Coma scale for use in brain-injured children

The association between admission coma score and eventual outcome was assessed using a coma scale developed for children with a variety of central nervous system injuries. As opposed to the Glasgow coma scale, this scale does not demand assessment of verbalization, and thus can be applied to the preverbal or previously intubated child. Cortical function is graded from 6 (purposeful, spontaneous movements) to 0 (flaccid), and brainstem function is graded from 3 (intact) to 0 (absent and apneic). Maximum total score is 9. In 91 children treated for intracranial hypertension, the association was moderately good. The scale was better in predicting the outcome of patients with hypoxic encephalopathy and head trauma than that of patients with Reye's syndrome, meningitis, or encephalitis. No child with a score of less than 3 survived in spite of intensive therapy. Most of these children were flaccid with depressed or absent brainstem reflexes. No child with flaccidity on admission survived.     

Fulminant Guillain-Barré syndrome mimicking cerebral death: case report and literature review

A 45-year-old woman was admitted to the intensive care unit (ICU) for respiratory arrest. One day prior to admission, she had been nauseated and in a state of total exhaustion. On the night of admission she was unresponsive and developed gasping respiration. The patient was comatose with absent brainstem reflexes and appeared brain dead. Blood chemistry findings and brain magnetic resonance imaging were normal. Electroencephalogram revealed an alpha rhythmical activity unresponsive to painful or visual stimuli. The cerebrospinal fluid showed an albuminocytological dissociation. Guillain-Barré syndrome (GBS) was suspected. The electrophysiological evaluation revealed an inexcitability of all nerves. The pathological findings of the sural nerve biopsy indicated an axonal degeneration secondary to severe demyelination. GBS can very rarely present with coma and absent brainstem reflexes. This case illustrates the importance of electrophysiological tests and laboratory and imaging studies in patients with suspected brain death where a cause is not clearly determined. Received: 13 August 1999 Final revision received: 27 January 2000 Accepted: 1 February 2000     

Clinical features and prognostic indicators in paediatric cerebral malaria: a study of 131 comatose Malawian children

We studied the relationship between presenting features and outcome in 131 Malawian children admitted with cerebral malaria (P. falciparum malaria and unrousable coma). A method was devised for the measurement of depth of coma in children too young to speak. Twenty patients (15 per cent) died and 12 (9 per cent) recovered with residual neurological sequelae. Presenting clinical signs significantly associated with adverse outcome (death or sequelae) were profound coma, signs of decerebration, absence of corneal reflexes, convulsions at the time of admission and age under three years. Laboratory findings of prognostic significance were hypoglycaemia, leucocytosis, hyperparasitaemia, elevated plasma concentrations of alanine and 5'-nucleotidase, and elevated plasma or cerebrospinal fluid lactate. A prognostic index based on eight of these risk factors that can readily be ascertained at the bedside or in a ward sideroom, was more accurately predictive of outcome than any single feature. Such an index may be valuable as a measure of severity of illness for establishing the comparability of study groups, and for evaluating the role of other factors in the pathogenesis of cerebral malaria.     

Roving eye movements in a patient with hypoglycemic coma

Roving eye movements are the sign of cortical dysfunction not involving the brainstem. This finding is useful in the differential diagnosis of impaired consciousness and indicates cerebral damage in patients with hypoglycemic coma.     

Decerebrate posturing in alcoholic coma.

Two cases of alcoholic coma are presented where extensor responses to noxious stimuli are demonstrated. Decerebrate posturing normally indicates severe structural or functional depression of midbrain function but can be caused by depressant drugs. Blood alcohol measurements are a vital test in the comatose patient as the clinical picture may be caused, or temporarily significantly worsened, by severe alcohol intoxication. The preservation of pupillary light reflexes in the presence of deep coma with decerebrate posturing should alert the clinician to a possible metabolic cause for the coma, including alcohol. Nevertheless, a diagnosis of alcoholic coma should not be made unless the blood alcohol concentration is grossly elevated and other causes of coma have been excluded by careful physical examination, blood glucose and electrolyte measurement, skull radiography and, in the absence of a rapid improvement, computerized tomography.     

