus pallidus, 28 Glucagon-like peptide-1, 53 Glucose
brain utilization of, 202 cerebral consumption of, 204 deprivation of, 202 measurement of, 313 metabolism of, 202–205 Glucose disorders hyperglycemia, 203, 222–223, 313 hypoglycemia, 203–205, 220–222, 313 Glut-1, 202 Glutamate, 80, 210–211, 223 Glutamine, 80 Glutethimide, 59 Gnosis, 186 Granulomas, 141–142 Granulomatous angiitis, 156, 273–274 Grasp reflex, 72 Great vein of Galen, 102 Guillain-Barre´ syndrome, 76–77, 170 Hallucinations, 6 Hashimoto’s encephalopathy, 237 Headaches increased intracranial pressure as cause of, 92 in infratentorial mass lesions, 323 in subdural hematoma, 124 supratentorial mass lesions and, 320 Heart rate, 45 Heatstroke, 260–261 392
Index Hematoma epidural, 121–123, 143–144 subdural description of, 123–126, 124t posterior fossa, 144 Hemiparesis, 101, 106 Hemodialysis, for uremia, 229 Hemorrhage brainstem, 166–168 cerebellar. See Cerebellar hemorrhage intraventricular, 137 lobar, 136, 136f midbrain, 166t, 167 perimesencephalic, 145 pontine clinical findings of, 167t coma caused by, 167 description of, 138b, 150–151 origin of, 167 pupillary findings, 167 subarachnoid description of, 129–131, 139b grading system for, 356t outcomes after, 355–356 posterior fossa, 145 thalamic, 137, 138b, 139 into tumors, 140 Hepatic coma description of, 190, 225 prognosis for, 356–357 Hepatic encephalopathy diagnosis of, 225 hyperventilation associated with, 224 mild, 227 onset of, 224 pathology of, 224 pupillary findings in, 225 Herniation syndromes central transtentorial herniation, 101–102, 107–110 corticosteroids for, 322 falcine herniation, 100 historical view of, 97b intracranial compartments, 95–100 lateral displacement of the diencephalon, 97b, 100 Monroe-Kellie doctrine, 95 rostrocaudal brainstem deterioration, 102 tonsillar, 102, 103f–104f uncal. See Uncal herniation upward brainstem herniation, 102–103 Heroin, 243 Herpes simplex encephalitis, 157, 157t, 267–269, 315 Herpes zoster, 275–276 Herring-Breuer reflex, 49 Hiccupping, 53 Hippocampus bilateral, 31–32 CA1 region of, 30 Histamine, 209–210 Histidine decarboxylase, 18, 209 History-taking, 39–40, 317–318 Histotoxic hypoxia, 211 Horner’s syndrome central, 57–58 clinical features of, 55 peripheral, 58 Hyperarousal, 183–184 Hyperbaric oxygenation, 325 Hypercalcemia, 256–257 Hypercarbia, 230 Hyperglycemia, 203, 222–223, 234, 313 Hyperglycemic hyperosmolar coma, 256 Hyperkinetic movement disorders, 28 Hypermagnesemia, 258 Hypernatremia, 255–256 Hypernatremic encephalopathy, 256 Hyperosmolality, 232 Hyperosmolar agents, 321–322 Hyperosmolar states, 255–256 Hyperphosphatemia, 258 Hypersomnia, 8 Hyperthermia, 260–262, 315 Hyperthyroidism, 237 Hyperventilation acid-base imbalances with metabolic acidosis, 188–189 respiratory alkalosis, 189–191, 190t in comatose patients, 51 in hepatic encephalopathy, 224 intracranial pressure reduced with, 321 sepsis and, 190 Hypocalcemia, 257–258 Hypocretin, 21b, 115. See also Orexin Hypoglycemia, 203–205, 234, 313 Hypomagnesemia, 258 Hyponatremia, 228–229, 237, 252f, 253–255 Hyponatremic encephalopathy, 254t Hypo-osmolar states, 253–255 Hypophosphatemia, 258 Hypothalamic ischemic lesions, 33 Hypothermia, 259–260, 315, 335 Hypothyroidism, 236–237 Hypoventilation, 191–192, 230 Hypoxia acute, 211–214 airway obstruction and, 211 anemic, 211 anoxic-ischemic brain damage caused by, 208 carbon