CLMD Stupor and Coma, Disorders of Equilibrium

Question 1

2 general causes of coma

Answer 1

Bilateral hemispheric dysfunction

Brainstem dysfunction (ARAS)

[could be both]

Question 2

State of altered consciousness characterized by attention deficit, orientation disturbed, and stimuli misinterpreted

Answer 2

Confusion

Question 3

State of altered consciousness characterized by disorientation, stimuli misinterpreted, visual hallucinations

Answer 3

Delirium

Question 4

State of altered consciousness characterized by mental blunting, increased sleep, arouses to mild stimuli (voice)

Answer 4

Obtundation

Question 5

State of altered consciousness characterized by arousal only to noxious stimuli and not environmental, only rudimentary awareness (e.g. purposful motor responses)

Answer 5

Stupor

Question 6

State of altered consciousness characterized by unarousable, unresponsive, unaware state

Answer 6

Coma

Question 7

Considerations for patient who presents with stupor/coma + HTN

Answer 7

Pheochromocytoma, drugs (amphetamine, cocaine, phencyclidine), increaced ICP, PRES

Question 8

Considerations for patient who presents with stupor/coma + hypotension

Answer 8

Addison’s, sepsis, drugs (beta blockers, Ca channel blocker, TCAs, Li, sedatives, organophosphates, opioids, methanol), progression to brain death

Question 9

Considerations for patient who presents with stupor/coma + hyperthermia

Answer 9

Infection, heat stroke, drugs (amphetamines, TCAs, cocaine, salicylates, neuroleptics), serotonin syndrome, central (pontine hemorrhage)

Question 10

Considerations for patient who presents with stupor/coma + hypothermia

Answer 10

Hypothyroid
Hypoglycemia
Exposure
Drugs (opioids, sedatives, barbiturates, phenothiazine, EtOH)

Question 11

Supratentorial causes of stupor and coma that affect unilateral hemisphere (mass effect)

Answer 11

Intracerebral hemorrhage
Large MCA infarct
Subdural hematoma
Epidural hematoma
Brain abscess
Neoplasm

Question 12

Supratentorial causes of stupor and coma that affect bilateral hemispheres

Answer 12

Subarachnoid hemorrhage
Multiple infarcts
Venous thrombosis
Cerebral edema
Acute hydrocephalus
Multiple metastases

Question 13

Subtentorial causes of stupor and coma

Answer 13

Pontine hemorrhage
Basilar a. occlusion
Central pontine myelinolysis
Cerebellar hemorrhage/infarct
Cerebellar/brainstem neoplasm
Cerebellar abscess

Question 14

Essential and nearly essential elements of neuro exam in stupor/coma pt

Answer 14

Essential:
Pupillary responses
Corneal reflex
EOMs
Cough/gag reflex
Motor responses
Respiratory pattern

Nearly essential:
Neck stiffness
Carotid auscultation
Funduscopic exam

Question 15

Anisocoria — which is the abnormal pupil?

Answer 15

If its large pupil, it should fail to constrict to light

If its small pupil, it should fail to dilate in dark

Question 16

3 P’s of pinpoint pupils

Answer 16

Pontine lesion
oPiates
Pilocarpine

Question 17

Damage to frontal gaze centers vs. pontine gaze centers

Answer 17

Frontal gaze center lesion —> deviate eyes to opposite side

Pontine gaze center lesion —> deviate eyes to same side

Question 18

Doll’s eyes maneuver tests which area of the brain?

Answer 18

Midpons — used to assess cranial nerves III, IV, and VI

Question 19

Cold water irrigation with intact brainstem causes….

Answer 19

Eyes to deviate to irrigated side if unilateral irrigation

Eyes to deviate downward if bilateral irrigation

[low brainstem lesion responses are not there]

Question 20

What does it mean for comatose pt to have decorticate, decerebrate or flaccid posturing?

Answer 20

Decorticate (arms flexed, legs extended) — hemispheric

Decerebrate (all extremities extended) - brainstem

Flaccid - pontomedullary or metabolic

Question 21

Hyperpnea regularly alternating with apnea

Answer 21

Cheynes-Stokes respiratory pattern - indicates bilateral hemisphere or diencephalon involvement

Question 22

Central neurogenic hyperventilation indicates damage where?

Answer 22

Midbrain

Question 23

Long inspiration followed by apnea (mid/low pons)

Answer 23

Apneustic breathing

Question 24

Ataxic, or completely irreglar breathing, indicates damage where?

