Pathophysiology of Acute Coma and Disorders of Consciousness: Considerations for Diagnosis and Management

Abstract

Disorders of consciousness are due to failure of the arousal system. In this review, the authors introduce the spectrum of disorders of consciousness and describe the structures, projections, and neurotransmitters involved in the generation and maintenance of arousal. Next, they discuss the neurologic diseases frequently associated with arousal failure. Evaluation of patients with disorders of arousal is summarized, including the neurologic exam, electrophysiological studies, biochemical testing, and imaging modalities. Finally, they review treatment options, including therapeutic hypothermia, medications, and deep brain and spinal cord stimulation.

Paroxysmal sympathetic hyperactivity syndrome in tuberculous meningitis with paradoxical reaction

“…Due to the existence of hydrocephalus, we inserted a ventriculoperitoneal shunt to lower intracranial pressure in this patient. However, pathology in ganglia basal, diencephalon, and midbrain, such as ischemia or inflammation, may also contribute to decrease of consciousness [27] . As in our instance, granulation lesions were suspected in the midbrain and thalamus.…”

Disorders of Consciousness: Practical Management in an Emergency Room

“…Several components of the anaerobic metabolism may damage neurons, including free radicals, extracellular glutamate causing excitotoxicity by calcium influx, changes in glial morphology, and astrocytic activation by increased levels of proinflammatory interleukins and tissue necrosis factor α. 4,15,16 Reversible causes of lowered level of consciousness. There are innumerable possible causes of lowered level of consciousness, and some of them can be immediately reversed with emergency intervention.…”

“…Modafinil (an orexin agonist), zolpidem (a GABAergic agonist) and baclofen (a GABAergic agonist) resulted in improvement of some persistent vegetative states; however, no randomized, multicenter, prospective, doubleblind study has been conducted to date, and only empirical measurements based on the individual observation of some centers are available. 4,28…”

“…Abulia is a decrease in initiative along with apathy; it can occur after frontal lobe damage, and it may evolve with akinetic mutism. [4][5][6][7][8] In the clinical practice, many patients arrive at the emergency room with a lower level of consciousness: the patient may be disoriented, sleepy, obtunded (sleepy and disoriented), apathic, or already comatose. Since there are many possible causes for this clinical picture, the clinical history and a proper physical examination are fundamental to establish an etiological diagnosis.…”