A7. Classification of unconscious conditions

Question 1

Clear consciousness definition

Answer 1

The brain’s ability to react (arousal or
alertness) and the adequate use of contents of memory and to
think (awareness).
Allows the adaptation of the individual to the environment and is the basis of cognition.
Awareness depends on alertness.

Question 2

The anatomical basis of arousal is the

Answer 2

intact functioning of the
ascending reticular activating system (ARAS)

Question 3

ascending reticular activating system (ARAS)
is
composed of the

Answer 3

1. pontomesencephalic reticular formation,
2. monoaminergic networks of the diencephalon and
3. the intralaminar and medial nuclei of the thalamus

Question 4

Disorders of consciousness:

Answer 4

• Disorder of arousal
• Disorder of awareness

NOTE: Locked in syndrome - Not disorder of consciousness, but often misdiagnosed as this.

Question 5

Is locked in syndrome a disorder of consciousness?

Answer 5

Not disorder of consciousness, but often misdiagnosed as this.

Question 6

what are the characteristics of Disorders of arousal

Answer 6

• Reduced arousal
• sleep-like state
• won’t react to awakening stimuli.

Question 7

list Disorder of arousal

Answer 7

● Somnolence - Mildest form. Awakens with verbal stimuli, but is asleep without stimuli.
● Stupor - Patient may open eyes to painful stimuli, verbal is not enough. Slow and inappropriate reaction to stimuli.
● Coma - Cannot be awakened. Abnormal posture (decorticate or decerebrate).
i. Coma I - Preserved brainstem reflexes
ii. Coma II - Lost brainstem reflexes

Question 8

● Somnolence

Answer 8

Mildest form of Disorder of arousal.
Awakens with verbal stimuli, but is asleep without stimuli.

Disorders of consciousness:
A. Disorder of arousal

Question 9

Stupor

Answer 9

• Patient may open eyes to painful stimuli, verbal is not enough.
• Slow and inappropriate reaction to stimuli.

Disorders of consciousness:
A. Disorder of arousal

Question 10

Coma

Answer 10

• Cannot be awakened.
• Abnormal posture (decorticate or decerebrate).

i. Coma I - Preserved brainstem reflexes
ii. Coma II - Lost brainstem reflexes

Disorders of consciousness:
A. Disorder of arousal

Question 11

coma 1 VS coma 2

Answer 11

i. Coma I - Preserved brainstem reflexes
ii. Coma II - Lost brainstem reflexes

Disorders of consciousness:
A. Disorder of arousal

Question 12

characteristics of Disorder of awareness

Answer 12

• Inadequate thinking and behavior.
• Global CNS function is impaired.
• Arousal is normal, but content of memory is disturbed, inaccessible or used inappropriately
• Signs of focal cognitive deficit (e.g. alexia, acalculia) are NOT part of this.

Question 13

Signs of focal cognitive deficit (e.g. alexia, acalculia) - are they a part of disorder of awareness

Answer 13

• Signs of focal cognitive deficit (e.g. alexia, acalculia) are NOT part of this.

Question 14

Arousal is normal, but content of memory is disturbed, inaccessible or used inappropriately

Answer 14

disorder of awareness

Question 15

list Disorder of awareness

Answer 15

• Persistent vegetative state (decorticate state, apallic syndrome)
• Akinetic mutism
• Confusion
• Delirium

Question 16

Persistent vegetative state (decorticate state, apallic syndrome)- how is the brainstem

Answer 16

Rostral brainstem remains intact
→
* Thermoregulation (hypothalamus),
* sleep-wake cycle,
* endocrine system,
* cardiorespiratory and
* other visceral functions are intact.

