Evaluation Of Coma Research Articles

Neuroimaging in Coma, Brain Death, and Related Conditions

Coma is a state of unresponsiveness to external stimuli, which can be secondary to a variety of CNS alterations affecting essential neuronal pathways, particularly the ascending reticular activating system. A comprehensive clinical evaluation is necessary for assessment of motor function and brainstem reflexes but is often insufficient for determination of the underlying etiology and extent of injury. Diagnostic brain imaging is typically needed for management and decision-making, particularly in acute settings where prompt diagnosis of reversible/treatable conditions is essential, as well as for prognostication. Understanding the pathophysiologic mechanisms leading to coma and comalike states and their imaging manifestations will enable selection of appropriate modalities and facilitate a clinically relevant interpretation. For evaluation of brain death, diagnostic imaging has a supportive role, and when indicated, selection of an ancillary diagnostic test is based on multiple factors, including susceptibility to confounding factors and specificity, in addition to safety, convenience, and availability.Learning objective: To describe the pathophysiology of alterations of consciousness and discuss the role of neuroimaging modalities in the evaluation of coma, brain death, and associated conditions

The Chinese Expert Consensus on Evaluation of Coma after Cardiopulmonary Resuscitation.

The Chinese Expert Consensus on Evaluation of Coma after Cardiopulmonary Resuscitation.

Diagnosis and evaluation of coma in the emergency department and ICU

Diagnosis and evaluation of coma in the emergency department and ICU

Rationality of Administered Gentamicin Dose in Cerebral Coma Patients Treated in an Intensive Care Unit

Gentamicin is still widely used in the treatment of patients in an intensive care unit (ICU). The efficacy of aminoglycosides correlates with the peak serum concentration (Cmax), and the toxicity with the minimum serum concentration (Cmin). The aim of this study was to determine Cmax and Cmin in serum of cerebral coma ICU patients when a dosage of gentamicin of 5 mg/kg body weight was administered once daily; to evaluate the rationality of mentioned dose; and to identify factors associated with these concentrations. Material and METHODS. A total of 24 ICU patients suffering from cerebral coma were included into this analysis. A dosage of gentamicin of 5 mg/kg body weight was administered once a day. Gentamicin concentrations were tested twice after the first dose infusion (immediately and 5 hours after 1-hour infusion). Cmax, Cmin, volume of distribution (Vd), and elimination half-life (T1/2) were obtained. RESULTS. The mean Cmax was 17.96 (SD, 4.31) µg/mL (range, 10.30-27.87 µg/mL). The desirable Cmax (≥ 20 µg/mL) was reached only in 6 patients (25%). Cmin was calculated using a special pharmacokinetic program "Kinetica." Cmin of 0.5 µg/mL was not exceeded in any patient. A correlative analysis indicated a significant inverse direct correlation between Cmax and Vd and between Cmax and treatment duration in the ICU. An inverse correlation was observed between Cmin and T1/2, evaluation of coma according to the Glasgow coma scale, and creatinine clearance. CONCLUSIONS. A dosage of 5 mg/kg body weight once a day was not sufficient in cerebral coma ICU patients. This dose was not associated with the nephrotoxic effect of gentamicin (additional risk factors were absent). It is recommended to obtain gentamicin concentration at two time points following administration of the first dose (e.g., immediately after 1-hour infusion and 5 hours later), and using a special pharmacokinetic software, to calculate a necessary dose and interval of administration.

Evaluation of Coma: A Critical Appraisal of Popular Scoring Systems

Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.

Clinical management and functional neuromonitoring in traumatic brain injury in children

Traumatic brain injury is the main cause of childhood disability and death. In this review, we highlight recent original findings and emerging themes from published literature on children with serious traumatic brain injury. We focus this review on lessons learned from our recent randomized clinical trial of hypothermia therapy in severe traumatic brain injury in children and on bedside neuromonitoring. We propose that integrating the measurement of biomarkers into clinical care as surrogate endpoints and as potential prognostic markers would allow us to evaluate earlier the effect of injury and clinical care in children after traumatic brain injury. Several methods are now more readily available to monitor cerebral physiology in children. These methods include indices evaluating the integrity of cerebral autoregulation, such as the pressure reactivity index derived from values obtained from intracranial pressure measurements, flow velocity measurements from transcranial Doppler ultrasonography or from cerebral oximetry. Other methods allow the evaluation of coma with the nonlinear analysis of electroencephalography or the evaluation of cerebral metabolism and cell death pathways with biomarkers from serum, cerebral spinal fluid, and cerebral microdialysis. We suggest expanding clinical functional neuromonitoring to help clinicians understand the burden of exposure to physiological variables and response to therapies during intensive care in order to enhance the management of critically ill children with traumatic brain injury.