Neurologic intensive care unit monitoring

Monitoring modalities unique to the neurologic intensive care unit include intracranial pressure monitors and neuroelectrophysiologic monitors. Each modality fullfills criteria for accuracy, responsivity during clinical change, and stability over time for trend analysis. Intracranial pressure monitoring may be accomplished by any of three approaches--ventricular catheter, subarachnoid bolt, or epidural pressure transducer. Intracranial pressure control has proved beneficial in at least three different illnesses--acute closed head injury, acute noncommunicating hydrocephalus, and Reye's syndrome. Other illnesses, such as cerebral hemorrhage, near drowning, meningitis, encephalitis, and cerebral mass lesions, are often associated with ICP elevations. Neuroelectrophysiologic monitoring encompassing electroencephalography (EEG), signal-processed EEG, and evoked potentials has proved to be most beneficial to the intensive care setting. Evoked potentials are most useful for monitoring patients in drug-induced coma or muscle paralysis in whom a clinical neurologic examination is unreliable. Focal neurologic deficits, incipient brainstem ischemia, and possibly brain death can be deduced from multimodality-evoked potentials (brainstem auditory and somatosensory). Evoked potential apparatus can be used to record sequential stimuli and trend changes. Signal-processed EEG apparatus (compressed spectral array and cerebral function monitor) are used to assess global or regional EEG activity for longer periods of time. Interpretation of signal-processed EEG recording requires some experience with this technique, but it is much easier to interpret than a standard 16-lead EEG. These monitors are useful in evaluating some forms of abnormal EEG activity and in monitoring gross changes in global or regional electrical activity. Currently available technology offers dynamic insight into the management of acute neurologic illnesses. The technology in evoked potential and signal processed EEG monitoring will eventually reduce the size and complexity of the instrumentation, making its application routine. Intracranial pressure monitoring is already routine in many intensive care units, although its use is occasionally sporadic. We believe that application of appropriate neurologic monitors improves therapy and outcome in neurologically injured and ill patients.     

Clinical Features and Prognostic Indicators in Paediatric Cerebral Malaria: A Study of 131 Comatose Malawian Children

SUMMARY We studied the relationship between presenting features andoutcome in 131 Malawian children admitted with cerebral malaria(P. falciparum malaria and unrousable coma). A method was devisedfor the measurement of depth of coma in children too young tospeak. Twenty patients (15 per cent) died and 12 (9 per cent)recovered with residual neurological sequelae. Presenting clinicalsigns significantly associated with adverse outcome (death orsequelae) were profound coma, signs of decerebration, absenceof corneal reflexes, convulsions at the time of admission andage under three years. Laboratory findings of prognostic significancewere hypoglycaemia, leucocytosis, hyperparasitaemia, elevatedplasma concentrations of alanine and 5'–nucleo–tidase,and elevated plasma or cerebrospinal fluid lactate. A prognosticindex based on eight of these risk factors that can readilybe ascertained at the bedside or in a ward sideroom, was moreaccurately predictive of outcome than any single feature. Suchan index may be valuable as a measure of severity of illnessfor establishing the comparability of study groups, and forevaluating the role of other factors in the pathogenesis ofcerebral malaria.     

基于脑性昏迷患者感知水平的唤醒干预对其觉醒意识及预后的影响

目的 探讨感知水平唤醒干预措施应用于脑性昏迷患者的效果。 方法 选取我院ICU于2010年3月至2014年2月收治的82例颅脑损伤伴重度脑性昏迷患者,根据诊治先后顺序进行分组,分别设为对照组（n=43）和实验组（n=39）。 对照组开展常规护理模式;实验组开展感知唤醒干预措施。 比较两组在不同时期的格拉斯哥昏迷评分（Glasgow Coma Score, GCS）、功能障碍评分（Dysfunction Score,DFS）、脑电图（Electroencephalogram,EEG）评分,并比较听觉脑干诱发电位潜伏期（auditory brainstem evoked potential,ABEP）、苏醒情况及意识状态。 结果 治疗2、3、4周末,实验组GCS及EEG评分均高于对照组（P<0.05）,DFS评分低于对照组（P<0.05）。 治疗4周末,实验组ABEP绝对潜伏期及峰间潜伏期均短于对照组（P<0.01）。 实验组在1~10d、11~20d及21~30d苏醒率高于对照组（P<0.01）,平均苏醒时间短于对照组（P<0.01）,且苏醒总有效率高于对照组（P<0.01）。 结论 感知水平的唤醒干预措施应用于重度脑性昏迷患者,能改善其意识状况,并促进苏醒。     

Les explorations neurophysiologiques chez l’enfant cérébrolésé : quand,comment ?

