[Disorders of consciousness in neurological practice].
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Brain Death↗
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Clinical trial of piracetam in disorders of consciousness due to head injury.
The authors first remind some toxicological and some pharmacological properties of piracetam (Nootropil), then present the results of a test giving evidence of the presence of this drug in the cerebrospinal fluid after intravenous administration to man. In a double blind study, the activity of piracetam is tested on 31 patients suffering from coma after head injury. Only 27 patients without intracranial space occupying lesions are taken into account. Methods and results are described. Piracetam, although showing no activity on mortality, improves the level of consciousness.
Adult↗
[Disorders of consciousness in trauma patients].
238 patients with multiple trauma hospitalized in the Intensive Care Unit of the Zagreb General Hospital during 1993 and 1994 were analyzed. They were grouped with respect to the type of their injury. The first group was composed of patients with isolated head injury. The second group was made up of patients with multiple trauma and head injury. Patients with multiple trauma but without head injury were inserted into group three. 138 patients were comatose (GCS < 8) and had to be reanimated. 143 patients underwent an urgent surgical procedure. Assisted ventilation over 24 hours needed 180 patients (average of 11,4 days). The most common complications were respiratory: pneumonia developed 60 and ARDS five patients. The rate of mortality was 35,9% (65 patients died.
Coma↗
[Brain stem insufficiency in acute ischemia and cerebral hemorrhage].
Consciousness disorders are closely related to the general dysfunction of the brain stem, and called by some authors brain stem insufficiency. To evaluate the degree of brain stem dysfunction, an original scale has been elaborated. Each group of brain stem functions are scored. Consciousness being the most important symptom of the brain stem insufficiency is scored about 50% in a 63-score scale. Scores are used to achieve the most objectivity in the clinical monitoring of the brain stem insufficiency. Its utility was examined in 75 patients with either ischemia or cerebral hemorrhage. Patients of both groups with severe insufficiency below 33 scores and persisting over 24 hours had no chance to survive. The authors suggest that the scores may successfully be used in the clinical monitoring of all disorders producing consciousness disturbances. Survival of patients with brain stem insufficiency in the course of cerebral ischemia or hemorrhage depends on the degree and duration of the brain stem insufficiency.
Acute Disease↗
Down and drowsy? Do apathetic nursing home residents experience low quality of life?
This cross-sectional study investigated the relationship between apathy and quality of life (QOL) in nursing home residents (n = 227). In all, 92 residents could be assessed with the Mini Mental State Examination (MMSE), the Geriatric Depression Scale (GDS) and the Philadelphia Geriatric Centre Morale Scale (PGCMS), and were able to answer a question about overall subjective QOL. Apathetic behaviour and consciousness disorders were measured with the Behaviour Rating Scale for Psychogeriatric Inpatients (GIP). Linear regression analysis was first applied to study the association of cognition, depression and consciousness with apathy. It was then used to study the relationship between apathy and QOL, controlling for the constructs that were associated with apathy. The relationship between apathy and QOL appeared to vary with the cognitive functioning of the residents: In residents with a low level of cognitive functioning, apathetic behaviour was associated with high QOL; in residents with a higher level of cognitive functioning, apathetic behaviour was associated with low QOL. The necessity and nature of interventions aimed at stimulating apathetic residents may depend on the level of cognitive functioning of the residents. Further research is needed to determine if and when apathy interventions are appropriate.
Affect↗
[Prognostic significance of initial loss of consciousness in cerebrovascular disorders].
An initial loss of consciousness is of grave prognostic significance in patients with acute ischaemic cerebrovascular disorders, both as regards the early course as well as the long-term prognosis. The aim of this study was to assess the prognostic importance of an initial loss of consciousness in patients who had survived the acute stage. Thus, 133 out of 139 patients suffering from ischaemic cerebrovascular disorders who survived the first 3 weeks after a stroke were clinically re-examined after a mean follow-up period of more than two years. The other 6 patients had died as a result of a second stroke in the post-acute period. Patients with an initial loss of consciousness suffered cerebrovascular disturbances or fatal strokes in the follow-up period slightly more frequently than patients without an initial loss of consciousness. However, there were no convincing differences between the two groups. Indeed, on follow up, patients with an initial loss of consciousness were slightly less socially disabled than patients without an initial loss of consciousness. The results suggest that an initial loss of consciousness is no longer a factor of prognostic importance in patients who have survived the initial stage.
Brain Ischemia↗
[Hypercalcemia complicated with status nervosus in an elderly patient on hemodialysis during parental nutrition].
