Professional Documents
Culture Documents
Brain Disorders
Brain Disorders
Brain Disorders
Sourcebook
Shannon
Brain Disorders
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Health
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3rd Edition
Omnigraphics
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Third Edition
Brain
Disorders
Sourcebook
ISBN 978-0-7808-1083-9
Edited by
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Brain
Disorders
SOURCEBOOK
Third Edition
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Basic Consumer Health Information about Acquired
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and Traumatic Brain Injuries, Brain Tumors, Cerebral
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Palsy and Other Genetic and Congenital Brain Disorders,
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Infections of the Brain, Epilepsy, and Degenerative
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Neurological Disorders Such as Dementia,
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Huntington Disease, and Amyotrophic
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Lateral Sclerosis (ALS)
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Along with Information on Brain Structure and
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Function, Treatment and Rehabilitation Options, a
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Glossary of Terms Related to Brain Disorders, and a
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Directory of Resources for More Information
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Edited by
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Joyce Brenneck Shannon
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Brain
Disorders
SOURCEBOOK
N
Bibliographic Note
Because this page cannot legibly accommodate all the copyright notices, the Bibliographic
Note portion of the Preface constitutes an extension of the copyright notice.
Edited by Joyce Brenneck Shannon
Health Reference Series
Karen Bellenir, Managing Editor
David A. Cooke, MD, FACP, Medical Consultant
Elizabeth Collins, Research and Permissions Coordinator
Cherry Edwards, Permissions Assistant
EdIndex, Services for Publishers, Indexers
***
Omnigraphics, Inc.
Matthew P. Barbour, Senior Vice President
Kevin M. Hayes, Operations Manager
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Peter E. Ruffner, Publisher
Copyright 2010 Omnigraphics, Inc.
ISBN 978-0-7808-1083-9
Electronic or mechanical reproduction, including photography, recording, or any other information storage and retrieval system for the purpose of resale is strictly prohibited without
permission in writing from the publisher.
The information in this publication was compiled from the sources cited and from other
sources considered reliable. While every possible effort has been made to ensure reliability,
the publisher will not assume liability for damages caused by inaccuracies in the data,
and makes no warranty, express or implied, on the accuracy of the information contained
herein.
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Printed in the United States
Table of Contents
Visit www.healthreferenceseries.com to view A Contents Guide to the
Health Reference Series, a listing of more than 15,000 topics and the
volumes in which they are covered.
Preface ............................................................................................ xi
vi
viii
ix
Preface
Bibliographic Note
This volume contains documents and excerpts from publications
issued by the following U.S. government agencies: Agency for Toxic
Substances and Disease Registry; Centers for Disease Control and
Prevention (CDC); Genetics Home Reference; Morbidity and Mortality
Weekly Report (MMWR); National Cancer Institute (NCI); National
Center for Infectious Diseases; National Heart, Lung, and Blood Institute (NHLBI); National Institute of Environmental Health Sciences
(NIEHS); National Institute of Mental Health (NIMH); National Institute of Neurological Disorders and Stroke (NINDS); National Institute
on Aging (NIA); National Institute on Drug Abuse (NIDA); National
Institutes of Health (NIH); U.S. Department of Labor; and the U.S.
Department of Veterans Affairs (VA)
In addition, this volume contains copyrighted documents from the
following organizations and individuals: A.D.A.M., Inc.; Alzheimers
Association; American Brain Tumor Association; Angioma Alliance;
Brain Injury Resource Center; Childrens National Medical Center;
Epilepsy.com; Haygoush Kalinian, PhD; Lewy Body Dementia Association; Lifespan; National Association of State Head Injury Administrators; National Stroke Association; Nemours Foundation; Traumatic
Brain Injury Model Systems National Data and Statistical Center;
United Leukodystrophy Foundation; University of Washington Model
xiii
Acknowledgements
In addition to the listed organizations, agencies, and individuals
who have contributed to this Sourcebook, special thanks go to managing editor Karen Bellenir, research and permissions coordinator
Liz Collins, and document engineer Bruce Bellenir for their help and
support.
Medical Consultant
Medical consultation services are provided to the Health Reference
Series editors by David A. Cooke, MD, FACP. Dr. Cooke is a graduate of
Brandeis University, and he received his MD degree from the University of Michigan. He completed residency training at the University of
Wisconsin Hospital and Clinics. He is board-certied in Internal Medicine. Dr. Cooke currently works as part of the University of Michigan
Health System and practices in Ann Arbor, MI. In his free time, he
enjoys writing, science ction, and spending time with his family.
xvi
Part One
Brain Basics
Chapter 1
10
Chapter 2
Brain Changes
Related to Healthy
Aging
In the past several decades, investigators have learned much about
what happens in the brain when people have a neurodegenerative
disease such as Parkinson disease, Alzheimer disease (AD), or other
dementias. Their ndings also have revealed much about what happens during healthy aging. Researchers are investigating a number
of changes related to healthy aging in hopes of learning more about
this process so they can ll gaps in our knowledge.