Neurophysiological tests complete clinical and radiological assessments in brain-injured children. Electroencephalogram (EEG) is clearly helpful to diagnose seizures and brain death while auditory evoked potentials (EP) to assess brainstem dysfunction and predict poor neurological outcome in post-anoxic coma. During the acute phase of severe traumatic brain injury (TBI) and bacterial meningitis, early recognition and treatment of convulsive seizures is essential. The incidence of non-convulsive seizures remains, however, high, varying between 7 and 48%. Although costly and time consuming, continuous EEG monitoring techniques may allow improving seizure detection. Therefore, amplitude integrated EEG techniques have been developed; however, they still require assessment in paediatrics. Some EEG patterns are indicative of a final bad outcome, including burst suppression, isoelectric pattern, and status epilepticus. EEG predictive value remains limited and less useful than somatosensory EP (SEP). SEP have excellent predictive value in post-anoxic coma in adults as well as in children (94 to 100%), especially in combination to pupillary reflexes and motor responses assessed after 48 h. In contrast, their predictive value of a good outcome is less reliable. In severe TBI and bacterial meningitis, this performance is also limited. Investigation of cognitive EP or mismatch negativity (MMN) could improve awakening prediction.     

Isolated basilar artery dissection following blunt trauma challenging the Glasgow coma score: A case report

Blunt cerebrovascular injury is a very rare complication of blunt trauma and a diagnostic challenge. A 14 year old male fell 10 m sustaining multi system trauma. The atypical Glasgow Coma Score was six with a fully preserved eye component. Initial whole-body CT scanning demonstrated multiple injuries but no obvious brain injury. Trauma management involved non-operative resuscitation and was successful, however profound coma occurred and brain stem reflexes disappeared on day two. Repeat brain CT scan demonstrated multiple cerebral and cerebellar ischemic lesions and no opacification of the vertebral or basilar arteries. Secondary analysis of the first CT scan demonstrated a small focal basilar artery dissection not initially reported.Our case report highlights an unusual cause of coma after traumatic brain injury where the clinical scenario mimics locked in syndrome. In such circumstances cerebrovascular injury, and in particular traumatic basilar artery dissection, must be actively excluded.     

Coma post-anoxique après arrêt cardiaque et hypothermie,peut-on encore prédire le pronostic en 2014 ?

Hypoxic-ischemic encephalopathy after cardiac arrest (CA) is a frequent cause of intensive care unit (ICU) admission. Incorporated in all recent guidelines, therapeutic hypothermia (TH) has become a standard of care and has contributed to improve prognosis after CA during the past decade. The accuracy of prognostic predictors validated in 2006 by the American Academy of Neurology before the era of TH is less accurate. Indeed, TH and sedation may delay the recovery of motor response and alter the predictive value of brainstem reflexes. A new approach is needed to accurately establish prognosis after CA and TH. A reactive and/or continuous electroencephalogram background (during TH or shortly thereafter) strongly predicts good outcome. On the contrary, unreactive/spontaneous burst-suppression electroencephalogram pattern, together with absent N20 on somatosensory evoked potentials, is almost 100% predictive of irreversible coma. TH also affects the predictive value of neuronspecific enolase (NSE), the main serum biomarker of postanoxic injury. A good outcome can occur despite NSE levels >33 μg/L, so this cutoff value should not be used alone to guide treatment. Diffusion magnetic resonance imagery may help predict long-term neurological sequelae. Awakening from postanoxic coma is increasingly observed, despite the absence of early motor signs and pathological elevation of NSE. In 2014, a multimodal approach to prognosis is recommended to optimize the prediction of outcome after CA.     