dioxide narcosis and, 231 causes of, 210–211 cerebral malaria and, 217 cerebral venous, 211 delayed postanoxic encephalopathy after, 219 disseminated intravascular coagulation and, 217 fat embolism and, 217 histotoxic, 211 hypoxic, 211 intermittent, 215–219 ischemic, 211 multifocal cerebral ischemia and, 215–216 pupillary responses in, 59 sequelae of, 219–220 sustained, 215–219 traumatic brain injury and, 346 Hypoxic inducible factor, 212 Hypoxic-ischemic attacks, 212 Hypoxic-ischemic encephalopathy, 352–354 Hysteresis, 50–51 Index 393
Immunosuppression, 229–230 Infarction brainstem, 165t cerebellar, 139b, 148–149, 324 cerebral artery, 153f thalamic, 154 Wallenberg’s lateral medullary, 59 Infection central nervous system. See Central nervous system infections opportunistic, 230 prion, 266, 277–278 subarachnoid, 131–135 treatment of, 315 Infratentorial inflammatory disorders, 169–170 Infratentorial lesions compressive, 142–143 destructive, 162–163 mass, 323–324 Infratentorial tumors, 170 Insulin, 202 Intensive care unit delirium, 283–284 Intention myoclonus, 220 Intermittent hypoxia, 215–219 Internuclear ophthalmoplegia, 63, 76 Interstitial nucleus of Cajal, 62 Intoxication. See also Drug intoxications drugs of abuse, 248 ethanol, 246, 248 methanol, 249 paraldehyde, 249–250 Intracerebral hemorrhage computed tomography of, 136f lobar hemorrhage, 136, 136f pathophysiology of, 135–136, 139–140 treatment of, 137 Intracerebral tumors, 140–141 Intracranial compartments, 95–100 Intracranial hypertension, 321, 323 Intracranial pressure, increased abducens palsy caused by, 113 cerebral arterial supply impairment secondary to, 92 compensatory mechanisms of brain to, 92–93 headaches caused by, 92 hyperventilation for, 321 papilledema caused by, 91–92 paroxysmal symptoms caused by, 93t patient positioning, 312 reduction of, 321 Intraventricular hemorrhage, 137 Intubation, 311–312 Ischemia focal, 207–208 global, 206–207 vertebrobasilar, 213 Ischemic anoxia, 212 Ischemic hypoxia, 211 Ischemic lesions, carotid, 152 Kernig sign, 133, 263 Kernohan’s notch, 101 Ketamine, 248 Ketone bodies, 202 Kussmaul breathing, 75–76 Laboratory tests blood tests, 77 computed tomography. See Computed tomography computed tomography angiography, 78 electroencephalography, 82–83 evoked potentials, 82–83 lumbar puncture. See Lumbar puncture magnetic resonance angiography, 79, 336 magnetic resonance imaging. See Magnetic resonance imaging magnetic resonance spectroscopy, 79–80 neurosonography, 80 urine tests, 77 Lactate, 80, 203 Lactic acidosis, 233, 250 Lateral displacement of the diencephalon, 97b, 100 Lateral rectus muscle, 60–61 Lateral sinus thrombosis, 92, 154 Lazarus sign, 334 Leptomeningeal tumors, 131 Leptomeningitis, 262–265 Level of consciousness determination of, 5, 9 evaluation of, 40, 42 reduced, 5 Libman-Sachs endocarditis, 274 Lipid peak, 80 Listeria meningitis, 132 Listeria monocytogenes, 116, 170, 263, 315 Lithium, 242t, 245–246 Liver failure acute, 224 chronic, 224 Lobar hemorrhage, 136, 136f Locked-in syndrome/state, 7, 363–364, 380 Locus coeruleus, 15 Loss of consciousness from cerebral blood flow reductions, 201 in concussion, 161 fractional, 5, 27 Lower motor neuron palsy, 113 Lumbar puncture description of, 80–82 safety of, 112–113 in subdural hematoma patient, 126 Magnetic resonance angiography, 79, 336 Magnetic resonance imaging description of, 