The Acutely Comatose Patient: Clinical Approach and Diagnosis

Abstract

A patient's acute and persistent unresponsiveness in the emergency department often triggers a neurology consultation. Given the many potential causes of unresponsiveness, the initial objective of the neurologist should be a comprehensive history and physical examination, which should allow localization of the lesion, if possible, and an initial narrowing of the differential diagnosis. In addition, neuroimaging review and laboratory evaluation have come to play an increasingly important role in identification of the potential causes of unresponsiveness. However, in some instances, the computed tomography or the magnetic resonance imaging scans are normal and sorting out the cause and depth of unresponsiveness requires clinical skill. The neurologist is adept at correctly moving through a differential diagnosis and this has a profound effect on management. Once appropriate treatment has been initiated, the outcome can be assessed. Recovery from coma can be prolonged, but is less likely if early involvement of the brainstem is apparent.

Keywords

unresponsiveness - coma - FOUR score - emergency neurology

• References

• 1 Posner JB, Saper CB, Schiff ND, Plum F. Plum and Posner's Diagnosis of Stupor and Coma. 4th ed. New York, NY: Oxford University Press; 2007: 3-37
• 2 Medical aspects of the persistent vegetative state (1). The Multi-Society Task Force on PVS. N Engl J Med 1994; 330 (21) 1499-1508
• 3 Medical aspects of the persistent vegetative state (2). The Multi-Society Task Force on PVS. N Engl J Med 1994; 330 (22) 1572-1579
• 4 Giacino JT, Ashwal S, Childs N , et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002; 58 (3) 349-353
• 5 Wijdicks EFM. The Practice of Emergency and Critical Care Neurology. New York, NY: Oxford University Press; 2010: 104-136
• 6 Tobin MJ, Snyder JV. Cheyne-Stokes respiration revisited: controversies and implications. Crit Care Med 1984; 12 (10) 882-887
• 7 Cherniack NS, Longobardo G, Evangelista CJ. Causes of Cheyne-Stokes respiration. Neurocrit Care 2005; 3 (3) 271-279
• 8 Tarulli AW, Lim C, Bui JD, Saper CB, Alexander MP. Central neurogenic hyperventilation: a case report and discussion of pathophysiology. Arch Neurol 2005; 62 (10) 1632-1634
• 9 Freeman WD, Sen S, Roy TK, Wijdicks EF. Cluster breathing associated with bihemispheric infarction and sparing of the brainstem. Arch Neurol 2006; 63 (10) 1487-1490
• 10 Saito Y, Hashimoto T, Iwata H , et al. Apneustic breathing in children with brainstem damage due to hypoxic-ischemic encephalopathy. Dev Med Child Neurol 1999; 41 (8) 560-567
• 11 Wijdicks EFM. The Comatose Patient. New York, NY: Oxford University Press; 2008: 64-83
• 12 Wijdicks EF. The bare essentials: coma. Pract Neurol 2010; 10 (1) 51-60
• 13 Jennett B, Teasdale G, Braakman R, Minderhoud J, Knill-Jones R. Predicting outcome in individual patients after severe head injury. Lancet 1976; 1 (7968) 1031-1034
• 14 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872) 81-84
• 15 Schefold JC, Storm C, Krüger A, Ploner CJ, Hasper D. The Glasgow Coma Score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia. Resuscitation 2009; 80 (6) 658-661
• 16 Mullie A, Verstringe P, Buylaert W , et al; Cerebral Resuscitation Study Group of the Belgian Society for Intensive Care. Predictive value of Glasgow coma score for awakening after out-of-hospital cardiac arrest. Lancet 1988; 1 (8578) 137-140
• 17 Geocadin RG, Buitrago MM, Torbey MT, Chandra-Strobos N, Williams MA, Kaplan PW. Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest. Neurology 2006; 67 (1) 105-108
• 18 Edgren E, Hedstrand U, Kelsey S, Sutton-Tyrrell K, Safar P. BRCT I Study Group. Assessment of neurological prognosis in comatose survivors of cardiac arrest. Lancet 1994; 343 (8905) 1055-1059
• 19 Phuenpathom N, Choomuang M, Ratanalert S. Outcome and outcome prediction in acute subdural hematoma. Surg Neurol 1993; 40 (1) 22-25
• 20 Chou CH, Lin GM, Ku CH, Chang FY. Comparison of the APACHE II, GCS and MRC scores in predicting outcomes in patients with tuberculous meningitis. Int J Tuberc Lung Dis 2010; 14 (1) 86-92
• 21 Hirai S, Ono J, Yamaura A. Evaluation of consciousness by the Glasgow Coma Scale in aneurysmal subarachnoid hemorrhage. Appraisal using logistic regression analysis. Clin Neurol Neurosurg 1997; 99 (Suppl. 01) S42-S43
