Coma

Question 1

hospitalized 50 y/o w/ MCA stroke started on heparin after 3 days. 1 day later unresponsive, R pupil dilated & fixed, L hemiparesis. Dx & workup

Answer 1

Conversion to ICH (elevated ICP & Brainstem compression)

ICP: Hyperventilation, head elevation, IV mannitol/hypertonic saline
Emergent NCCT
Surgical decompression
Reverse heparin (protamine)

Question 2

45 y/o w/ HTN unresponsive, ataxic breathing, BP 220/110, HR 88, pupils pinpoint but reactive, no oculovestibular reflex. Body flaccid, reflexes 1+, flexor posturing. Dx?

Answer 2

Brainstem dysfunction (pontine hemorrhage)

Question 3

47 y/o unresponsive, found with EtOH, BP 150/100, HR 56, moves R side to noxious stim, trace reflexes on R, doll’s eyes bilaterally, Hoffman on L. DDx?

Answer 3

R frontoparietal SDH (2/2 fall and EtOH abuse)

Other bleeds w/ elevated ICP
Meningitis
Encephalitis
Intoxication

Question 4

50 y/o hospitalized woman w/ metastatic adenocarcinoma becomes unresponsive, eyes deviated to R, R facial droop, R sided hyperreflexia, R sided Babinski. Dx?

Answer 4

L Frontal Metastisis w/ Non-convulsive epilepsy