EVALUATION AND PROGNOSIS OF COMA

ABSTRACT Evaluation of coma in the intensive care unit can be a very common and complicated consultation for the neurologist. Unlike other consultations, the neurologist often is asked to counsel the family in addition to providing an opinion on the prognosis of the patient. As an aid to this difficult challenge, this chapter will discuss the definition of coma, two approaches to the evaluation of coma, and strategies to determine the prognosis of a patient with coma. In addition, the chapter will discuss recent research in the nature of the vegetative state, which is one of the major outcomes of coma. Ultimately, the decisions that are made by families with their physicians about withdrawing or continuing life-preserving care for patients rest in the understanding of the likely prognosis of the patient. Well-informed discussions are becoming increasingly difficult as our understanding of cognitive function in coma and vegetative state evolves.

Search for clinical and neurophysiological prognostic patterns of brain coma outcomes in children

The aim of the study was to evaluate the possible predictive values of clinical examinations combined with the recordings of electroencephalography and brainstem auditory-evoked potentials in traumatic coma of pediatric patients. A total of 43 children in coma with severe acute head trauma were included in the study. They were investigated and treated in pediatric intensive care unit using standard evaluation and treatment protocol. Evaluation of coma was performed using Glasgow Coma Scale. Electroencephalography for 35 patients and brainstem auditory-evoked potentials for 24 patients were recorded. Glasgow coma scale statistic pool median was equal to 4 points as measured in presence of brain edema, meanwhile it was 6 as measured in absence of edema. In case of supratentorial damage, median duration of consciousness recovery was 10 days. In absence of above-mentioned supratentorial damage, recovery of the consciousness was earlier - median was 5 days. Determined duration of artificial lung ventilation was statistically significantly shorter for those who had edema (P=0.048). In 20 patients (57% of all cases), constant or alternating slow wave activity was observed during the first electroencephalographic recording. In other cases, "alpha coma" or low amplitude of arrhythmic activity and local slowing activity corresponding to brain damage seen on computerized tomography were recorded. For 24 patients, brainstem auditory-evoked potentials were recorded. In 9 cases, they were abnormal; in these cases, the consciousness of the patients recovered after 44 days or did not recover. Glasgow coma scale results alone may have limited prognostic value in absence of other objective neurophysiologic investigation data concerning the coma outcome in children. Prognosis may be worse if pathological brainstem auditory-evoked potentials correlate with pathological dynamic changes in electroencephalography and brain lesions, diagnosed during computerized tomography scan.

Computed Tomography Findings in Thiamine Deficiency-Induced Coma

Although brain magnetic resonance imaging is a more sensitive diagnostic tool in the evaluation of coma, noncontrast head computed tomography (CT) may demonstrate highly specific findings in some cases of coma. We present a case of thiamine deficiency-induced coma associated with acute necrosis of fornices documented on CT and review cardinal neuroimaging features of Wernicke encephalopathy. Acute fornices necrosis is a novel finding on head CT suggestive of thiamine deficiency.

Neurology for the Non-Neurologist, 5th ed.