As a person gets older, changes occur in all parts of the body, including the brain:
s #ERTAIN PARTS OF THE BRAIN SHRINK ESPECIALLY THE PREFRONTAL CORtex (an area at the front of the frontal lobe) and the hippocampus.
Both areas are important to learning, memory, planning, and
other complex mental activities.
s #HANGES IN NEURONS AND NEUROTRANSMITTERS AFFECT COMMUNICAtion between neurons. In certain brain regions, communication
between neurons can be reduced because white matter (myelincovered axons) is degraded or lost.
s #HANGES IN THE BRAINS BLOOD VESSELS OCCUR "LOOD mOW CAN BE REduced because arteries narrow and less growth of new capillaries
occurs.
Excerpted from Alzheimers Disease: Unraveling the Mystery, National Institute on Aging (NIA), updated November 25, 2008.
11
14
Chapter 3
Chapter Contents
Section 3.1Impact of Drug Abuse and
Addiction on the Brain............................................ 16
Section 3.2Mercury and Neurodevelopment............................ 19
Section 3.3Dangers of Lead Exposure...................................... 22
Section 3.4Manganese and Brain Damage .............................. 24
15
Section 3.1
18
Section 3.2
Mercury
Mercury is an element and a metal that is found in air, water, and
soil. It exists in three forms that have different properties, usage, and
toxicity. The three forms are called elemental (or metallic) mercury,
inorganic mercury compounds, and organic mercury compounds.
Elemental mercury is liquid at room temperature. It is used in
some thermometers, dental amalgams, uorescent light bulbs, some
electrical switches, mining, and some industrial processes. It is released into the air when coal and other fossil fuels are burned.
Inorganic mercury compounds are formed when mercury combines
with other elements, such as sulfur or oxygen, to form compounds or
salts. Inorganic mercury compounds can occur naturally in the environment. Inorganic mercury compounds are used in some industrial processes and in the making of other chemicals. Outside the United States,
inorganic mercury salts have been used in cosmetic skin creams.
Organic mercury compounds are formed when mercury combines
with carbon. Microscopic organisms in water and soil can convert elemental and inorganic mercury into an organic mercury compound,
methylmercury, which accumulates in the food chain. Thimerosal and
phenylmercuric acetate are other types of organic mercury compounds
made in small amounts for use as preservatives.
Section 3.3
Section 3.4
What is manganese?
Manganese is a naturally occurring substance found in many types
of rocks and soil. Pure manganese is a silver-colored metal; however,
it does not occur in the environment as a pure metal. Rather, it occurs
combined with other substances such as oxygen, sulfur, and chlorine.
Manganese is a trace element and is necessary for good health.
Manufacturing uses: Manganese is used principally in steel production to improve hardness, stiffness, and strength. It is used in carbon steel, stainless steel, high-temperature steel, and tool steel, along
with cast iron and super-alloys.
Consumer products: Manganese occurs naturally in most foods
and may be added to food or made available in nutritional supplements.
Manganese is also used in a wide variety of other products, including: reworks, dry-cell batteries, fertilizer, paints, a medical imaging
agent, and cosmetics. It may also be used as an additive in gasoline
to improve the octane rating of the gas. Small amounts of manganese
are used in a pharmaceutical product called mangafodipir trisodium
(MnDPDP) to improve lesion detection in magnetic resonance imaging
of body organs.
28
Chapter 4
Chapter Contents
Section 4.1Symptom Overview ................................................. 30
Section 4.2Headache ................................................................. 35
Section 4.3Memory Loss (Amnesia).......................................... 40
29
Section 4.1
Symptom Overview
Symptoms of Brain Disorder, 2005 Haygoush Kalinian, PhD. For
additional information about neurological disorders and neuropsychological evaluation, along with information about contacting Dr. Kalinian,
visit www.neuropsychconsultant.com. Reviewed in January, 2010 by
David A. Cooke, MD, FACP, Diplomate, American Board of Internal
Medicine.
