NEUROLOGY 2.

Arousal
TOPIC NO.2  ARAS, awakefulness
APPROACH TO PATIENT WITH ALTERED LEVEL OF CONCIOUSNESS  Altered consciousness
Dr. Rabo  Dependent at Ascending reticular activating
system
History
 is there? Alteration of Consciousness
 where?  Widespread cortical impairment
 what?  Injury to specific set of brainstem, diencephalon pathways
that regulate the overall level of cortical function
ARAS ( Ascending Reticular Activating System)
 center of consciousness (UMN) Examination of the Comatose Patient
 History (from relatives, friends or attendants)
UMN  Onset of Coma (abrupt, gradual)
 Cerebrum (Cortex) – should be widespread or generalized  Recent complaints ( e.g. headache, depression, focal
e.g. metabolic problem near the brainstem weakness, vertigo)
 Brainstem – ARAS  Recent injury
 Spinal cord – not included because lesion here does not  Previous Medical Illness ( e.g. diabetes, renal failure, heart
altered the level of conciousness disease)
 Previous psychiatric history
Anterior Horn Cell problem  Access to drugs ( sedatives, psychotic drugs)
Examples:
 Amyotrophic Lateral Sclerosis(ALS) – with atrophy and General Physical Examination
fasciculation  Vital Signs
 Polio – atrophy  Evidence of Trauma
 Evidence of Acute or Chronic Systemic illness
Peripheral nerve problem  Evidence of Drug ingestion (needle marks)
Examples:  Alcohol on death
 Guillan Barre Syndrome  Nuchal rigidity (assuming that cervical trauma has been
 Ascending paralysis occluded
 DM neuropathy
 Glove and Stock *Nuchal rigidity- if Acute – vascular/subarachnoid hemorrhage;
subacute to chronic – meningeal irritation
Myoneural junction problem
Examples: Key Parameters of Neuro Exam
 Myasthenia Gravis  Level of consciousness
 Fatigue  Pattern of breathing
 Size and Activity of the pupil
Muscle problem  Eye movement and Oculovestibular responses
Example:  Skeletal motor response
 Hypokalemic periodic paralysis
- proximal muscle weakness (cannot comb hair, Abnormal state of consciousness
cannot stand from seating position) (Acute)
 Poliomyelitis  Clouding of consciousness
 Dermatomyositis  Delirium
 Lethargy
Cortex  Obtundation
 Diffuse Lesion – altered consciousness(Metabolic disease)  Stupor
 Local lesion – confused e.g. hemineglect, aphasia  Coma

