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396 Index

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

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

vascular disease, 355–356 vegetative state, 357–360

Progressive multifocal leukoencephalopathy, 266, 279, 280f

Propofol, 323 Propylene glycol, 250

Psychogenic seizures, 304–306 Psychogenic unresponsiveness

‘‘Amytal interview,’’ 298, 307–308, 327 catatonia, 299, 302–304, 303t characteristics of, 310t, 327 conversion reactions, 299–302 description of, 197

398 Index

Psychogenic unresponsiveness (continued) diagnostic approach to, 297–299 laboratory tests, 299

malingering, 299–300 management of, 327

psychiatric disorders that cause, 299 psychiatrist involvement for, 324 signs and symptoms of, 298t studies of, 298–299

Pull reflex, 72

Pulmonary disease, 230–231 Pulmonary embolism, 214 Pulmonary encephalopathy, 231 Pulmonary stretch receptors, 51 Pulse oximetry, 312

Pupil(s)

brain death-related findings, 333–334 examination of, 54–55

ipsilateral, 101, 122 reactions of, 319, 333

Pupillary dilation description of, 57

in uncal herniation syndrome, 101, 105–106 Pupillary fixation, 339

Pupillary light reflex description of, 54

metabolic encephalopathy effects, 59 retinal ganglion cells, 57

Pupillary responses abnormal, 58–59

central pathways of, 56–57 diencephalic injury effects on, 58 examination of, 54–55

in hypoxia, 59

in metabolic coma, 76, 193 midbrain injury effects on, 58–59 pathophysiology of, 55–56 seizure effects, 59

traumatic brain injury outcome and, 346 in uncal herniation syndrome, 101

Pupilloconstrictor muscle, 56 Pupilloconstrictor neurons, 56 Pupillodilator muscle, 55 Pupillomotor system, 56

Pure adrenal myeloneuropathy, 278

Quadrigeminal cistern, 96

Raeder’s paratrigeminal syndrome, 55, 58 Reactive hyperemia, 200

Reflex syncopal attacks, 213 Refractory nystagmus, 71

Relative afferent pupillary defect, 54 REM sleep

cholinergic influences on, 24 definition of, 22

description of, 16b monoaminergic influences on, 24 NREM sleep switched to, 24

Renal bicarbonate excretion, 231 Renal disease

description of, 227

dialysis disequilibrium syndrome, 229 uremic encephalopathy, 227–229

Renal failure, 228

Renal transplant, 229–230 Respiration

abnormalities of, 46t, 46–47

in brain death patients, 334–335

in central transtentorial herniation, 107 Cheyne-Stokes, 49–51, 50f, 75, 187 control pathways for, 48f

diabetic ketoacidosis effects on, 187 evaluation of, 319

functions of, 47–48 medullary control of, 49

in uncal herniation, 105f–106f Respiratory acidosis, 192, 192t Respiratory alkalosis, 189–191, 190t, 258 Respiratory rhythm, 48–49

Resting eye movements, 69 Retinal ganglion cells, 57 Reverse ocular bobbing, 69t, 71 Reverse ocular dipping, 69t Reye’s syndrome, 271

Rostrocaudal brainstem deterioration, 102 Roving eye movements, 70–71

Saccular aneurysms, 129, 136 Sagittal sinus thrombosis, 154

Salicylate intoxication/poisoning, 190, 250–251 Schilder’s disease, 278

Scotoma, 92

Sedatives, 76, 240–241, 243–245 Seesaw nystagmus, 71

Seizures

cessation of, 313–315 characteristics of, 280

epileptic, 213–214, 280, 304–306 postictal coma, 280–281 psychogenic, 304–306

pupillary responses affected by, 59 status epilepticus, 82, 281, 314f

Self-determination, 376 Sentinel headache, 129 Sepsis, 190

Serotonin, 209 Serotonin syndrome, 262

Sheehan’s syndrome, 237–238 Skeletal muscle tone, 320 Skew deviation, 70

Sleep

coma vs., 5, 25 definition of, 5

non-rapid eye movement, 16b–17b paradoxical, 22

REM, 16b, 22, 24 slow-wave, 16b

Sleep apnea. See also Apnea central, 52

obstructive, 52–53

pathologic breathing patterns vs., 75 Slow syndrome, 361b

Slow-wave sleep, 16b Sodium, 253

Sodium bicarbonate, 324, 326 Somatosensory evoked potentials

in anoxic-ischemic encephalopathy, 354t description of, 346

Spontaneous blinking, 64

Spontaneous eye movements, 69, 69t Status epilepticus, 82, 228, 281, 314f Stokes-Adams attacks, 44–45 Stroke, 355