Memory
s &ORGETTING WHERE ) LEAVE THINGS KEYS GLOVES AND SO FORTH
30
Nonverbal Skills
s $IFlCULTY TELLING RIGHT FROM LEFT
s $IFlCULTY DOING THINGS ) SHOULD AUTOMATICALLY BE ABLE TO DO SUCH
as brushing teeth)
s 0ROBLEMS DRAWING OR COPYING
s $IFlCULTY DRESSING NOT DUE TO PHYSICAL DIFlCULTY
s 0ROBLEMS lNDING MY WAY AROUND PLACES )VE BEEN TO BEFORE
s $IFlCULTY RECOGNIZING OBJECTS OR PEOPLE
s 0ARTS OF MY BODY DO NOT SEEM AS IF THEY BELONG TO ME
s 5NAWARE OF TIME SUCH AS TIME OF DAY SEASON YEAR
s 3LOW REACTION TO TIME
s /THER NONVERBAL PROBLEMS
Sensory Symptoms
s ,OSS OF FEELING OR NUMBNESS
s 4INGLING OR STRANGE SKIN SENSATIONS
s $IFlCULTY TELLING HOT FROM COLD
s 0ROBLEMS SEEING ON ONE SIDE
s "LURRED VISION
s "LANK SPOTS IN VISION
s "RIEF PERIODS OF BLINDNESS
s h3EEING STARSv OR mASHES OF LIGHT
s $OUBLE VISION
s $IFlCULTY LOOKING QUICKLY FROM ONE OBJECT TO ANOTHER OBJECT
s .EED TO SQUINT OR MOVE CLOSER TO SEE CLEARLY
s ,OSING HEARING
s 2INGING IN MY EARS OR HEARING STRANGE SOUNDS
s $IFlCULTY TASTING FOOD
s $IFlCULTY SMELLING
s 3MELLING STRANGE ODORS
s /THER SENSORY PROBLEMS
33
Mood/Emotion Symptoms
s 3ADNESS OR DEPRESSION
s !NXIETY OR NERVOUSNESS
s 3TRESS
s 3LEEPING PROBLEMS SUCH AS FALLING ASLEEP STAYING ASLEEP
s "ECOME ANGRY MORE EASILY
s %UPHORIA FEELING ON TOP OF THE WORLD
s -UCH MORE EMOTIONAL FOR EXAMPLE CRYING MORE EASILY
s &EEL AS IF ) JUST DONT CARE ANYMORE
Behavior Symptoms
s $OING THINGS AUTOMATICALLY WITHOUT AWARENESS
s ,ESS INHIBITED TO DO THINGS ) WOULD NOT DO BEFORE
s $IFlCULTY BEING SPONTANEOUS
s #HANGE IN EATING HABITS
s #HANGE IN INTEREST IN SEX
s ,OSS OF ENERGY
s )NCREASE OF ENERGY
s %XPERIENCING NIGHTMARES ON A DAILYWEEKLY BASIS
34
Section 4.2
Headache
Excerpted from Headache: Hope through Research,
National Institute of Neurological Disorders and Stroke (NINDS),
NIH Publication No. 09158, updated December 21, 2009.
Section 4.3
Causes
s !GING
s !LCOHOLISM
s !LZHEIMER DISEASE
s "RAIN DAMAGE DUE TO DISEASE OR INJURY
s "RAIN GROWTHS CAUSED BY TUMORS OR INFECTION
s "RAIN INFECTIONS SUCH AS ,YME DISEASE OR SYPHILIS
40
Home Care
The family should provide support. Reality orientation is recommendedsupply familiar music, objects, or photos, to help the person
stay oriented. Some people may need support to help them relearn.
Any medication schedules should be written down so the person
does not have to rely on memory.
Extended care facilities, such as nursing homes, should be considered for people whose basic needs cannot be met in any other way, or
whose safety or nutrition is in jeopardy.
Reference
Knopman DS. Regional cerebral dysfunction: higher mental functions.
In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia,
Pa: Saunders Elsevier; 2007: chap 424.
43
Chapter 5
Neurological Emergencies
Chapter Contents
Section 5.1Brain Attack: Know the Signs, Act in Time ........... 46
Section 5.2Brain Herniation ..................................................... 48
Section 5.3Cerebral Hypoxia .................................................... 50
Section 5.4Subarachnoid Hemorrhage..................................... 53
Section 5.5First Aid for Seizures .............................................. 57
Section 5.6Delirium (Acute Onset Cognitive Changes)........... 59
45
Section 5.1
Know Stroke
Stroke is the third leading cause of death in the United States and a
leading cause of serious, long-term disability in adults. About 600,000
new strokes are reported in the U.S. each year. The good news is that
treatments are available that can greatly reduce the damage caused
by a stroke. However, you need to recognize the symptoms of a stroke
and get to a hospital quickly. Getting treatment within 60 minutes
can prevent disability.