• 22 Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care 2005; 2 (2) 110-118
• 23 Juarez VJ, Lyons M. Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs 1995; 27 (5) 283-286
• 24 Menegazzi JJ, Davis EA, Sucov AN, Paris PM. Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma 1993; 34 (1) 46-48
• 25 Fielding K, Rowley G. Reliability of assessments by skilled observers using the Glasgow Coma Scale. Aust J Adv Nurs 1990; 7 (4) 13-17
• 26 Gill MR, Reiley DG, Green SM. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med 2004; 43 (2) 215-223
• 27 Marion DW, Carlier PM. Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. J Trauma 1994; 36 (1) 89-95
• 28 Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58 (4) 585-593
• 29 Wijdicks EF, Kokmen E, O'Brien PC. Measurement of impaired consciousness in the neurological intensive care unit: a new test. J Neurol Neurosurg Psychiatry 1998; 64 (1) 117-119
• 30 Looser RR, Metzenthin P, Helfricht S , et al. Cortisol is significantly correlated with cardiovascular responses during high levels of stress in critical care personnel. Psychosom Med 2010; 72 (3) 281-289
• 31 Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc 2007; 82 (4) 435-438
• 32 Stead LG, Wijdicks EF, Bhagra A , et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care 2009; 10 (1) 50-54
• 33 Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 2009; 84 (8) 694-701
• 34 Fugate JE, Rabinstein AA, Claassen DO, White RD, Wijdicks EF. The FOUR score predicts outcome in patients after cardiac arrest. Neurocrit Care 2010; 13 (2) 205-210
• 35 Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 2012; 16 (1) 95-101
• 36 Idrovo L, Fuentes B, Medina J , et al. Validation of the FOUR score (Spanish version) in acute stroke: an interobserver variability study. Eur Neurol 2010; 63 (6) 364-369
• 37 Fischer M, Rüegg S, Czaplinski A , et al. Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care 2010; 14 (2) R64
• 38 Wijdicks EF, Rabinstein AA, Bamlet WR, Mandrekar JN. FOUR score and Glasgow Coma Scale in predicting outcome of comatose patients: a pooled analysis. Neurology 2011; 77 (1) 84-85
• 39 Hassan A, Lanzino G, Wijdicks EF, Rabinstein AA, Flemming KD. Terson's syndrome. Neurocrit Care 2011; 15 (3) 554-558
• 40 Trobe JD. Papilledema: the vexing issues. J Neuroophthalmol 2011; 31 (2) 175-186
• 41 van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351 (18) 1849-1859
• 42 Ludwig CL, Smith MT, Godfrey AD, Armbrustmacher VW. A clinicopathological study of 323 patients with oligodendrogliomas. Ann Neurol 1986; 19 (1) 15-21
• 43 Wijdicks EF. Temporomandibular joint compression in coma. Neurology 1996; 46 (6) 1774
• 44 Kirk MM, Hoogwerf BJ, Stoller JK. Reversible decerebrate posturing after profound and prolonged hypoglycemia. Cleve Clin J Med 1991; 58 (4) 361-363
• 45 Jabre A, Sawaya R, Arthur S. Decerebrate posturing with the syndrome of inappropriate secretion of antidiuretic hormone. Surg Neurol 1985; 23 (1) 56-58
• 46 Wijdicks EF, Parisi JE, Sharbrough FW. Prognostic value of myoclonus status in comatose survivors of cardiac arrest. Ann Neurol 1994; 35 (2) 239-243
• 47 Fugate JE, Wijdicks EF, Mandrekar J , et al. Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol 2010; 68 (6) 907-914
• 48 Caviness JN, Evidente VG. Cortical myoclonus during lithium exposure. Arch Neurol 2003; 60 (3) 401-404
• 49 Sidman R, Connolly E, Lemke T. Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 1996; 3 (9) 827-831
• 50 Perry JJ, Stiell IG, Sivilotti ML , et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 2011; 343: d4277
• 51 Bhadelia RA, Bengoa F, Gesner L , et al. Efficacy of MR angiography in the detection and characterization of occlusive disease in the vertebrobasilar system. J Comput Assist Tomogr 2001; 25 (3) 458-465
• 52 du Mesnil de Rochemont R, Neumann-Haefelin T, Berkefeld J, Sitzer M, Lanfermann H. Magnetic resonance imaging in basilar artery occlusion. Arch Neurol 2002; 59 (3) 398-402
• 53 Wijdicks EFM. Catastrophic Neurologic Disorders in the Emergency Department. 2nd ed. New York, NY: Oxford University Press; 2004
• 54 Husain AM, Horn GJ, Jacobson MP. Non-convulsive status epilepticus: usefulness of clinical features in selecting patients for urgent EEG. J Neurol Neurosurg Psychiatry 2003; 74 (2) 189-191