Stroke volume, 45 Structural coma

diagnosis of, 9, 113–114

false localizing signs in, 113–114 metabolic coma vs., 89, 197–198

Stupor catatonic, 302 causes of, 4t definition of, 7

drug-induced causes of. See Drug intoxications Subacute dementia, 277

Subacute diencephalic angioencephalopathy, 275 Subacute meningitis, 133

Subacute sclerosing panencephalitis, 114 Subarachnoid hemorrhage

description of, 129–131, 139b grading system for, 356t outcomes after, 355–356 posterior fossa, 145

Subarachnoid infection, 131–135 Subarachnoid tumors, 131 Subdural empyema, 144 Subdural hematoma

description of, 123–126, 124t posterior fossa, 144

Subdural hygroma, 124 Subdural tumors, 127, 144 Subendocardial ischemia, 44 Subfalcine herniation, 103f Subtentorial lesions

diagnostic characteristics of, 310t list of, 4t

Sulfhemoglobin, 324 Sundowning, 183 Suprachiasmatic nucleus, 57

Supranuclear bulbar weakness, 113 Suprasellar tumors, 115 Supratentorial destructive lesions

causes of

acute disseminated encephalomyelitis, 157–158 carotid ischemic lesions, 152

distal basilar occlusion, 152–154 vascular, 152–156

vasculitis, 156, 156t

venous sinus thrombosis, 154, 156 viral encephalitis, 156–157, 157t

description of, 151–152 Supratentorial mass lesions

computed tomography evaluations, 321 diagnostic characteristics of, 310t historical view of, 97b

list of, 4t

management of, 320–323 tentorium cerebelli’s role in, 96

Surrogate decision making

in brain death situations, 378 description of, 376–377

in minimally conscious state situations, 379 time-delimited prognostication, 377–379 in vegetative state situations, 378–379

Sympathoexcitation, 44

Sympathoexcitatory system, 44 Syncope

causes of, 213t description of, 212

pulmonary embolism and, 214 Systemic lupus erythematosus, 274–275

Temporal lobe herniation, 97b Tendon reflexes, 320 Tentorium cerebelli

description of, 96 opening, 96–97

Thalamic infarction, 154 Thalamic relay neurons, 13b–14b Thalamus

arterial supply of, 155t

bilateral infarction of, in paramedian regions, 138b coma caused by injury to, 33

hemorrhage of, 137, 138b, 139 Thermoregulation disorders

description of, 259 fever, 260–261 heatstroke, 260–261

hyperthermia, 260–262, 315 hypothermia, 259–260, 315, 335 treatment of, 315

Thiamine, 223, 313 Thyroid disorders, 236–237 Thyrotoxicosis, 237

‘‘Tip of the basilar’’ syndrome, 32 Todd’s paralysis of gaze, 69 Tonsillar herniation, 102, 103f–104f

Toxic encephalopathy, 262, 266, 269–271 Toxoplasmosis, 141

Transient ischemic attacks, vertebrobasilar, 213 Transtentorial herniation

central

clinical findings of, 107–110 description of, 101–102

diencephalic stage of, 107–108, 108f–109f medullary stage of, 109

midbrain stage of, 107–108 pontine stage of, 108–109

description of, 99 evaluation of, 321 Traumatic brain injury

cerebral metabolism affected by, 374–375 closed head, 159–161

delayed encephalopathy after, 161–162 diagnosis of, 159

diffuse axonal injury, 161 in elderly, 345

hyperthermia associated with, 261 hypotension with, 346

hypoxia with, 346

late recovery after, 373 mortality rates for, 343 prevalence of, 344

prognostic and outcome factors age, 345–346

biochemical markers, 347 coma duration, 346

electrophysiologic measures, 346–347 Glasgow Coma Scale, 345, 345t motor findings, 345