A stroke, sometimes called a brain attack, occurs when blood ow
to the brain is interrupted. When a stroke occurs, brain cells in the
immediate area begin to die because they stop getting the oxygen and
nutrients they need to function.
Although stroke is a disease of the brain, it can affect the entire
body. The effects of a stroke range from mild to severe and can include
paralysis, problems with thinking, problems with speaking, and emotional problems. Patients may also experience pain or numbness after
a stroke.
Neurological Emergencies
s 3UDDEN TROUBLE SEEING IN ONE OR BOTH EYES
s 3UDDEN TROUBLE WALKING DIZZINESS LOSS OF BALANCE OR COORDINAtion
s 3UDDEN SEVERE HEADACHE WITH NO KNOWN CAUSE
If you believe someone is having a strokeif he or she suddenly loses
the ability to speak, or move an arm or leg on one side, or experiences
facial paralysis on one sidecall 911 immediately.
Act in Time
Stroke is a medical emergency. Every minute counts when someone
is having a stroke. The longer blood ow is cut off to the brain, the
greater the damage. Immediate treatment can save peoples lives and
enhance their chances for successful recovery.
Ischemic strokes, the most common type of strokes, can be treated
with a drug called t-PA, that dissolves blood clots obstructing blood
ow to the brain. The window of opportunity to start treating stroke
patients is three hours, but to be evaluated and receive treatment,
patients need to get to the hospital within 60 minutes.
A ve-year study by the National Institute of Neurological Disorders
and Stroke (NINDS) found that some stroke patients who received t-PA
within three hours of the start of stroke symptoms were at least 30%
more likely to recover with little or no disability after three months.
The best treatment for stroke is prevention. There are several risk
factors that increase your chances of having a stroke including high
blood pressure, heart disease, smoking, diabetes, and high cholesterol.
If you smokequit. If you have high blood pressure, heart disease,
diabetes, or high cholesterol, getting them under controland keeping them under controlwill greatly reduce your chances of having
a stroke.
47
Section 5.2
Brain Herniation
Brain Herniation,
2009 A.D.A.M., Inc. Reprinted with permission.
Alternative names: Herniation syndrome; transtentorial herniation; uncal herniation; subfalcine herniation; tonsillar herniation,
herniationbrain
Denition: A brain herniation is when brain tissue, cerebrospinal
uid, and blood vessels are moved or pressed away from their usual
position in the head.
Causes
A brain herniation occurs when something inside the skull produces pressure that moves brain tissues. This is most often the result
of brain swelling from a head injury. Brain herniations are the most
common side effect of tumors in the brain, including metastatic brain
tumor and primary brain tumor. A brain herniation can also be caused
by abscess, hemorrhage, hydrocephalus, or strokes that cause brain
swelling. A brain herniation can occur between areas inside the skull,
such as those separated by a rigid membrane called the tentorium;
through a natural opening at the base of the skull called the foramen
magnum; or through openings created during brain surgery.
Symptoms
s #ARDIAC ARREST NO PULSE
s #OMA
s )RREGULAR BREATHING
s )RREGULAR PULSE
s ,OSS OF ALL BRAINSTEM REmEXES BLINKING GAGGING PUPILS REACTING
to light)
48
Neurological Emergencies
s 0ROGRESSIVE LOSS OF CONSCIOUSNESS
s 2ESPIRATORY ARREST NO BREATHING
Treatment
Brain herniation is a medical emergency. The goal of treatment is
to save the patients life. To help reverse or prevent a brain herniation,
the medical team will treat increased swelling and pressure in the
brain. Treatment may involve the following:
s 0LACING A DRAIN PLACED INTO THE BRAIN TO HELP REMOVE mUID
s #ORTICOSTEROIDS SUCH AS DEXAMETHASONE ESPECIALLY IF THERE IS A
brain tumor
s -EDICATIONS THAT REMOVE mUID FROM THE BODY SUCH AS MANNITOL OR
other diuretics, which reduce pressure inside the skull
s 0LACING A TUBE IN THE AIRWAY ENDOTRACHEAL INTUBATION AND INcreasing the breathing rate to reduce the levels of carbon dioxide
(CO2) in the blood
s 2EMOVING THE BLOOD IF BLEEDING IS CAUSING HERNIATION
Outlook (Prognosis)
The outlook varies and depends on where in the brain the herniation occurred. Death is possible. A brain herniation itself often causes
massive stroke. There can be damage to parts of the brain that control breathing and blood ow. This can rapidly lead to death or brain
death. Possible complications include brain death or permanent and
signicant neurologic problems.
