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PubMed1978

The structure of vigilance.

Vigilance is understood as a primarily behavioral category. Identical stimuli tend to evoke more or less differentiated behavioral responses dependent on a low or high state of vigilance. The rise of vigilance from coma to full attention moves along with increasing differentiation of evoked behavioral responses. With heterogeneous physical, figurative, and verbal stimuli, responses are elicited which can be arranged on an additive (Guttman) scale. Thus, vigilance is suggested to represent a one-dimensional function of the brain.

Arousal↗
PubMed1979

Factors influencing the development of periventricular lucencies in patients with raised intracranial pressure.

Sixty patients with raised intracranial pressure and lowered attenuation areas around the lateral ventricles ('periventricular lucency', PVL) on CT scanning were reviewed, and compared with a control group of 90 similar patients who did not have PVL. It was confirmed that PVL tends to occur in patients with acute or subacute obstructive hydrocephalus due to a tumour, and is more common in the presence of papilloedema and/or a decreased level of consciousness. Patients with very dilated lateral ventricles did not in general have PVL, but it was frequently seen in association with diastasis of the sutures. Twelve patients with PVL had no other clinical or radiological indication of raised intracranial pressure. Comparison with the control cases did not reveal any reason as to why some patients should develop PVL while others did not.

Adolescent↗
PubMed1977

Brain monoamines in metabolic (endotoxic) coma. A preliminary biochemical study in human postmortem material.

Spectrofluorometric assays of DA, 5-HT and 5-HIAA were performed in different areas of postmortem brains of humans who died in hepatic and uremic coma. Brain DA showed a mild general decrease, the average reduction being 20 to 30 percent of the controls. By contrast, 5-HT and 5-HIAA were markedly increased in most brain areas, most significantly in the reticular and raphé nuclei of the brainstem and in some parts of the limbic system. Despite individual and regional differences, the monoamine changes had similar patterns in both hepatic and uremic coma. These data in human brain which confirm previous clinical and experimental studies in hepatic encephalopathy suggest some common disorders of central monoamine metabolism in endotoxic coma of different origin. Brain edema, a constant feature in toxic coma, is probably due to increased 5-HT content in the brain, the pathophysiologic effect of 5-HT on the blood-brain barrier being well established. The prominent changes of indoleamine metabolism in the reticular brainstem and limbic systems may be related to disorders of consciousness.

Aged↗
PubMed1984

Factors influencing the outcome in acute subdural haematoma. A review of 330 cases.

A series of 330 consecutive patients with acute subdural haematomas has been selected to analyze the clinical signs which influence the outcome. To assure a uniformity, the material dates from before the CT era. Four main factors have been selected: age, pupillary changes, dynamics of the clinical development, and the state of consciousness. The importance and the characteristics of different factors are discussed. A simple grading system, which was used as a prognostic orientation guide, is presented. Finally, some prognostic conclusions are made.

Acute Disease↗
PubMed1993

Impairment of consciousness induced by valproate treatment following neurosurgical operation.

Eight patients, who underwent neurosurgery for various supratentorial lesions presented unexplained impairment of consciousness during the first post-operative days. These states ranged from stupor to deep coma, and two patients had an emergency re-exploration. All these patients were receiving the usual dosage (1000 to 1500 mg per day) of Valproic acid (VPA). The treatment had been initiated either several weeks or months previously in 4 cases, and was thus well tolerated, or the day before surgery in the 4 other cases. EEG recordings displayed diffuse abnormalities, delta waves and/or high voltage triphasic complexes, that led to the diagnosis of VPA intolerance and drug withdrawal. Then full clinical recovery and EEG clearing occurred within 1 to 5 days. VPA intolerances are wellknown but remain exceptional, about 1 case per 100.000. In our neurosurgical population, however, the rate was higher, approximately 2%. Wide areas of blood brain barrier destruction may contribute to the higher frequency of this easily reversible cause of post-operative stupor or coma.

Adolescent↗
PubMed1979

The prognosis of intracranial saccular aneurysms when the surgeon refused surgery.

Despite our basic policy of performing intracranial definitive surgery whenever possible in cases of intracranial saccular aneurysms, we have had 80 patients with non-radically treated aneurysms. This investigation is based on an analysis of the prognosis in 54 cases where we refused definitive surgery; it provides insight into the factors and circumstances leading to the use of treatment of secondary choice, conservative rather than definitive treatment.

Brain↗
PubMed1996

Hyponatremia with consciousness disturbance caused by omeprazole administration. A case report and literature review.

A 68-year-old man developed severe consciousness disturbance after daily administration of 20 mg omeprazole for four days for the treatment of bleeding gastric ulcer. Systemic investigation revealed severe hyponatremia (111 meq/liter). Consciousness did not become clear until his sodium intake was increased to 480 meq/day, and his serum sodium concentrations reached 130 meq/liter. After the discontinuation of omeprazole, his serum sodium levels returned to the normal range with only minimum supplementation of sodium in the form of dietary sodium chloride intake of 10 g/day. Although the mechanism of hyponatremia induced by omeprazole is not clear, an excessive loss of urinary sodium appears to be more likely than water retention with an increase in fluid intake. The literature was also reviewed.