Effect of thiopental therapy on cerebral blood flow after total cerebral ischemia

The effect of barbiturate coma upon regional cerebral blood flow (RCBF) and ultimate neurologic outcome was examined after total cerebral ischemia (TCI). TCI was induced in dogs using a relatively noninvasive double-occlusion balloon technique; cardiopulmonary protection was provided during the period of ischemia. RCBF was measured using 15-mu radioactively labeled microspheres. A reproducible pattern of impaired reperfusion of the central nervous system (CNS) was observed in control animals after the restoration of cerebral perfusion pressure after TCI. This pattern was accentuated by the administration of pentothal to induce barbiturate coma. The additional depression in RCBF in those animals receiving pentothal was most prominent in cortical gray matter and brainstem structures at 3 and 6 h after TCI. It was also observed in cortical white matter. No untreated animal surviving TCI achieved a neurologic functional level better than persistent vegetative (decerebrate) survival over 1 wk of observation. Animals receiving 90 mg/kg body weight of pentothal post-TCI demonstrated irreversible cardiogenic shock related to the myocardial depressant effect of the drug. Animals receiving 40 to 60 mg/kg of pentothal post-TCI demonstrated a survival rate similar to that of untreated animals. Although this study did not establish the possible effectiveness of barbiturate coma in improving residual neurologic damage after TCI, the data do demonstrate that any possible effectiveness in this model is not associated with any improvement in the markedly decreased cerebral perfusion after TCI.     

Should we use full analgesic dose of opioids for organ procurement in brainstem dead?

Families facing the growing demand for organ removal from their loved ones are questioning the possible suffering of the brainstem dead patient. A frequent question they ask to coordinating doctors is: Are you sure he will not feel anything? Currently due to the risk of exacerbation of spinal reflexes and abnormal movements following surgical stimuli, it is recommended to use a curarization and an analgesic agent (most often morphine). The doses of opioids are less important than during usual anaesthesia, whereas the person is considered brainstem dead and there is no longer any cerebral integration of the pain. But what assures us that absolutely no more sensibility exists at this precise moment? Should the use of full analgesic dose of opioids not be continued anyway? Could this make the levies more "ethical"?     

Spinal-, brainstem- and cerebrally mediated responses at- and below-level of a spinal cord contusion in rats: Evaluation of pain-like behavior

Pain is a frequent consequence of spinal cord injury (SCI) which may profoundly impair the patients’ quality of life. Valid experimental models and methods are therefore desirable in the search for better treatments. Usually, experimental pain assays depend on stimulus-evoked withdrawal responses; however, this spinal-mediated reflex response may be particularly problematic when evaluating below-level SCI pain due to the development of hyperactive reflex circuitries. In this study, we applied and compared assays measuring cold (acetone), static (von Frey filaments), and dynamic mechanical (soft brush) hypersensitivity at different levels of the neuroaxis at and below the level of injury in a rat model of SCI. We induced an experimental SCI (MASCIS 25 mm weight-drop) and evaluated the development of spinal reflexes (withdrawal), spinal-brainstem-spinal reflexes (licking, guarding, struggling, vocalizing, jumping, and biting) and cerebral-dependent behavior (place escape/avoidance paradigm (PEAP)). We demonstrated increased brainstem reflexes and cerebrally mediated aversive reactions to stimuli applied at the level of SCI, suggesting development of at-level evoked pain behavior. Furthermore, stimulation below-level increased innate reflex responses without increasing brainstem reflexes or aversive behavior in the PEAP, suggesting development of the spasticity syndrome rather than pain-like behavior. While spinal reflex measures are acceptable for studying changes in the spinal reflex pathways and spinal cord, they are not suited as nociceptive behavioral measures. Measuring brainstem organized responses eliminates the bias associated with the spastic syndrome, but pain requires cortical involvement. Methods depending on cortical structures, as the PEAP, are therefore optimal endpoints in animal models of central pain.     

Brain death--think twice before labeling a patient

Brain death is defined as the cessation of cerebral and brainstem function. A 12-year-old boy presented with alleged history of snake bite. He was brain dead with Glasgow Coma Score of 3 and absent corneal reflexes. However, it was only neuroparalytic effect of the venom, which improved in due course of time with antivenoms. This case highlights the occurrence of both internal and external ophthalmoplegia, which would mimic brain death in many ways, thus prompting an intensivist to consider withdrawing ventilatory support, which would be disastrous.     