When to contact a medical professional: Call your local emergency
number (such as 911) or take the patient to a hospital emergency room
if decreased alertness or other symptoms suddenly develop, especially if
49
Reference
Nkwuo N, Schamban N, Borenstein M. Selected Oncologic Emergencies.
In: Marx, JA, ed. Rosens Emergency Medicine: Concepts and Clinical
Practice. 6th ed. Philadelphia, Pa: Mosby Elsevier; 2006: chap 121.
Section 5.3
Cerebral Hypoxia
Cerebral Hypoxia,
2009 A.D.A.M., Inc. Reprinted with permission.
Causes
There are many causes of cerebral hypoxia. These include, but are
not limited to the following:
s !SPHYXIATION CAUSED BY SMOKE INHALATION
s #ARBON MONOXIDE POISONING
s #ARDIAC ARREST WHEN THE HEART STOPS PUMPING
s #HOKING
s #OMPLICATIONS OF GENERAL ANESTHESIA
50
Neurological Emergencies
s #OMPRESSION OF THE WINDPIPE TRACHEA
s $ISEASES THAT CAUSE A LOSS OF MOVEMENT PARALYSIS OF THE BREATHing muscles
s $ROWNING
s $RUG OVERDOSE
s (IGH ALTITUDES
s )NJURIES BEFORE DURING OR SOON AFTER BIRTH
s 3TRANGULATION
s 3TROKE
s 6ERY LOW BLOOD PRESSURE
Brain cells are extremely sensitive to oxygen deprivation. Some brain
cells actually start dying less than ve minutes after their oxygen
supply disappears. As a result, brain hypoxia can rapidly cause death
or severe brain damage.
Symptoms
Symptoms of mild cerebral hypoxia include change in attention
(inattentiveness), poor judgment, and uncoordinated movement.
Symptoms of severe cerebral hypoxia include complete unawareness and unresponsiveness (coma), no breathing, and no response to light. If only blood pressure and heart function remain, then
the brain may actually be completely dead.
Treatment
Cerebral hypoxia is an emergency condition that requires immediate treatment. The sooner the oxygen supply is restored to the brain,
the lower the risk of severe brain damage and death.
Treatment depends on the underlying cause of the hypoxia. Basic
life support is most important. Treatment involves:
s BREATHING ASSISTANCE MECHANICAL VENTILATION
s CONTROLLING THE HEART RATE
s mUIDS BLOOD PRODUCTS OR MEDICATIONS TO CONTROL BLOOD PRESSURE
and
s MEDICATIONS INCLUDING PHENYTOIN PHENOBARBITAL VALPROIC ACID
and general anesthetics to calm seizures.
Sometimes cooling the person with cold blankets is used, because
cooling slows down the activity of the brain cells and decreases their
need for oxygen. However, the benet of such treatment has not been
rmly established.
Outlook (Prognosis)
The outlook depends on the extent of the brain injury, which is
determined by how long the brain lacked oxygen. If the brain lacked
oxygen for only a very brief period of time, a coma may be reversible
and the person may have some return of function. However, this depends on the extent of injury. Some patients recover many functions,
but have abnormal movements such as twitching or jerking. Seizures
may sometimes occur, and may be continuous (status epilepticus).
Most people who make a full recovery were only briey unconscious. The longer the person is unconscious, the higher the risk for
death or brain death, and the lower the chances for a meaningful
recovery.
Possible Complications
Complications of cerebral hypoxia include prolonged vegetative
statebasic life functions such as breathing, blood pressure, sleep-wake
52
Neurological Emergencies
cycle, and eye opening may be preserved, but the person is not alert
and does not respond to their surroundings. Such patients usually die
within a year, although some may survive longer.
Length of survival depends partly on how much care is taken to
prevent other problems. Major complications may include bed sores,
clots in the veins (deep vein thrombosis), improper nutrition, and lung
infections (pneumonia).
When to contact a medical professional: Cerebral hypoxia is
a medical emergency. Call 911 immediately if someone is losing consciousness or has other symptoms of cerebral hypoxia.
Prevention: Prevention depends on the specic cause of hypoxia.
Unfortunately, hypoxia is usually unexpected. This makes the condition somewhat difcult to prevent. Cardiopulmonary resuscitation
(CPR) can be lifesaving, especially when it is started right away.