78–79 fat embolism evaluations, 217–218 hepatic encephalopathy evaluations, 225, 226f herpes simplex encephalitis findings, 158f Marchiafava-Bignami disease evaluations, 278 meningeal tumors, 132f meningioma evaluation, 127 meningitis evaluation, 135t, 264f minimally conscious state findings, 370f progressive multifocal leukoencephalopathy evaluations, 280f subarachnoid hemorrhage findings, 130 subdural hematoma evaluations, 125 Magnetic resonance spectroscopy, 79–80 Malaria, cerebral, 217 Malignant hyperthermia, 262 Malingering, 299–300 394 Index
Mannitol, 322 Marchiafava-Bignami disease, 278 MDMA, 242t, 248 Mean arterial pressure, 313 Medial longitudinal fasciculus anatomy of, 60f lesions of, 63, 70 Median raphe nuclei, 15 Mediodorsal thalamic nucleus, 28 Medulla, respiratory control by, 49 Memory, 185–186 Meningeal neoplasms, 131 Meningiomas, 127, 144 Meningismus, 40 Meningitis aseptic, 134t aspergillus, 133 bacterial acute, 132–133, 133t, 263 algorithm for, 316f chronic, 133, 265–266 corticosteroids for, 322 regimen for, 325 treatment of, 316f, 322, 325 cephalosporins for, 134 cerebrospinal fluid findings in, 134, 134t in children, 133, 263 chronic, 133, 265–266 community-acquired, 132–133, 133t, 263 computed tomography of, 133–134, 135t corticosteroids for, 134, 322 description of, 80–81 in elderly, 133, 263 imaging of, 135t laboratory tests, 133–134 Listeria, 132 magnetic resonance imaging of, 135t nuchal rigidity associated with, 133 pathogens associated with, 132 pathophysiology of, 131–132 signs and symptoms of, 131 subacute, 133 treatment of, 134 tuberculous, 265 viral, 132 Mental status assessments affect, 186 arousal, 183–184 attention, 185 cognition, 185 Confusion Assessment Method for the Intensive Care Unit, 184t description of, 183–184 memory, 185–186 orientation, 185 pathogenesis of changes, 186 perception, 186 Meropenem, 134 Mesopontine afferents, 14 Mesopontine tegmentum, 14, 19 Metabolic acidosis description of, 258 diagnosis of, 324 drugs that cause, 248–251 hyperventilation and, 188–189, 228 Metabolic alkalosis, 191t, 191–192, 231, 258 Metabolic coma causes of, 210 characteristics of, 324 diagnosis of, 324 hypoglycemia and, 220–222 laboratory tests, 321t neurotransmitter changes in acetylcholine, 208–209 dopamine, 209 gamma-aminobutyric acid, 209 glutamate, 210–211 histamine, 209–210 norepinephrine, 210 serotonin, 209 ocular motor responses in, 76–77 oculocephalic responses in, 76–77 pupillary responses in, 76, 192–193 respiratory responses in, 75–76 structural coma vs., 89, 197–198 Metabolic encephalopathy arousal abnormalities in, 183 asterixis in, 195–197 cerebral symptoms of, 186 delirium associated with, 181, 183 hypoglycemia and, 221 management of, 324–326 memory loss in, 185–186 mental status in affect, 186 arousal, 183–184 attention, 185 cognition, 185 Confusion Assessment Method for the Intensive Care Unit, 184t description of, 183–184 memory, 185–186 orientation, 185 pathogenesis of changes, 186 perception, 186 mixed, 281–282 motor activity abnormalities in, 194–197 multifocal myoclonus in, 197 ocular motility in, 193 pupillary findings, 192–193 pupillary light reflex during, 59 respiratory changes in description of, 187 evaluation of, 187–188 hyperventilation. See Hyperventilation hypoventilation, 191–192 neurologic, 187–188 signs of, 181 tremor of, 195 Metabolic unresponsiveness, 197 Metachromatic leukodystrophy, 114 Metastatic tumors, 141 Methanol intoxication, 249 Methaqualone, 242t Methemoglobin, 324 Midazolam, 323 Midbrain destructive lesions of, 115 dorsal, compression, 90, 110–112 Midbrain hemorrhage, 166t, 167 Index 395
