Файл: PLUM AND POSNER S DIAGNOSIS OF STUPOR AND COM-1.pdf

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Index

393

Hematoma

Hyperarousal, 183–184

 

epidural, 121–123, 143–144

Hyperbaric oxygenation, 325

 

subdural

Hypercalcemia, 256–257

 

description of, 123–126, 124t

Hypercarbia, 230

 

posterior fossa, 144

Hyperglycemia, 203, 222–223, 234, 313

 

Hemiparesis, 101, 106

Hyperglycemic hyperosmolar coma, 256

 

Hemodialysis, for uremia, 229

Hyperkinetic movement disorders, 28

 

Hemorrhage

Hypermagnesemia, 258

 

brainstem, 166–168

Hypernatremia, 255–256

 

cerebellar. See Cerebellar hemorrhage

Hypernatremic encephalopathy, 256

 

intraventricular, 137

Hyperosmolality, 232

 

lobar, 136, 136f

Hyperosmolar agents, 321–322

 

midbrain, 166t, 167

Hyperosmolar states, 255–256

 

perimesencephalic, 145

Hyperphosphatemia, 258

 

pontine

Hypersomnia, 8

 

clinical findings of, 167t

Hyperthermia, 260–262, 315

 

coma caused by, 167

Hyperthyroidism, 237

 

description of, 138b, 150–151

Hyperventilation

 

origin of, 167

acid-base imbalances with

 

pupillary findings, 167

metabolic acidosis, 188–189

 

subarachnoid

respiratory alkalosis, 189–191, 190t

 

description of, 129–131, 139b

in comatose patients, 51

 

grading system for, 356t

in hepatic encephalopathy, 224

 

outcomes after, 355–356

intracranial pressure reduced with, 321

 

posterior fossa, 145

sepsis and, 190

 

thalamic, 137, 138b, 139

Hypocalcemia, 257–258

 

into tumors, 140

Hypocretin, 21b, 115. See also Orexin

 

Hepatic coma

Hypoglycemia, 203–205, 234, 313

 

description of, 190, 225

Hypomagnesemia, 258

 

prognosis for, 356–357

Hyponatremia, 228–229, 237, 252f, 253–255

 

Hepatic encephalopathy

Hyponatremic encephalopathy, 254t

 

diagnosis of, 225

Hypo-osmolar states, 253–255

 

hyperventilation associated with, 224

Hypophosphatemia, 258

 

mild, 227

Hypothalamic ischemic lesions, 33

 

onset of, 224

Hypothermia, 259–260, 315, 335

 

pathology of, 224

Hypothyroidism, 236–237

 

pupillary findings in, 225

Hypoventilation, 191–192, 230

 

Herniation syndromes

Hypoxia

 

central transtentorial herniation, 101–102, 107–110

acute, 211–214

 

corticosteroids for, 322

airway obstruction and, 211

 

falcine herniation, 100

anemic, 211

 

historical view of, 97b

anoxic-ischemic brain damage caused by, 208

 

intracranial compartments, 95–100

carbon dioxide narcosis and, 231

 

lateral displacement of the diencephalon, 97b, 100

causes of, 210–211

 

Monroe-Kellie doctrine, 95

cerebral malaria and, 217

 

rostrocaudal brainstem deterioration, 102

cerebral venous, 211

 

tonsillar, 102, 103f–104f

delayed postanoxic encephalopathy

 

uncal. See Uncal herniation

after, 219

 

upward brainstem herniation, 102–103

disseminated intravascular coagulation

 

Heroin, 243

and, 217

 

Herpes simplex encephalitis, 157, 157t, 267–269, 315

fat embolism and, 217

 

Herpes zoster, 275–276

histotoxic, 211

 

Herring-Breuer reflex, 49

hypoxic, 211

 

Hiccupping, 53

intermittent, 215–219

 

Hippocampus

ischemic, 211

 

bilateral, 31–32

multifocal cerebral ischemia and, 215–216

 

CA1 region of, 30

pupillary responses in, 59

 

Histamine, 209–210

sequelae of, 219–220

 

Histidine decarboxylase, 18, 209

sustained, 215–219

 

History-taking, 39–40, 317–318

traumatic brain injury and, 346

 