Section 5.4
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage,
2009 A.D.A.M., Inc. Reprinted with permission.
Causes
Subarachnoid hemorrhage can be caused by:
s BLEEDING FROM AN ARTERIOVENOUS MALFORMATION !6-
s BLEEDING DISORDER
s BLEEDING FROM A CEREBRAL ANEURYSM
s HEAD INJURY
53
Symptoms
The main symptom is a severe headache that starts suddenly and is
often worse near the back of the head. Patients often describe it as the
worst headache ever and unlike any other type of headache pain. The
headache may start after a popping or snapping feeling in the head.
Other symptoms are:
s SUDDEN OR DECREASED CONSCIOUSNESS AND ALERTNESS
s DIFlCULTY OR LOSS OF MOVEMENT OR FEELING
s MOOD AND PERSONALITY CHANGES INCLUDING CONFUSION AND IRRITABILity;
s MUSCLE ACHES ESPECIALLY NECK PAIN AND SHOULDER PAIN
s NAUSEA AND VOMITING
s PHOTOPHOBIA LIGHT BOTHERS OR HURTS THE EYES
s SEIZURE
s STIFF NECK AND
54
Neurological Emergencies
s VISION PROBLEMS INCLUDING DOUBLE VISION BLIND SPOTS OR TEMPOrary vision loss in one eye.
Additional symptoms that may be associated with this disease are:
s EYELID DROOPING
s EYES PUPILS DIFFERENT SIZE
s SUDDEN STIFFENING OF BACK AND NECK WITH ARCHING OF THE BACK
(Opisthotonos; not very common); and
s SEIZURES
Treatment
The goals of treatment are to save your life, repair the cause of bleeding, relieve symptoms, and prevent complications such as permanent
brain damage (stroke).
If the hemorrhage is due to an injury, surgery is done only to remove
large collections of blood or to relieve pressure on the brain. If the
hemorrhage is due to the rupture of an aneurysm, surgery is needed
to repair the aneurysm. If the patient is critically ill, surgery may
have to wait until the person is more stable. Surgery may involve a
craniotomy (cutting a hole in the skull) and aneurysm clipping, which
closes the aneurysm, or endovascular coiling, a procedure in which coils
are placed within the aneurysm to reduce the risk of further bleeding.
If no aneurysm is found, the person should be closely watched by a
health care team and may need repeated imaging tests.
Treatment for coma or decreased alertness status may be needed.
This may include special positioning, life support, and methods to
protect the airway. A draining tube may be placed into the brain to
relieve pressure.
If the person is conscious, strict bed rest may be advised. The
person will be told to avoid activities that can increase pressure
inside the head. Such activities include bending over, straining, and
suddenly changing position. The doctor may prescribe stool softeners or laxatives to prevent straining during bowel movements.
Blood pressure will be strictly controlled. This requires medicines
given through an intervenous (IV) line. The medicine often requires
frequent adjustments. A medicine called calcium channel blocker is
used to prevent blood vessel spams. Pain killers and anti-anxiety
medications may be used to relieve headache and reduce intracranial
pressure. Phenytoin or other medications may be used to prevent or
treat seizures.
Outlook (Prognosis)
How well a patient with subarachnoid hemorrhage does depends
on a number of different factors, including the location and extent of
the bleeding, as well as any complications. Older age and more severe
symptoms from the beginning are associated with a poorer prognosis.
Complete recovery can occur after treatment, but death may occur in
some cases even with aggressive treatment.
Possible complications: Repeated bleeding is the most serious complication. If a cerebral aneurysm bleeds for a second time, the outlook is
56
Neurological Emergencies
signicantly worsened. Changes in consciousness and alertness due
to a subarachnoid hemorrhage may become worse and lead to coma or
death. Other complications include stroke, seizures, medication side
effects, and complications of surgery.
When to contact a medical professional: Go to the emergency
room or call the local emergency number (such as 911) if you have
symptoms of a subarachnoid hemorrhage.
Prevention: Identication and successful treatment of an aneurysm would prevent subarachnoid hemorrhage.
Reference
Zivin J. Hemorrhagic cerebrovascular disease. In: Goldman L, Ausiello
D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier;
2007:chap 432.
Section 5.5
First aid for seizures involves responding in ways that can keep
the person safe until the seizure stops by itself. Here are a few things
you can do to help someone who is having a generalized tonic-clonic
(grand mal) seizure:
s +EEP CALM AND REASSURE OTHER PEOPLE WHO MAY BE NEARBY
s 0REVENT INJURY BY CLEARING THE AREA AROUND THE PERSON OF ANYthing hard or sharp.
s %ASE THE PERSON TO THE mOOR AND PUT SOMETHING SOFT AND mAT LIKE
a folded jacket, under his head.
s 2EMOVE EYEGLASSES AND LOOSEN TIES OR ANYTHING AROUND THE NECK
that may make breathing difcult.