Question 17

Persistent vegetative state is permenent if

Answer 17

Permanent when >30 days

Question 18

in Persistent vegetative state Patients seem to be

Answer 18

awake with open eyes and elicitable eye movement reflexes
(e.g. vestibulo-ocular reflex)

Question 19

Persistent vegetative state reaches decortication position after how many days

Answer 19

After days/week

Question 20

Persistent vegetative state shows signs of

Answer 20

Signs of
* corticospinal tract lesion (e.g. Babinski reflex)
* and primitive reflexes
(suction reflex, Bulldog reflex)
can be elicited

Question 21

a painful stimulus to a patient with Persistent vegetative leads to

Answer 21

• Increased decortication(lesion above RN)
  *Flexion of upper limb,
  *extension of lower limb
• may see autonomic response (sweating, tachycardia, hyperventilation)

Question 22

causes of Persistent vegetative state

Answer 22

• Extensive functional or structural impairment of cerebral cortex
  (e.g.
  *global cerebral ischemia, *hypoglycemia,
  *renal/hepatic failure,
  *post-convulsive state,
  *Wernicke’s encephalopathy,
  *final stages of cortical dementias)
• Extensive white matter damage (diffuse axonal injury after head trauma)
• Bilateral damage to the thalamus

Question 23

list Extensive functional or structural impairment of cerebral cortex which can cause Persistent vegetative state

Answer 23

• global cerebral ischemia
• hypoglycemia,
• renal/hepatic failure,
• post-convulsive state,
• Wernicke’s encephalopathy,
• final stages of cortical dementias)

Question 24

Akinetic mutism- how do they appear

Answer 24

Awake, but mute and does not move

Question 25

can Akinetic mutism be caused by aphasia?

Answer 25

Not caused by aphasia,
can see signs of comprehension

Question 26

how is paralysis excluded in Akinetic mutism

Answer 26

Paralysis is excluded by normal withdrawal reactions to painful stimuli.

Question 27

Akinetic mutism what signs are present

Answer 27

Usually frontal release signs are present:
sucking reflex,
bulldog reflex,
palmar grasp reflex

Question 28

Akinetic mutism is caused by

Answer 28

• bilateral interruption of connections between the supplementary motor area,
  cingular region
  and midline nuclei of the thalamus

Question 29

list causes of Akinetic mutism

Answer 29

○ Jet bleeding (rupture of anterior communicating artery aneurysm)
○ Frontobasal contusion
○ Bilateral ischemia in the anterior cerebral artery territory (Willis-circle variants)
○ Subfalcial herniation
○ Occlusive hydrocephalus
○ Butterfly tumors growing across the corpus callosum into the prefrontal lobes
○ Tumors of third ventricle

Question 30

Confusion def

Answer 30

Impaired thinking and attention.
Slow and vague.
Incoherent thinking.
No signs suggestive of delusions.
E.g. after epileptic seizure
(post-convulsive state or tenebrosity)

Question 31

Delirium def

Answer 31

• Disorder of attention and awareness (old definition: also disorder of
  perception. Can use this to differentiate from confusion).
• Cannot focus, change or fix attention.
• Disoriented and incoherent thinking.

Question 32

confusion vs delerium

Answer 32

delerium is a disorder of attention and awareness
(old definition: also disorder of perception.

Can use this to differentiate from confusion).

Question 33

Delirium- onset?how does it evolve

Answer 33

Evolves quickly (hours-24h)

Question 34

Delirium how are symptoms

Answer 34

Characteristic diurnal fluctuation of intensity, symptoms deteriorate at night or in an environment lacking stimuli.

Question 35

symptoms of delerium symptoms deteriorate at

Answer 35

• at night or
• in an environment lacking stimuli.

Question 36

in Delirium how is the sleep wake cycle

Answer 36

Typical inversion of sleep/wake cycle

Question 37

Delirium can have autonomic instability such as

Answer 37

Autonomic instability (excitatory):
* sweating,
* tachycardia,
* unstable BP

Question 38

Delirium may be a complication of

Answer 38

• right hemispheric lesions,
• metabolic disorders,
• drug or
  alcohol