Aged↗
PubMed1981

Acute neurologic complications of hemodialysis. Study of 14,000 hemodialyses in 103 patients with chronic renal failure.

We have examined and subjected to statistical analysis the transient acute neurological complications arising in the course of hemodialysis in 103 patients with chronic renal failure (13,969 hemodialysis sessions). Our data show that such complications are multiform. Some of the symptoms are aspecific: headache, nausea and/or vomiting, muscle cramps. We have found these symptoms in over 96% of patients, often combined with extraneurological symptoms and phenomena, such as cardiocirculatory shock or increased blood pressure. The other symptoms denote real cerebral impairment: convulsions, consciousness disturbances, psychomotor agitation. They are present in 36% of the patients, but only 10.5% of the patients show a combination of at least two symptoms. In these patients the so-called "Disequilibrium syndrome" is present: its percentage in our case-series is similar to that reported in literature.

Adolescent↗
PubMed1991

The TURP syndrome.

This article discusses the presentation, aetiology, treatment and prevention of central nervous system disturbances after transurethral resection of the prostate. Nausea and vomiting, visual symptoms, and altered states of consciousness have been reported as complications due to intravascular absorption of irrigating fluid. Hypotonicity after absorption of the irrigating fluid causes cerebral oedema. Hyperglycinaemia may cause visual disturbances and hyperammonaemia may cause delayed coma.

Consciousness Disorders↗
PubMed1998

[Diagnostic pitfalls in sulfonylurea-induced neuroglycopenic syndrome with hemiparesis, dysphasia and somnolence].

BACKGROUND: The neuroglycopenic syndrome, which is often due to sulfonylurea-induced hypoglycemia, is frequently overlooked or misinterpretated as cerebral ischemia. PATIENTS: Two women aged 81 and 83 years, respectively, with type II diabetes treated with sulfonylureas presented with hemiparesis, dysphasia and somnolence. Both, general practitioner and emergency room physician first interpretated the symptoms as clinical signs of stroke without determination of blood glucose. After hours of delay due to unnecessary and expensive examinations including cerebral computed tomography the correct diagnosis of hypoglycemia was finally made. After injection of i.v. glucose the symptomatology was completely reversible. CONCLUSION: In every case of disturbance of consciousness, acute neurologic deficits and psychiatric abnormalities an immediate blood glucose test should be performed to exclude hypoglycemia.

Aged↗
PubMed2006

[Spectrum of patients in prehospital emergency services. What has changed over the last 20 years?].

BACKGROUND: In Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes. METHODS: In a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients' demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions performed by prehospital emergency physician. RESULTS: In 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV-VI (39% vs. 50%) or patients with GCS < or =8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each category was higher than in 1984 (NACA IV-VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01). CONCLUSIONS: The results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

Consciousness Disorders↗
PubMed2004

[Generalized pain syndrome, fever and somnolence in an 81-year-old patient].

We present a case of an 81-year-old diabetic man with anaerobic sepsis due to acalculous cholecystitis. The patient was admitted to our hospital with a seven-day history of severe abdominal pain accompanied with fever and somnolence. Blood cultures taken during the initial procedure developed Clostridium perfringens. The patient was immediately treated with parenteral penicillin. The ultrasonography pointed out the case: the gall bladder was found to be distended and slightly thickened. This result was interpreted as an acute non-emphysematous cholecystitis. The material obtained by needle aspiration and therapeutical emptying of the gall bladder revealed large gram positive rods, that also proved to be Clostridium perfringens. The patients course afterwards was uneventful. Antibiotics were continued and he was discharged after 13 days in a stable condition.

Aged↗
PubMed2002

[Hawaiian baby woodrose: (Psycho-) Pharmacological effects of the seeds of Argyreia nervosa. A case-orientated demonstration].

The seeds of the Hawaiian baby woodrose ( Argyreia nervosa) are used by adolescents as a supposed hallucinogenic drug. These seeds are legally available and broadly sold. The active components are alkaloids structurally related to lysergic acid diethylamide (LSD). However, the psychic effects are very different from those of LSD and are dominated by rather sedative, uncomfortable autonomic disturbances similar to the effects of scopolamine. The (psycho)pharmacological profile is described on the basis of the active substances lysergacidamide and lysergacidethylamide (and their isomers). It is shown that neither the substances themselves nor the mixture are able to evoke LSD-like perceptual variances. The exposure of Argyreia nervosa is described focusing on potential fetal distress by contained ergometrine and the case history of an intoxication.

Arousal↗
PubMed2007

[Evaluating extensive consciousness disturbance. Roulette or well-founded forensic diagnostics?].

The difficulties of experts to judge and evaluate so-called affect crimes are due to theoretical and conceptual shortcomings on the one hand and problems of reproducibility on the other. This study describes an attempt to set up diagnostic guidelines for such cases. A vulnerability/stress model was developed which integrates features from different areas: predisposition (including social perception, thinking, and problem solving), triggering conditions (mainly derived from stress theories and concepts), and the established Sass criteria (1983). The characteristics of these respective diagnostic features were collected from a sample of 31 criminal responsibility examinations. Finally, implementing multivariate analysis, 13 criteria were established that could be useful in evaluating criminal responsibility with regard to consciousness disturbances in that they enable testimony based on the prognostic and discriminant validity of the individual criteria.

Adult↗