57
Neurological Emergencies
s 4HE PERSON CANNOT BE AWAKENED AFTER THE SEIZURE ACTIVITY HAS
stopped.
s 4HE PERSON BECAME INJURED DURING THE SEIZURE
s 4HE PERSON BECOMES AGGRESSIVE
s 4HE SEIZURE OCCURS IN WATER
s 4HE PERSON HAS A HEALTH CONDITION LIKE DIABETES OR HEART DISEASE
or is pregnant.
Section 5.6
Causes
Delirium is most often caused by physical or mental illness and
is usually temporary and reversible. Many disorders cause delirium,
including conditions that deprive the brain of oxygen or other substances. Causes include drug abuse; infections such as urinary tract
infections or pneumonia (in people who already have brain damage
from stroke or dementia); poisons; and, uid/electrolyte or acid/base
disturbances. Patients with more severe brain injuries are more likely
to get delirium from another illness.
Symptoms
Delirium involves a quick change between mental states (for example, from lethargy to agitation and back to lethargy).
59
Neurological Emergencies
s #HEST X
RAY
s #EREBROSPINAL mUID #3& ANALYSIS
s #REATINE PHOSPHOKINASE #0+ LEVEL
s $RUG ALCOHOL LEVELS TOXICOLOGY SCREEN
s %LECTROENCEPHALOGRAM %%'
s 'LUCOSE TEST
s (EAD COMPUTED TOMOGRAPHY #4 SCAN
s (EAD MAGNETIC RESONANCE IMAGING -2) SCAN
s ,IVER FUNCTION TESTS
s -ENTAL STATUS TEST
s 3ERUM CALCIUM
s 3ERUM ELECTROLYTES
s 3ERUM MAGNESIUM
s 4HYROID FUNCTION TESTS
s 4HYROID STIMULATING HORMONE LEVEL
s 5RINALYSIS
Treatment
The goal of treatment is to control or reverse the cause of the symptoms. Treatment depends on the condition causing delirium. Diagnosis
and care should take place in a pleasant, comfortable, nonthreatening, physically safe environment. The person may need to stay in the
hospital for a short time.
Stopping or changing medications that worsen confusion, or that
are not necessary, may improve mental function. Medications that may
worsen confusion include:
s ALCOHOL AND ILLEGAL DRUGS
s ANALGESICS
s ANTICHOLINERGICS
s CENTRAL NERVOUS SYSTEM DEPRESSANTS
s CIMETIDINE AND
s LIDOCAINE
61
Outlook (Prognosis)
Acute conditions that cause delirium may occur with chronic disorders that cause dementia. Acute brain syndromes may be reversible by
treating the cause. Delirium often lasts only about one week, although
62
Neurological Emergencies
it may take several weeks for mental function to return to normal
levels. Full recovery is common.
Possible complications include:
s LOSS OF ABILITY TO FUNCTION OR CARE FOR SELF
s LOSS OF ABILITY TO INTERACT
s PROGRESSION TO STUPOR OR COMA AND
s SIDE EFFECTS OF MEDICATIONS USED TO TREAT THE DISORDER
When to contact a medical professional: Call your health care
provider if there is a rapid change in mental status.
Prevention: Treating the conditions that cause delirium can reduce its risk.
63
Chapter 6
Impaired Consciousness
Chapter Contents
Section 6.1Coma ........................................................................ 66
Section 6.2Facts about Vegetative and
Minimally Conscious States ................................... 68
65
Section 6.1
Coma
What Is Coma? October 2008, reprinted with permission from www.
kidshealth.org. Copyright 2008 The Nemours Foundation. This information was provided by KidsHealth, one of the largest resources online
for medically reviewed health information written for parents, kids, and
teens. For more articles like this one, visit www.KidsHealth.org or www.
TeensHealth.org.
What is a coma?
What do you think about when you hear the word coma (say: komuh)? Does it make you think of someone in a deep sleep, or the way
you feel after eating too much Thanksgiving turkey? Does the word
remind you of a television (TV) soap opera, where it seems that at least
one character is always in a coma?
A coma can be difcult to understand, especially because people
sometimes jokingly use the words coma and comatose (say: ko-muhtose, which means in a coma or coma-like state) to describe people who
arent paying attention or who are drowsy or sleeping. But a coma is
a serious condition that has nothing to do with sleep.