An 89-year-old male patient on hemodialysis presented clouding of consciousness caused by hypoglycemia during taking an anti-diabetic agent. His somnolent state continued in spite of glucose dispensation, and parental nutrition was started by a nasogastric tube because he couldn't have peroral ingestion. Though his blood glucose level recovered normal, his consciousness disorder was suspended, and he showed remarkable hypercalcemia. He was dosed with elcatonin, and the parental nutrient was changed to the other one that contained less vitamin D and calcium, and so his serum calcium level diminished slowly but he showed drowsiness about a month long. After resumption of peroral ingestion, his consciousness restored to the former condition rapidly. This case suggests that careful observation is needed in less active dialysis patients with parental nutrition because nutrient-contained vitamin D and calcium, which doesn't harm patients without renal insufficiency, may cause hypercalcemia.
Aged↗
[Hospitalization in the elderly patient: a risk or benefit?].
The aim of this work was to study the impact of hospital admission on functional status of elders. Eighty six patients (63 male) aged 73 +/- 4 years old admitted to the Internal Medicine Service of a public hospital were studied. Functional status was measured on admission, discharge and 15 days after discharge using the Northwestern Functional Status Review Instrument. Fifteen patients died during hospital stay. Functional status improved in patients admitted with disordered consciousness, in those admitted due to neurologic disorders, in those with less than two chronic diseases, in those whose disease cured during hospitalization and those that did not acquire new disease during admission. Prolonged hospitalizations of more than 13 days were associated with functional status worsening. It is concluded that functional status or elders does not always deteriorate during hospital admissions.
Aged↗
[Agenesis of the corpus callosum].
This paper presents a case of a sixteen-year-old female patient with agenesis of corpus callosum which was accidentally discovered during etiological investigation of the consciousness disorder. Agenesis of corpus callosum, a rare congenital defect, might be associated with macrocephalia and various degrees of mental impairment, optic defects, and seizures. Apart from patients with these pathologic states, there are individuals with agenesis of corpus callosum, but without any clinical disturbances.
Adolescent↗
[Manifestation of primary biliary cirrhosis and Basedow's disease caused by exposure to carbon monoxide in a patient with HTLV-1 associated myelopathy].
A 55-year-old woman with HTLV-1 associated myelopathy (HAM) was discovered in a rentan kotatsu (Japanese foot warmer with a frame and a coverlet by burning briquet) with conscious disorder and admitted to an emergency hospital. Her conscious disturbance waned the 3rd day after admission with gradual improvement of communication and food intake. However, on the 18th day after admission, her orientation was poor again and she was unable to take food for herself and keep sitting. She was diagnosed as suffering from an interval form of acute carbon monoxide (CMO) poisoning and transferred to our hospital for the purpose of hyperbaric oxygen therapy on the 20th day after exposure to CMO. In the course of treatment she recovered but showed jaundice, pruritus, liver dysfunction and elevation of antimitochondrial antibody. She received liver biopsy and was found to have primary biliary cirrhosis (PBC). On the 150th day, she manifested perspiration and hypertension. The clinical and immunological feature revealed her Basedow's disease. The relationship between HAM and PBC due to the autoimmune process has been predicted by investigators. The implication of autoimmune disease and HLA haplotype is a main focus of attention. Our case supports their hypothesis, and suggested that the complication occurred with immunological and genetic correlation. Anti-HTLV-1 antibody was positive at a titer of 1:8192 before exposure to CMO. On transferring to us, it was negative and revealed excessive positive at a titer of 1:20,480 on the 80th day. Immunoglobulin analysis was normal on admission and increased during hospitalization. It was reported that prenatal exposure to relatively mild concentrations of CMO in rats reduces splenic macrophage phagocytosis and killing ability as well as macrophage respiratory burst. These data suggested that PBC and Basedow's disease were manifested by exposure to carbon monoxide.
Acute Disease↗
[The age-related factor in the pathology of consciousness in craniocerebral trauma].
In children (n = 103), elderly and old persons (n = 42), abnormal consciousness was comparatively studied in the acute period of brain injury. The revealed clinical features were compared with the previously described syndromes of consciousness disorders in young and middle-aged patients. The authors consider it appropriate to identify quantitative (deafening, sopor, coma) and qualitative (obscure consciousness, confusion, and mixed types differing in the ratio of productive to deficiency symptoms). Depressed consciousness was found to be prevalent in children, obscure consciousness was most typical in adults, confusion was common in elderly and old patients. The low presentation of productive disorders and their low association mainly with brain injury in patients who are on the different poles of ontogenesis are explained in the context of the teaching of cerebral functional asymmetry.
Acute Disease↗
Sensorimotor stimulation of comatose patients.
Coma is a state of unconsciousness from which the patient cannot be aroused. The causes of coma are classified into structural and nonstructural disorders. The depth and duration of post-traumatic consciousness disorder are a sensitive and reliable indicator of the severity of head trauma. The social prognosis aggravates with age and duration of unconsciousness. Early sensorimotor stimulation by adequate series of stimuli paves the road for new collaterals of the weakened and lost neurons, and for their connection. In such a way. the entire system of structures required for successful regeneration and reorganization of functions in the damaged parts of the brain is maintained in a relatively functional tone. This is substantiated by two examples taken from practice, presented as brief case reports.