Histotoxic hypoxia, 211

Hypoxic inducible factor, 212

 

Horner’s syndrome

Hypoxic-ischemic attacks, 212

 

central, 57–58

Hypoxic-ischemic encephalopathy,

 

clinical features of, 55

352–354

 

peripheral, 58

Hysteresis, 50–51

 

394

Index

 

Immunosuppression, 229–230

Laboratory tests

Infarction

 

blood tests, 77

brainstem, 165t

computed tomography. See Computed tomography

cerebellar, 139b, 148–149, 324

computed tomography angiography, 78

cerebral artery, 153f

electroencephalography, 82–83

thalamic, 154

evoked potentials, 82–83

Wallenberg’s lateral medullary, 59

lumbar puncture. See Lumbar puncture

Infection

 

magnetic resonance angiography, 79, 336

central nervous system. See Central nervous

magnetic resonance imaging. See Magnetic

system infections

resonance imaging

opportunistic, 230

magnetic resonance spectroscopy, 79–80

prion, 266, 277–278

neurosonography, 80

subarachnoid, 131–135

urine tests, 77

treatment of, 315

Lactate, 80, 203

Infratentorial inflammatory disorders, 169–170

Lactic acidosis, 233, 250

Infratentorial lesions

Lateral displacement of the diencephalon, 97b, 100

compressive, 142–143

Lateral rectus muscle, 60–61

destructive, 162–163

Lateral sinus thrombosis, 92, 154

mass, 323–324

Lazarus sign, 334

Infratentorial tumors, 170

Leptomeningeal tumors, 131

Insulin, 202

Leptomeningitis, 262–265

Intensive care unit delirium, 283–284

Level of consciousness

Intention myoclonus, 220

determination of, 5, 9

Intermittent hypoxia, 215–219

evaluation of, 40, 42

Internuclear ophthalmoplegia, 63, 76

reduced, 5

Interstitial nucleus of Cajal, 62

Libman-Sachs endocarditis, 274

Intoxication. See also Drug intoxications

Lipid peak, 80

drugs of abuse, 248

Listeria meningitis, 132

ethanol, 246, 248

Listeria monocytogenes, 116, 170, 263, 315

methanol, 249

Lithium, 242t, 245–246

paraldehyde, 249–250

Liver failure

Intracerebral hemorrhage

acute, 224

computed tomography of, 136f

chronic, 224

lobar hemorrhage, 136, 136f

Lobar hemorrhage, 136, 136f

pathophysiology of, 135–136, 139–140

Locked-in syndrome/state, 7, 363–364, 380

treatment of, 137

Locus coeruleus, 15

Intracerebral tumors, 140–141

Loss of consciousness

Intracranial compartments, 95–100

from cerebral blood flow reductions, 201

Intracranial hypertension, 321, 323

in concussion, 161

Intracranial pressure, increased

fractional, 5, 27

abducens palsy caused by, 113

Lower motor neuron palsy, 113

cerebral arterial supply impairment

Lumbar puncture

secondary to, 92

description of, 80–82

compensatory mechanisms of brain to, 92–93

safety of, 112–113

headaches caused by, 92

in subdural hematoma patient, 126

hyperventilation for, 321

 

papilledema caused by, 91–92

Magnetic resonance angiography, 79, 336

paroxysmal symptoms caused by, 93t

Magnetic resonance imaging

patient positioning, 312

description of, 78–79

reduction of, 321

fat embolism evaluations, 217–218

Intraventricular hemorrhage, 137

hepatic encephalopathy evaluations, 225, 226f

Intubation, 311–312

herpes simplex encephalitis findings, 158f

Ischemia

 

Marchiafava-Bignami disease evaluations, 278

focal, 207–208

meningeal tumors, 132f

global, 206–207

meningioma evaluation, 127

vertebrobasilar, 213

meningitis evaluation, 135t, 264f

Ischemic anoxia, 212

minimally conscious state findings, 370f

Ischemic hypoxia, 211

progressive multifocal leukoencephalopathy

Ischemic lesions, carotid, 152

evaluations, 280f

 