Impaired Consciousness
s BRAIN DAMAGE CAUSED BY A LACK OF OXYGEN FOR TOO LONG
s AN OVERDOSE TAKING TOO MUCH OF MEDICINE OR OTHER DRUGS
s A STROKE
When one of these things happens, it can mess up how the brains cells
work. This can hurt the parts of the brain that make someone conscious,
and if those parts stop working, the person will stay unconscious.
Section 6.2
Severe brain injury causes a change in consciousness. Consciousness refers to awareness of the self and the environment. Brain injury
can cause a wide range of disturbances of consciousness. Some injuries
are mild and may cause relatively minor changes in consciousness such
as brief confusion or disorientation.
The most severe injuries cause profound disturbance of consciousness. Twenty to 40% of persons with injuries this severe do not survive.
Some persons who survive have a period of time of complete unconsciousness with no awareness of themselves or the world around them.
The diagnosis given these people depends on whether their eyes are
always closed or whether they have periods when their eyes are open.
The state of complete unconsciousness with no eye opening is called
coma. The state of complete unconsciousness with some eye opening
68
Impaired Consciousness
and periods of wakefulness and sleep is called the vegetative state. As
people recover from severe brain injury, they usually pass through various phases of recovery. Recovery can stop at any one of these phases.
Characteristics of Coma
1.
No eye-opening.
2.
3.
4.
No purposeful movement.
2.
3.
May cry or smile or make other facial expressions without apparent cause.
4.
5.
6.
7.
8.
No purposeful movement.
2.
3.
4.
5.
6.
8.
9.
Impaired Consciousness
disabilities. People in a vegetative state due to stroke, loss of oxygen
to the brain (anoxia), or some types of severe medical illness, may not
recover as well as those with traumatic brain injury. Those few persons
who remain in a prolonged vegetative state may survive for an extended
period of time but they often experience medical complications such
as pneumonia, respiratory failure, infections, and so forth which may
reduce life expectancy.
People who have a slow recovery of consciousness continue to have
a reduced level of self-awareness or awareness of the world around
them. They have inconsistent and limited ability to respond and communicate. This condition of limited awareness is called the minimally
conscious state.
2.
3.
4.
May respond to people, things, or other events by: crying, smiling, or laughing; making sounds or gesturing; reaching for objects;
trying to hold or use an object; or, keeping the eyes focused on
people or things for a sustained period of time whether they are
moving or staying still.
Vegetative
State
Minimally
Conscious State
Eye opening
No
Yes
Yes
Sleep/wake cycles
No
Yes
Yes
Visual tracking
No
No
Often
Object recognition
No
No
Inconsistent
Command following
No
No
Inconsistent
Communication
No
No
Inconsistent
Contingent emotion
No
No
Inconsistent
2.
3.
4.
Restlessness.
5.
6.
7.
Delusions or hallucinations.
Impaired Consciousness
tract infection may prolong the confused state but do not necessarily
inuence the nal outcome.
Once the confusional state resolves, people are usually much better
able to pay attention, orient themselves to place and time, and retain
memories for day to day experiences. Nevertheless, they are very likely
to have some signicant cognitive problems such as impaired memory
or slowed thinking. These cognitive problems are likely to continue
to improve as time passes. Some people make limited progress, while
others make a good deal of progress.
Impaired Consciousness
1.
2.
The staff at the facility makes you feel comfortable, is accessible to talk with about your concerns, and answers your questions.
3.
4.
5.
6.
7.
2.
Managing medical equipment and supplies: It is important to be knowledgeable about your loved ones equipment and
supplies, and know how to communicate with the companies
who provide these items.
3.
5.
Impaired Consciousness
How to Interact with Your Loved One Who Is Unconsciousness or at a Low Level of Responsiveness
The most natural way of interacting is to talk to your loved one,
even though he or she may not respond or understand. Simple things
like telling him or her about recent events in your life, what is going
on in your family or neighborhood, or the latest news might make you
feel a sense of connection. Talking with your loved one about what
you are doing as you provide care can increase your comfort with the
process of care giving. For example, telling your loved one that you are
going to move his or her arms and legs to help prevent joint tightness
might make you feel more comfortable with this task. Only do this
range-of-motion type activity if you have been instructed to do so by
the doctor, nurse, or therapist.
Physical touch is another way of having a sense of connection. Some
family members have said that the act of giving a massage or applying
lotion to the hands or face helps them to feel close to their loved one.
It is also important to avoid the risk of overstimulation as this may
result in rapid breathing, tightening of the muscles, grinding of the
teeth, restlessness, and fatigue.
78
Chapter 7
Brain Death
79