Structural lesion – meningioma near brainstem (ARAS) Clouding of consciousness

 A term applied to a patient who has inattention and
Consciousness minimally reduced wakefulness and awareness
 State of full awareness of the self and ones relationship to  E.g. drowsiness
environment
 It is possible for a patient to be conscious yet not Delirium
responsive to the examiner  Abnormal mental state characterize by disorientation
(first time, next to place and then to person and their
2 Components environment) misperception of sensory stimuli and often
1. Content vivid hallucination (visual)
 mental activity, cortex
 represent the sum of all function mediated at Lethargy
cerebral cortical level, including both cognitive  Consist of severe drowsiness in with the patient can be
and affective responses aroused by moderate stimuli than drift back to sleep
Obtundation Pupillary Light Reflex
 Mild to moderate reduction on alertness, with level  Single most important physical sign in differentiating
interest in environment metabolic from structural coma
 One of the most resistant brain response during metabolic
Stupor encephalopathy
 A condition of deep sleep or similar behavioral  Nearly any metabolic encephalopathy result in small
unresponsiveness from which the patient can be aroused reactive pupil
only with vigorous and continuous stimulation
*metabolic ( Diffuse cerebral problem) – symmetric/isocoric? ;
Coma structural lesion - assymetric
 A atate of unresponsiveness in which the patient lies with
eyes closed and cannot be aroused to respond Optic Pathway
appropriately to stimuli; even with vigorous stimulation Pupillary dilatation – cervical dilatation ; never a function of Cranial
Nerves
Glasgow Coma Scale e.g. Horners syndrome – myosis, anhydrosis, ptosis
Eye Response Pupillary constriction - parasympathetic
4 = eyes open spontaneously
3 = eye opening to verbal command  Optic nerveOptic chiasmOptic tractLateral
2 = eye opening to pain Geniculate bodyOptic radiation (Visual Pathway)
1 = no eye opening  Optic nerveOptic chiasmOptic tractPretectal
nucleus in Superior cunniculus (pupillary constriction)
Motor Response  Bifurcate to Edinger Wesphal is circumfere ( responsible
6 = obey command for pupillary constriction)CNIIIciliary ganglion
5 = localizing pain  Pupillary constriction muscle is circumferential
4 = withdrawal for pain  Pupillary dilatation muscle is radial
3 = flexion response to pain  CNIII – efferent ; CNII – afferent
2 = extension response to pain  Diffuse metabolic problem and Diencephalic thalami area–
1 = no motor response equal , small reactive pupil
 Pretectal – large, fixed, hyperpigmented?
Verbal Response  Focal deficit – assymetrical pupil, dilated, fixed ; seen in
5 = oriented unchal herniation
4 = confused Unchal herniation
3 = inappropriate words e.g. CNIII on Right Side
2 = incomprehensible words - Dilated
1 = no verbal response - Topographically arranged
- Outermost segment area is pupillary constriction
*Glasgow lowest score is 3 (1st manifestation in impending herniation)
- 3 Function of CNIII:
Stimulation of Pain o EOM (inner) – Diabetic neuropathy;
 Supraorbital arteriopathy secondary to diabetes
 Nail bed o Levator palpebrae (middle)
 Sternal rub o Pupillary constriction (outer)
 Temporomandibular joint  Midbrain – midposition, fixed
 Pons – pinpoint
Pattern of Breathing
Cheyne strokes Occulomotor response/ Dolls Eye
- Bilateral Cortical Diencephalic Lesion (thalami)  Assymetric occulomotor function typically identifies a
- Hyperpnea, Apnea patient with a structural rather than metabolic cause of
Kussmauls Breathing coma
- Metabolic problem  Normal response generated by vestibular input to the
- Bilateral Cerebral Cortex ocular motor system is for the eyes to rotate counter to
- Ketoacidosis direction
 Normal response in both horizontal and vertical imply
Central Neurogenic Hyperventilation intact brainstem pathways from the lower pontine
- Midbrain problem tegmentum and hence upper pontine and median pontine
tegmentum
Cluster Breathing
- Pons problem Occulovestibular reflex
- Inspiratory gasp, pontomedullary - ataxic, irregular  Vestibular (semicircular canal)
breathing  Upper pons
 Semicircular canalvestibular nucleiAbducens
Apneustic Breathing nerveMedial Longitudinal Fasciculus (MLF)
- Medulla (Respiratory center) – apnea  Abducens
o Motorsupplies medial and lateral rectus
 o Interneurons join MLF and synapse with CNIII  Subarachnoid hemorrhage
(conjugate eye) to medial rectus o Red is equal all throughout
e.g. demyelination in MLF o There is absence of clot because fibrinogen lyse
Internuclei opthalmophlegia – one eye not move the clot
medially ; “Lateral rectus nakatingin pero yung o Xantochromic fluid – due to lysis
medial rectus hindi”
Viral Bacterial TB Fungal
Motor Response Opening Normal or Increase Increase Increase
Decorticate Pressure increase
- Upper midbrain problem (flex) Appearance Clear of Cloudy Cloudy Cloudy
- Rubrospinal tract (Red nucleus) – function is flexure of cloudy purulent
upper extremities because it synapse with cervical cord WBC Increase Increase Increase Increase
Deccerebrate Lympho PMN Lympho Lympho
- Upper pontine and below (extend) Protein Normal or Increase Increase Decrease
- Spare rubrospinal tract Increase
Sugar Normal Decrease Decrease Increase
BRAIN DEATH
 Prerequisites (all must be checked) Contraindication
 Coma, irreversible and known cause  Infection at the puncture site
 Examination  Bleeding diathesis
 Pupil nonreactive to bright light  Increase ICP due to an intracranial mass lesion obstructed
 Corneal reflex absent CSF outflow (e.g. due to aqueductal stenosis or Chiari I
 Occulocephalic reflex absent (dolls eye), tested malformation) or spinal cord CSF blockage (e.g. due to
only if C-spine integrity…. tumor cord compression)
 Occulovestibular reflex absent
 No facial movement to noxious stimuli and *After tap the patient must lie in bed for 4-6hrs to prevent spinal
supraorbital nerve, temporomandibular joint headache
 Gag reflex absent
 Cough reflex absent to tracheal suctioning 2. Computed Tomography
 Absent Motor Response  Provide rapid, noninvasive, imaging of the brain and skull
 Without repiration to 4 minutes  Superior to MRI in visualizing from bone detail in ( but not
 Apnea contents of) posterior fossa
 Hyperdense – bone and blood
________________________________________________________  Blurred – Posterior fossa