Midbrain stage, of central transtentorial herniation, 107–108 Midpontine destruction, 162 Miller Fisher syndrome, 76, 170 Minimally conscious state akinetic mutism and, 360–362, 361b case study of, 362–363 cerebral metabolic rates in, 374 definition of, 8, 360 diagnostic criteria for, 360t diffusion tensor imaging of, 371f emergence from, 379 functional imaging of, 369–372 late recoveries from, 363, 375 magnetic resonance imaging of, 370f residual cognitive capacity in, 372–376 studies of, 368–372 surrogate decision making in, 379 vegetative state vs., 360 Mixed metabolic encephalopathy, 281–282 Monoamine oxidase inhibitors, 245 Monoaminergic neurons, 15 Monroe-Kellie doctrine, 95 Motor abnormalities, 194–197 Motor examination description of, 72 motor responses, 73–75 motor tone, 72 muscle stretch reflexes, 72–73 Motor responses brain death and, 332 examination of, 73–75, 320 in metabolic coma, 77 Multifocal cerebral ischemia, 215–216 Multifocal myoclonus, 197 Multiple sclerosis, 158 Muscle stretch reflexes, 72–73 Mycotic aneurysms, 140 Myo-inositol, 80 Myorhythmias, 265 Myxedema coma, 236–237 N-Acetylaspartate, 80 Naloxone, 316 Narcolepsy characteristics of, 20b orexin and, 20b–22b Neurogenic pulmonary edema, 190 Neuroleptic malignant syndrome, 261 Neurologic examination, 9, 318–319. See also Examination Neurons, 200, 201f Neurosonography, 80 Neurotransmitters acetylcholine, 208–209 dopamine, 209 gamma-aminobutyric acid, 209 glutamate, 210–211 histamine, 209–210 norepinephrine, 210 serotonin, 209 NK-1 receptors, 52 N-Methyl-D-aspartate, 114, 205 Nonconjugate eye deviation, 70 Nonconvulsive status epilepticus, 281 Nonketotic hyperglycemic hyperosmolality, 256 Non-rapid eye movement sleep description of, 16b–17b flip-flop switching of, 24f switching of, to REM sleep, 24 ‘‘No-reflow phenomenon,’’ 206 Norepinephrine, 210 Nuchal rigidity, 318 Nucleus of the solitary tract, 45 Nystagmoid jerks, 71–72 Nystagmus, 71 Obstructive sleep apnea, 52–53 Obtundation, 6–7 Ocular bobbing, 69t, 71–72, 162 Ocular dipping, 69t, 71–72 Ocular dysmetria, 63 Ocular flutter, 63 Ocular motility, 193 Ocular motor examination abnormal movements, 68–72 description of, 63 eyelids, 64 motility, 64–68 Oculocephalic responses description of, 65, 66f–67f drugs that stimulate, 76 examination of, 319 in metabolic coma, 76–77 Oculogyric crises, 70 Oculomotor nerve anatomy of, 61 course of, 61, 97 impairment of, 70 medial temporal lobe and, 97, 100f posterior communicating artery and, 97, 99
Oculomotor nucleus description of, 61–62 lesion of, 70 Oculomotor system anatomy of, 61–63 central, 61–63 cortical descending inputs to, 62 peripheral, 60–61 Oligodendroglial cells, 198 Oligodendrogliomas, 140–141 Olivary pretectal nucleus, 111 Ondine’s curse, 52–53 Ophthalmoplegia, 63, 76 Opioids/opiates, 242t, 243, 316 Opportunistic infections, 230 Optic disk, 91 Orexin, 18, 20b–22b, 115 Orientation assessments, 185 Orthostatic hypotension, 46 Osmolality definition of, 251 expression of, 251, 253 Otitic hydrocephalus, 154 Outcomes. See also Prognosis factors that affect, 349 Glasgow Outcome Scale, 344, 344t mechanisms underlying, 364–365 nontraumatic coma, 347–355 396 Index