Back to table of contents Previous article Next article Book Forum: Neurology and NeuropsychiatryFull AccessNeurology for the Non-Neurologist, 5th ed.FRANCINE M. BENES, M.D., Ph.D., FRANCINE M. BENESSearch for more papers by this author, M.D., Ph.D., Belmont, Mass.Published Online:1 Jul 2005https://doi.org/10.1176/appi.ajp.162.7.1394-aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This multiauthored book provides a practical overview of clinical neurology for physicians who work in other areas of medicine. It begins with a concise and well-focused discussion of the basic neurological examination, beginning with the cranial nerves and peripheral nervous system and moving systematically through basic diagnostic tests and the evaluation of coma. Each chapter is individually authored and covers a broad variety of neurological problems, including cerebrovascular disease, headache, epilepsy, multiple sclerosis, Parkinson’s disease, alcoholism, peripheral neuropathy, the dementias, traumatic brain injury, neuromuscular disorders, and neurological manifestations of cancer. There is also an entire chapter devoted to neurological complications of pregnancy. These topics are all dealt with in a straightforward way that is suitable for the average psychiatrist. NeuroAIDS and other conditions with relevance to psychiatry, such as low back pain and insomnia, are also dealt with in a clear and practical way.Most chapters provide a description of the correct ways to perform a neurological examination and enumerate the forms of treatment that are available for different neurological disorders. In the chapter on “eye signs,” detailed diagrams showing visual pathways are provided and visual field defects are depicted in simple diagrams. The final chapter includes a discussion of medical-legal issues involved in the care of patients with neurological disorders as well as a discussion of the problems associated with obtaining informed consent from patients who are not legally competent. This chapter also contains a fairly extensive discussion of brain death, including the use of electroencephalography and cerebral blood flow as part of the evaluation. For the psychiatrist who is seeking to learn more about behavioral neurology, there is a description of the Papez circuit and a fairly comprehensive discussion of temporal lobe epilepsy. Beyond this, however, there is very little information regarding psychiatric manifestations of neurological disorders. For those who treat the geriatric population, where behavioral manifestations of delirium and dementia are common, this book is probably not an appropriate resource. Overall, however, Neurology for the Non-Neurologist provides a well-illustrated and clearly written overview of basic clinical neurology.By William Weiner and Christopher Goetz. Philadelphia, Lippincott Williams & Wilkins, 2004, 528 pp., $59.95 (paper). FiguresReferencesCited byDetailsCited ByNone Volume 162Issue 7 July 2005Pages 1394-a-1395 Metrics PDF download History Published online 1 July 2005 Published in print 1 July 2005

Considerations on Neuroradiological Evaluation of Coma

Considerations on Neuroradiological Evaluation of Coma

A CASE REPORT OF NEUROLEPTIC MALIGNANT SYNDROME FOLLOWING AN OPERATION FOR ACUTE APPENDICITIS

A 41-year-old man with mental retardation, deaf and dumb underwent appendectomy under spinal anesthesia for gangrenous appendictis with ileocecal abscess at elsewhere. On the 4th postoperative day, intractable high fever, coma, fasciculation and rigidity on the extrimities developed and rapidly progressed. The patient was transferred to the hospital. We suspected an intraabdominal remnant abscess, but exploratory laparotomy under general anesthesia revealed no evidence of remnant abscess. A lumber puncture also yielded no abnormal findings of cerebrospinal fluid. He died of sudden cardiac arrest on the next day after the second operation. It was found postoperatively that he had been treated with neuroleptic drugs for a long period at slightly manic state, and he was diagnosed as neuroleptic malignant syndrome according to his clinical course and its diagnostic criteria. In this case we failed to make the correct diagnosis preoperatively, because postoperative high fever was considered due to remnant abscess; we had difficulty in evaluation of coma and abdominal symptoms for his mental retardation, deaf and dumb; and we did not confirm his former treatment with neuroleptic drugs (and he had not been diagnosed as psychosis).

Evaluation of coma and vegetative states.

The Coma/Near-Coma (CNC) scale was designed to measure small clinical changes in patients with severe traumatic and nontraumatic brain injuries who were functioning at very low levels characteristic of near-vegetative and vegetative states. In 20 patients followed for 16 weeks the scale identified 25% who ultimately showed modest improvement. Interrater reliability was high (r = .95); validity was supported by significant correlations between CNC- and brain-multimodality evoked potential abnormality scores as well as between scores on the CNC and the Disability Rating Scale. The CNC scale was easily learned and it could be completed quickly and cost effectively. Staff found it useful in recognizing among relatively homogeneous low-level patients those most likely to respond to further rehabilitation care. The CNC appears to be useful for justifying ongoing intensive rehabilitation and for preventing premature transfer to lower levels of care.

Transient Unresponsiveness in the Elderly

Five hospitalized elderly patients had one or more self-limited episodes of unresponsiveness that could not be explained by metabolic, structural, convulsive, or psychiatric disorders. They accounted for approximately 2% of cases referred to us for evaluation of coma. Despite some heterogeneity, shared clinical features in these patients suggest an age-related disorder of arousal that may be more common than is generally appreciated.