DIAGNOSTIC TEST USED IN NEUROLOGY 3. MRI

1. Lumbar Puncture
 Used to evaluate ICP and CSF composition
 To therapeutically reduce ICP
 To administer intrathecal drugs or radio opaque agent for
myelography
 Location in Adult: anywhere below L1; use ASIS as a guide
o Target L3,L4 interspace and when you hear the
pop sound your at the subarachnoid space
 Children: L2,L3
 Better resolution of neural structure than CT scan
 These difference is most significant in CN problem
 For CN, brainstem lesion, abnormalities in posterior fossa
and brainstem
Contraindication
 In patient with pacemaker or cardiac or carotid stents for
<6wks have ferromagnetic clip
*12hrs before you see stroke in CT scan

Opening Pressure <180mm H2O 4. Angiography

Gross Appearance Clear colorless  Gold standard
Total cell 5 Lymphocyte or Monocyte  In blood vessel, aneurysms, AV malforamation, very
Protein <45 – 50mg/dL invasive
Sugar 15 – 80mg/dL *CTA – CT angiography ; MRA – Magnetic Resonance Angiography
>50% of RBS
5. Myelography
*If yellowish this means that he protein is increased  X-ray taken after a radioopaque agent is injected to
*Neutrophil must always be absent, even in small amount – subarachnoid space via lumbar puncture
indicates infection!
6. EEG
*Bloody Tap  Deteriorate electrical activity of the brain
 Traumatic tap  Electrodes are distributed over the brain, detect electrical
o Usually 5 test tubes were used, the first test tube charges associated with seizure disorder, sleep disorder,
is reddish in color but the succeeding test tubes metabolic structural encephalopathy
will be lighter  The Normal awake: wave 8-12Hz
o There is a presence of clots  Look for asymmetry:
o Clear colorless
 o If Asymmetric between 2 hemisphere -
structural disease.
o Alpha activity – good if symmetrical
 Abnormal wave pattern maybe nonspecific (e.g.
epileptiform – spikes)
o Absence seizure – 3Hz spike and waves
o Epileptic – spikes
o Slow – encepalopathies

7. Evoke Potentials
 Useful detecting clinically inapparent deficits in a
demyelinating disorder, appraising sensory system in
infants, substantially deficit suspected to be histrionic and
following the sublinical course of disease
 Which area?
 Visual, auditory, Somatosensory
 Based on electrical response elevated by stimulation of
sense organs of peripheral nerve in the corresponding….

8. Electromyography and nerve conduction velocity studies

 when determining whether weakness is due to a
nerve, muscle, neuromuscular junction disorder is
clinically difficult, these studies can identify the
affected nerve and muscle
 Peripheral nerve problem, which muscle and nerve?

Thank you Grace Manarang for the NOTES ! 