Quel examen d’imagerie en première intention devant un coma non traumatique en 2012 ?

Causes of non-traumatic coma are multiple, including vascular (basilar artery occlusion, bilateral thalamic infarction, deep cerebral venous system thrombosis, aneurismal subarachno?d hemorrhage, cocaine overdose, posterior reversible encephalopathy), metabolic (hypoglycemic encephalopathy, central pontine and extrapontine myelinolysis, hepatic encephalopathy), and toxic (carbon monoxide or methanol poisoning, Marchiafava-Bignami disease, Gayet-Wernicke encephalopathy), as well related to a tumor, an infection, status epilepticus seizures, and cerebral anoxia. Routinely, due to its availability and acquisition speed, CT-scan is the first-line screening tool at the acute phase. The main objective of CT-scan is to rule out intracranial hemorrhage or space-occupying process. However, its sensitivity is insufficient and MRI is increasingly performed for the etiologic diagnosis of non-traumatic coma to detect brain damage, allowing earlier diagnosis of the causal disease and, in some cases, to introduce a specific treatment.     

Electrical stimulation of motor cortex for pain control: a combined PET-scan and electrophysiological study.

Although electrical stimulation of the precentral gyrus (MCS) is emerging as a promising technique for pain control, its mechanisms of action remain obscure, and its application largely empirical. Using positron emission tomography (PET) we studied regional changes in cerebral flood flow (rCBF) in 10 patients undergoing motor cortex stimulation for pain control, seven of whom also underwent somatosensory evoked potentials and nociceptive spinal reflex recordings. The most significant MCS-related increase in rCBF concerned the ventral-lateral thalamus, probably reflecting cortico-thalamic connections from motor areas. CBF increases were also observed in medial thalamus, anterior cingulate/orbitofrontal cortex, anterior insula and upper brainstem; conversely, no significant CBF changes appeared in motor areas beneath the stimulating electrode. Somatosensory evoked potentials from SI remained stable during MCS, and no rCBF changes were observed in somatosensory cortex during the procedure. Our results suggest that descending axons, rather than apical dendrites, are primarily activated by MCS, and highlight the thalamus as the key structure mediating functional MCS effects. A model of MCS action is proposed, whereby activation of thalamic nuclei directly connected with motor and premotor cortices would entail a cascade of synaptic events in pain-related structures receiving afferents from these nuclei, including the medial thalamus, anterior cingulate and upper brainstem. MCS could influence the affective-emotional component of chronic pain by way of cingulate/orbitofrontal activation, and lead to descending inhibition of pain impulses by activation of the brainstem, also suggested by attenuation of spinal flexion reflexes. In contrast, the hypothesis of somatosensory cortex activation by MCS could not be confirmed by our results.     

高血压脑干出血显微手术治疗

目的：探讨高血压脑干出血的显微外科治疗的手术指征、手术技巧、效果和预后。方法：回顾性分析21例高血压脑干出血患者的临床资料、手术方式、治疗效果及随访资料。结果：21例患者均于显微镜下清除血肿,无手术死亡,术中运用神经电生理监测。11例患者术后神经功能障碍得到改善,5例症状加重持续昏迷。5例术后死亡,术后随访6～18个月,9例生活基本能够自理,7例长期卧床。结论：采用显微外科技术治疗高血压脑干出血,效果良好。     

Approach to the comatose patient

BACKGROUND: Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist. OBJECTIVE: To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient. DATA SOURCE: Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs. DATA SYNTHESIS AND CONCLUSIONS: Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.     

脑干反射对脑性瘫痪的诊断价值探讨

目的：探索脑性瘫痪简便、可靠的诊断方法。方法：研究分析５７例脑性瘫痪患儿１０种脑干反射出现及异常情况。结果：在１０种脑干反射中,除角膜反射,咽反射无明显改变外,其余各种反射均有不同程度异常。主要表现为６个月以内以反射发育落后和延迟出现为主,以后各年龄主要为反射残存和亢进等。结论：脑干反射检查有助于脑性瘫痪的早期诊断;临床类型的区分;脑干损害的存在与否及病变部位的定位等。