 

subarachnoid hemorrhage findings, 130

Kernig sign, 133, 263

subdural hematoma evaluations, 125

Kernohan’s notch, 101

Magnetic resonance spectroscopy, 79–80

Ketamine, 248

Malaria, cerebral, 217

Ketone bodies, 202

Malignant hyperthermia, 262

Kussmaul breathing, 75–76

Malingering, 299–300

 

Index

395

Mannitol, 322

Metabolic alkalosis, 191t, 191–192, 231, 258

 

Marchiafava-Bignami disease, 278

Metabolic coma

 

MDMA, 242t, 248

causes of, 210

 

Mean arterial pressure, 313

characteristics of, 324

 

Medial longitudinal fasciculus

diagnosis of, 324

 

anatomy of, 60f

hypoglycemia and, 220–222

 

lesions of, 63, 70

laboratory tests, 321t

 

Median raphe nuclei, 15

neurotransmitter changes in

 

Mediodorsal thalamic nucleus, 28

acetylcholine, 208–209

 

Medulla, respiratory control by, 49

dopamine, 209

 

Memory, 185–186

gamma-aminobutyric acid, 209

 

Meningeal neoplasms, 131

glutamate, 210–211

 

Meningiomas, 127, 144

histamine, 209–210

 

Meningismus, 40

norepinephrine, 210

 

Meningitis

serotonin, 209

 

aseptic, 134t

ocular motor responses in, 76–77

 

aspergillus, 133

oculocephalic responses in, 76–77

 

bacterial

pupillary responses in, 76, 192–193

 

acute, 132–133, 133t, 263

respiratory responses in, 75–76

 

algorithm for, 316f

structural coma vs., 89, 197–198

 

chronic, 133, 265–266

Metabolic encephalopathy

 

corticosteroids for, 322

arousal abnormalities in, 183

 

regimen for, 325

asterixis in, 195–197

 

treatment of, 316f, 322, 325

cerebral symptoms of, 186

 

cephalosporins for, 134

delirium associated with, 181, 183

 

cerebrospinal fluid findings in, 134, 134t

hypoglycemia and, 221

 

in children, 133, 263

management of, 324–326

 

chronic, 133, 265–266

memory loss in, 185–186

 

community-acquired, 132–133, 133t, 263

mental status in

 

computed tomography of, 133–134, 135t

affect, 186

 

corticosteroids for, 134, 322

arousal, 183–184

 

description of, 80–81

attention, 185

 

in elderly, 133, 263

cognition, 185

 

imaging of, 135t

Confusion Assessment Method for the Intensive Care

laboratory tests, 133–134

Unit, 184t

 

Listeria, 132

description of, 183–184

 

magnetic resonance imaging of, 135t

memory, 185–186

 

nuchal rigidity associated with, 133

orientation, 185

 

pathogens associated with, 132

pathogenesis of changes, 186

 

pathophysiology of, 131–132

perception, 186

 

signs and symptoms of, 131

mixed, 281–282

 

subacute, 133

motor activity abnormalities in, 194–197

 

treatment of, 134

multifocal myoclonus in, 197

 

tuberculous, 265

ocular motility in, 193

 

viral, 132

pupillary findings, 192–193

 

Mental status assessments

pupillary light reflex during, 59

 

affect, 186

respiratory changes in

 

arousal, 183–184

description of, 187

 

attention, 185

evaluation of, 187–188

 

cognition, 185

hyperventilation. See Hyperventilation

 

Confusion Assessment Method for the Intensive

hypoventilation, 191–192

 

Care Unit, 184t

neurologic, 187–188

 

description of, 183–184

signs of, 181

 

memory, 185–186

tremor of, 195

 

orientation, 185

Metabolic unresponsiveness, 197

 

pathogenesis of changes, 186

Metachromatic leukodystrophy, 114

 

perception, 186

Metastatic tumors, 141

 

Meropenem, 134

Methanol intoxication, 249

 

Mesopontine afferents, 14

Methaqualone, 242t

 

Mesopontine tegmentum, 14, 19

Methemoglobin, 324

 

Metabolic acidosis

Midazolam, 323

 

description of, 258

Midbrain

 

diagnosis of, 324

destructive lesions of, 115

 

drugs that cause, 248–251

dorsal, compression, 90, 110–112

 

hyperventilation and, 188–189, 228

Midbrain hemorrhage, 166t, 167

 

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

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