overview of, 342 studies of, 342–343, 347–351 Overdoses benzodiazepine, 316 description of, 241, 243 gastric lavage for, 326 management of, 326 opioid, 316 Oxygen deprivation, 182t Oxygenation brain deprivation of, 46 hyperbaric, 325 maintenance of, 311–313 skin color and, 46 Pancreatic encephalopathy, 231–232 Papilledema, 91–92 Paradoxical sleep, 22 Parainfectious encephalomyelitis, 266, 271–273 Paraldehyde, 249–250 Paramedian artery, 155t Paramedian midbrain reticular formation, 15 Paramedian pontine reticular formation, 60f, 62 Paramedian tegmental zone, 33 Paramedian thalamus injury, 375 Paratonic rigidity, 72 Parietal lobe tumor, 26–27 Paroxysmal hypothermia, 260 Penetrating head trauma, 159 Perfusion pressure. See Cerebral perfusion pressure Pericallosal artery, 95 Perimesencephalic hemorrhage, 145 Periodic alternating eye movements, 71 Periodic alternating gaze deviation, 69t, 71 Peripheral chemoreceptors, 188 Peripheral Horner’s syndrome, 58 Peripheral oculomotor system, 60–61 Perseveration, 185 Persistent vegetative state atypical behavioral features in, 365–366 brain metabolism areas in, 365–366 cortical responses, 366–372 definition of, 8 fluorodeoxyglucose-positron emission tomography evaluations, 365, 367f functional imaging of, 365–372 Phencyclidine, 242t, 248 Phenothiazines, 242t Phenytoin, 314 Physical examination. See Examination Physician’s professional obligations, 377 Pilocarpine, 56 Pineal mass lesions, 90 Pineal tumors, 129 Ping-pong gaze, 69t, 71 Pituitary adenomas, 127–128 Pituitary apoplexy, 127–128, 128f, 238f Pituitary failure, 237 Pituitary tumors, 127–128 Plateau waves, 93 Pontine abscess, 170f Pontine hemorrhage clinical findings of, 167t coma caused by, 167 description of, 138b, 150–151 origin of, 167 pupillary findings, 167 Pontine level dysfunction, 76 Pontine stage, of central transtentorial herniation, 108–109 Pontine tegmentum injuries to, pupillary responses secondary to, 59 rostral, destructive lesion of, 115 Postanoxic encephalopathy, delayed, 219 Postconcussion syndrome, 162 Posterior cerebral artery from basilar artery, 153 compression of, 102f description of, 96 Posterior choroidal artery, 96, 155t Posterior communicating artery, 97, 99 Posterior fossa cerebellar hemorrhage, 145–147 compressive lesions of, 90–91 epidural abscess in, 144 epidural hematomas in, 143–144 intraparenchymal mass lesions, 145–151 subarachnoid hemorrhage, 145 subdural empyema of, 144 subdural hematoma of, 144 Posterior leukoencephalopathy syndrome, 77 Posterior reversible leukoencephalopathy syndrome, 168–169, 169t, 215, 216f Posthyperventilation apnea, 49, 187 Postictal coma, 280–281 Postoperative delirium, 283 Postsynaptic potentials, 13b Posturing responses, 74 Potassium imbalances, 325–326 Pre-Bo¨tzinger complex, 48, 52 Prefrontal cutaneous reflexes, 72 Primary CNS lymphoma, 141 Prion infections and diseases, 266, 277–278 Proconvulsants, 247t Prognosis. See also Outcomes acute disseminated encephalomyelitis, 356 central nervous system infections, 356 in coma, 343–344 depressant drug poisoning, 357 etiology of injury and, 344 hepatic coma, 356–357 nontraumatic coma, 347–355 overview of, 342–343 stroke, 355 time-delimited, 377–379 traumatic brain injury. See Traumatic brain injury, prognostic and outcome factors Yüklə 9,02 Mb. Dostları ilə paylaş:
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