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signs CT scanning or MRI (which preferably should precede lumbar puncture) may be normal or abnormal A Subarachnoid hemorrhage from ruptured aneurysm, arteriovenous malformation, occasionally trauma (Chaps 34 and 35) B Acute bacterial meningitis (Chap 32) C Some forms of viral encephalitis (Chap 33) D Neoplastic and parasitic meningitides III Diseases that cause focal brainstem or lateralizing cerebral signs, with or without changes in the CSF CT scanning and MRI are usually abnormal A Hemispheral hemorrhage or massive infarction (Chap 34) B Brainstem infarction due to basilar artery thrombosis or embolism (Chap 34) C Brain abscess, subdural empyema, Herpes encephalitis (Chap 32) D Epidural and subdural hemorrhage and brain contusion (Chap 35) E Brain tumor (Chap 31) F Cerebellar and pontine hemorrhage G Miscellaneous: cortical vein thrombosis, some forms of viral encephalitis (herpes), focal embolic infarction due to bacterial endocarditis, acute hemorrhagic leukoencephalitis, disseminated (postinfectious) encephalomyelitis, intravascular lymphoma, thrombotic thrombocytopenic purpura, diffuse fat embolism, and others Using the clinical criteria outlined above, one can usually ascertain whether a given case of coma falls into one of these three categories Concerning the group without focal or lateralizing or meningeal signs (which includes most of the metabolic encephalopathies, intoxications, concussion, and postseizure states), it must be kept in mind that residua from previous neurologic disease may confuse the clinical picture Thus, an earlier hemiparesis from vascular disease or trauma may reassert itself in the course of uremic or hepatic coma with hypotension, hypoglycemia, diabetic acidosis, or following a seizure In hypertensive encephalopathy, focal signs may also be present Occasionally, for no understandable reason, one leg may seem to move less, one plantar re ex may be extensor, or seizures may be predominantly or entirely unilateral in a metabolic coma, particularly in the hyperglycemic-hyperosmolar states Babinski signs and extensor rigidity, conventionally considered to be indicators of structural disease, do sometimes occur in profound intoxications with a number of agents The diagnosis of concussion or of postictal coma depends on observation of the precipitating event or indirect evidence thereof Often a convulsive seizure is marked by a bitten tongue, urinary incontinence, and an elevated CK-skeletal muscle fraction; it may be followed by another seizure or burst of seizures The presence of small clonic or myoclonic convulsive movements of a hand or foot or uttering of the eyelids requires that an EEG be performed to determine whether status epilepticus is the cause of coma This state, called nonconvulsive status or spike-wave stupor and described in Chap 16, must always be considered in the diagnosis of unexplained coma, especially in known epileptics (Table 17-3) With respect to the second group in the above classi cation, the signs of meningeal irritation (head retraction, stiffness of neck on forward bending, Kernig and Brudzinski signs) can usually be elicited in both bacterial meningitis and subarachnoid hemorrhage However, if the coma is profound, stiff neck may be absent in both.

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infants and adults In such cases the spinal uid must be examined in order to establish the diagnosis In most cases of bacterial meningitis, the CSF pressure is not exceptionally high (usually less than 400 mmH2O) However, in cases associated with brain swelling, the CSF pressure is greatly elevated; the pupils become xed and dilated, and there may be signs of compression of the brainstem with arrest of respiration Patients in coma from ruptured aneurysms also have high CSF pressure; the CSF is overtly bloody and the blood is invariably visible in the CT scan throughout the basal cisterns and ventricles if the bleeding has been severe enough to cause coma In the third group of patients, it is the focality of sensorimotor signs and the abnormal pupillary and ocular re exes, postural states, and breathing patterns that provide the clues to serious structural lesions in the cerebral hemispheres and their pressure effects upon segmental brainstem functions As the brainstem features become more prominent, they may obscure earlier signs of cerebral disease It is worth emphasizing once more that profound hepatic, hypoglycemic, hyperglycemic, and hypoxic states may resemble the coma due to a brainstem lesion in that asymmetrical motor signs, focal seizures, and decerebrate postures arise and deep coma from drug intoxication may obliterate re ex eye movements Also, certain structural lesions of the cerebral hemispheres are so diffuse as to produce a picture that simulates a metabolic disturbance; thrombotic thrombocytopenic purpura (TTP), fat embolism, and the late effects of global ischemia-anoxia are examples of such states At other times they cause a diffuse encephalopathy with superimposed focal signs Unilateral cerebral infarction due to anterior, middle, or posterior cerebral artery occlusion produces no more than drowsiness, as a rule; however, with massive unilateral infarction due to carotid artery occlusion, coma can occur if extensive brain edema and secondary tissue shift develop Edema of this degree seldom develops before 12 or 24 h Rapidly evolving hydrocephalus causes smallness of the pupils, rapid respiration, extensor rigidity of the legs, Babinski signs, and sometimes a loss of eye movements Finally, it should be restated that diagnosis has as its prime purpose the direction of therapy The treatable causes of coma are drug and alcohol intoxications, shock due to infection, cardiac failure, or systemic bleeding, epidural and subdural hematomas, brain abscess, bacterial and fungal meningitis, diabetic acidosis or hyperosmolar state, hypoglycemia, hypo- or hypernatremia, hepatic coma, uremia, status epilepticus, Hashimoto encephalopathy, and hypertensive encephalopathy Also treatable to a varying degree are uremia; putaminal and cerebellar hemorrhages, which can sometimes be evacuated successfully; edema from massive stroke, which may be ameliorated by hemicraniectomy; and hydrocephalus from any cause, which may respond to ventricular drainage.

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