Answer 24

Medullary respiratory center

Question 25

Effects of uncal transtentorial herniation

Answer 25

Compression of CN III (ipsilateral dilated pupil, poor EOM, ptosis), then contralateral brainstem (ipsilateral hemiparesis, then respiratory abnormalities, fixed pupils, and death

Question 26

Central transtentorial herniation

Answer 26

Early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest and death

Question 27

Signs/symptoms of diffuse/metabolic coma

Answer 27

Confusion and stupor commonly precede motor signs Motor signs usually symmetrical Pupillary reactions usually preserved Asterixis, myoclonus, tremor, seizures common Acid-base imbalance with hyepr or hypoventilation frequently seen Level of consciousness may fluctuate

Question 28

Definition of brain death

Answer 28

Irreversible Complete cessation of brain function (including respiration but not heartbeat) Persistence

Question 29

Management of comatose pt

Answer 29

ABCs first H and P EKG to monitor for arrhythmias Give glucose and thiamine Give antidote if necessary (narcan) Adjust body temp Control agitation Stop seizures if present Labs: venous blood, arterial blood, urine, LP if neck stiffness Diagnostic tests: noncontrast CT, LP, possibly MRI and EEG

Question 30

Importance of Romberg test

Answer 30

Tests proprioceptive ability (judges posture), not necessarily cerebellum

Question 31

Which nonvertiginous altered static/dynamic balance condition is associated with a Romberg sign?

Answer 31

Sensory disequilibrium: proprioceptive deficit, visual impairment, compensated vestibular disorders, worse in the dark Motor and cerebellar disequilibrium do not show Romberg sign

Question 32

Typical direction of nystagmus in peripheral vs. CNS pathology

Answer 32

Peripheral: horizontal/diagonal Central: can be vertical

Question 33

Clinical syndrome characterized by brief recurrent episodes of vertigo triggered by changes in head position with respect to gravity; thought due to debris floating in endolymph of any of the semicircular canals (posterior most commoN)

Answer 33

BPPV

Question 34

What in-office maneuver is typically used to diagnose BPPV?

Answer 34

Dix-Hallpike In posterior canal BPPV, nystagmus is provoked with affected ear down In anterior canal BPPV, nystagmus is provoked with affected ear up

Question 35

Treatment for BPPV

Answer 35

Vestibular suppressants (meclizine, scopolamine, valium) Antiemetics Anxiolytics Physical therapy and positional exercises often helpful

Question 36

Spontaneous attack of vertigo that does not involve hearing loss or tinnitus and resolves spontaneously; characterized by vertigo, nausea, and vomiting of acute onset, typically lasting up to 2 weeks and not characteristically positional

Answer 36

Vestibular neuronitis

Question 37

Conditions characterized by recurrent episodes of spontaneous vertigo, low frequency hearing loss, tinnitus, and aural fullness possibly d/t increase in volume of labyrinthine endolymph because of poor absorption (endolymphatic hydrops) Onset between 20-50 y/o, M:F 1:3

Answer 37

Menieres disease

Question 38

Drug-induced causes of equilibrium disorders

Answer 38

``` Alcohol Salicylates Antiepileptics (phenytoin, carbamazepine) Quinine compounds Abx (aminoglycosides) Diuretics Chemotherapeutics ```

Question 39

Obligatory features of friedrich’s ataxia

Answer 39

Onset before age 20 Gait ataxia Progression of ataxia to involve all 4 limbs Dysarthria Impaired position/vibratory sense in legs Muscle weakness Absent tendon reflexes in legs [secondary features: extensor plantar responses, pes cavus, scoliosis, cardiomyopathy, +/- optic atrophy, nystagmus]

Question 40

Progressive pancerebellar degeneration involving nystagmus, dysarthria, and gait, limb, and trunk ataxia which begins in infancy (<4 y/o) Characterized by progressive ataxia, oculocutaneous cutaneous findings, and immunologic deficiency

Answer 40

Ataxia-telangiectasia

Question 41

Vitamin deficiency associated with insidious onset, vague fatigue, gait and balance problems, distal sensory loss, babinski signs, romberg sign, +/- Lhermitte sign

Answer 41

Vit B12 Deficiency [note that nitric oxide can deplete vit B12 and lead to these symptoms]

Question 42

What deficiency might present very similarly to vit b12 def?

Answer 42

Copper deficiency

Question 43

What vitamin deficiency presents as spinocerebellar similar to friederich’s and is associated with peripheral neuropathy?

Answer 43

Vit E deficiency