Adult↗
[Clinico-psychopathologic features of hysterical disorders with altered consciousness in children].
In 7 children aged from 6 to 13 years with hysterical psychoses relatively rare psychopathological phenomena were found which were named by the author as short-time lethargy, prolonged somnabulism, hysterical automatism, the phenomenon of "personality split" and special fantasies. The paper contains a psychopathological analysis related to the age traits and clinical aspects of these conditions. A special place occupied by these symptoms in the psychotic structure is due, in the opinion of the author, to the appearance of "hypnoid-hypobulic" disturbances.
Adolescent↗
Delirium: how its concept has developed.
The development of the concept of delirium spans nearly 2,500 years. Its core clinical features were recognized at least as early as the 16th century, while its management reflected a humane approach from the beginning of the modern era. In the 19th century delirium became linked with the concepts of disordered consciousness and confusion, but these two terms were also used in regard to certain functional mental disorders. The most important contribution in this century was the work of Engel, Romano, and associates, who postulated that the syndrome was due to reduction in brain metabolic rate, as reflected in slowing of the EEG background activity. These and other developments are discussed in this article. A list of proposed research priorities is included.
Aged↗
[Post-traumatic psychological disorders].
Mental disorders after closed-head injury are reviewed. Post-concussive syndrome and post-contusional disability are described with particular emphasis on consciousness disorders, amnesia, frontal disturbance and long-term outcome.
Brain Concussion↗
[Mental disorder in strangulation asphyxia].
In order to study the mental, neurological and EEG changes due to strangulative asphyxia, the authors studied 163 patients who attempted suicide by selfhanging. In the poststrangulative period there was changed consciousness, disorders of memory, emotions, as well as neurological symptoms which eventually had a reversible course. All these data were confirmed by EEG studies. The convened investigation demonstrated a high therapeutical effect of modern resuscitative measures which can be rendered to this contingent of patients.
Asphyxia↗
Changes in phenytoin concentrations in blood and cerebrospinal fluid caused by direct hemoperfusion in a patient intoxicated with phenytoin.
We performed direct hemoperfusion (DHP) 5 times on a patient with consciousness disorder and phenytoin intoxication. We then measured the phenytoin concentrations in her cerebrospinal fluid (CSF) and blood at various times. After the first DHP session, consciousness began to improve, and it normalized after the fourth DHP session when the blood concentration of phenytoin had decreased from 54.0 microg/ml to 16.5 microg/ml. The average plasma phenytoin elimination rate of DHP was 18.0% over 120-180 min. The concentration of phenytoin in the CSF decreased as that in the blood was lowered by DHP. The average reduction rate of phenytoin in the CSF after a DHP session was 23.7%, which was similar to the rate of elimination from the blood. The CSF/blood phenytoin ratio was 0.17, and no marked changes were detected before or after a DHP session.
Acute Disease↗
[Disorders of executive consciousness].
UNLABELLED: Executive function is a higher order cognitive capacity that involves memory, perception and performance of complex tasks. Disorders of the executive functions are sign of lesions in the prefrontal cortex, involving the prefrontal-striatal-thalamic networks and the parietal association areas. According to signs and localization, five basic prefrontal syndromes are recognised. 1. Damage in posterior dorsolateral prefrontal cortex and subcortical nuclei causes the dorsolateral syndrome with impaired decision making, working memory and planning. 2. The ventromedial-orbitofrontal syndrome: if lesion spares the basal forebrain, memory can be preserved, but poor social decision making develops. 3. The dorsomedial syndrome consists of attention disorder, akinesia, mutism and apathy. 4. The bilateral ventrolateral prefrontal regions serve perception of self and environment. 5. The ventral lateral (verbalizer) area of the dominant hemisphere coordinates language. Executive impairments can be found in cerebrovascular, Parkinson's and other diseases of basal ganglia, and in frontotemporal lobar degeneration. The dorsolateral syndrome can be examined by the use of Wisconsin card sorting test, self ordered pointing task and the delayed response task. Prefrontal-basal function can be assessed by Gambling-, Faux Pas-, and Emotion identification tasks. CONCLUSIONS: 1. A dysexecutive syndrome does not fulfil the criteria of dementia. 2. A "frontal syndrome" is an indefinite eponym. Focal lesions in prefrontal systems lead to localization-specific symptoms, which can be defined by psychometric tests. 3. In neurological diseases associated with multifocal damage of the brain neuropsychologic tests may help to determine strategic lesions, which are responsible for the actual syndromes.
Akinetic Mutism↗