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Section

Disorders of consciousness

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.Consciousness
the

state of the patients


awareness of self and environment
and
his responsiveness to external
stimulation and inner need.

Content of consciousness
Orientation
percepbility
attitudes
emotions
active

Structural basis
1.ascending

reticular activating system,

ARAS
reticular formation
cerebral hemisphere
2.cortex

thalamus
alert state

clinical manifestation
1.according to level of consciousness
2.according to content of consciousness

1.level of consciousness

(1) Somnolent
(2) Stupor
(3) Coma lesser degree
deep

Somnolent

stupor
Can be roused only by vigorous and
repeated stimuli, when left
unstimulated they quickly drift into a
sleeplike state.

coma
The

patient who appears to be asleep and at


the same time incapable of being aroused
by external stimuli or inner need.
lesser degree coma: reflex (+)
Deep coma: no reaction of any kind is
obtainable, corneal, pupillary, pharyngeal,
tenden reflex (-)

2.content of consciousness
Confusion
(2) Delirium
(3) Special Type
Decorticated Syndrome
Akinetic mutism
(1)

confusion
clouding

of the sensorium
Inability to think with customary speed
Marked by some degree of
inattentiveness and disorientation
accompanied by illusions

Delirium state
Hallucination,

hyperactivity
High fever, atropine overdose, alcohol

Decorticated syndrome
Neocortical

death
ARAS is normal, arousal-nonarousal cycle
Open eyes, blink, swallow, eyes move
Coma, Show no signs of awareness of the
environment or inner need
Vegetative state, decerebrate rigidity
12 in 45 awakened in 2 weeks, >3 month:PVS

Akinetic mutism
The

term akinetic mutism has been applied


to yet another group of patients who are
silent and inert as a result of bilateral
lesions of the anterior parts of the frontal
lobes, leaving the intact of the motor and
sensory pathways; the patient is profoundly
apathetic, lacking to an extreme degree the
psychic drive or impulse to action(abulia).
The abulic patient registers most of what is
happening about him and forms memories.

differential diagnosis
(1) Abulia
(2) Locked-in

syndrome

abulia
The

patient are silent and inert as a result of


bilateral lesions of the anterior parts of the
frontal lobe, leaving intact the motor and
sensory pathways, the patient is lacking to
an extreme degree the psychic drive or
impulse to action.

Locked-in syndrome
Lesion

of the ventral pons (basis pons)


Interrupts the corticobulbar and
corticospinal pathways
depriving the patient of speech and the
capacity to respond in any way except by
vertical gaze and blinking
wakefulness

brain death
Harvard medical school committee 1968
1. Absence

of cerebral function
2. Absence of brainstem function

including spontaneous respiration


3. Irreversibility

Brain death
1. Absence

of cerebral function: Deep coma, total lack of


spontaneous movement, and of motor and vocal responses to
all visual auditory and cutaneous stimulation
2. No spontaneous respiration
3. Absence of brain stem function: Dilated midposition
fixed pupils, corneal reflex, oculocephalic and
oculovestibular test, gag reflex(-), last for 12 hours
4. EEG: flat or isoelectric (<2V) during a 30-minutes
recording
5. Spinal reflex may persist
6. Exclude intoxication, hypothermia, metabolic
disturbance

Section

Aphasia, apraxia, agnosia

aphasia
A loss

or impairment of the production


and/or the comprehension of the spoken or
written language due to an acquired lesion of
the brain
No higher order mental function disturbance
i.e. Confusion, delirium, mental retardation
Not dysarthria
Not aphonia

classification

1.Parasylvian fissure aphasic syndrome


Broca aphasia, Wernicke aphasia
Conduction aphasia
2.Transcortical aphasia
Transcortical motor, sensory, mixed
3.Global aphasia
4.Anomic aphasia
5.Subcortical aphasia syndrome
thalamic aphasia, basal ganglion aphasia

Broca aphasia
Primary

deficit in speech production


Dominant hemisphere
Inferior frontal gyrus, posterior portion

Wernicke aphasia
Primary

deficit in comprehension
Paraphasia: literal: the grass is greel
verbal: the grass is blue
Disturbance in repetition
Wernicke area: posterior portion of
supratemporal gyrus

Transcortical aphasia
Watershed

area
Repetition is remarkably preserved

Anomic aphasia
The

patient lose only the ability to name


people and objects
Middle temporal lobe

Global (Total) aphasia


Left

middle cerebral artery occlusion


All aspects of speech and language are
affected
Can say only a few words

Subcortical aphasia
Thalamic

aphasia
Basal ganglion aphasia: nonfluent,
dysarthric, paraphasic

apraxia
The

term apraxia is applied to a state in which a


clear-minded patient with no weakness, ataxia or
other extrapyramidal derangement and no defect of
the primary modes of sensation loses the ability to
execute highly complex and previously learned
skills and gestures.

apraxia
Ideomotor

apraxia
Ideational apraxia
Melokinetic apraxia
Constructional apraxia
Facial-oral apraxia
Dressing apraxia

agnosia
A highly-ordered

perceptual disturbance, no
elementary sensation disturbance, can not
interpret sensations correctly.
Due to disorders of the association areas in
the parietal lobes.

agnosia
Visual

agnosia: object, face, verbal


Auditory agnosia: verbal
Sensory agnosia
Body image disturbance
non-dominant parietal lobe
Gerstmann syndrome
finger agnosia, right-left confusion, dysgraphia,
Dyscalculation
Dominant hemisphere angular gyrus

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2002 09 07
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Section 3
A.Disturbance of Vision
B. Disturbance of Ocular Movement

A . Visual pathway
Retinaoptic

nerve
optic chiasmoptic tract
lateral geniculate
nucleus (LGN)optic
radiationoccipital
lobe(calcarine sulcus)
Optic chiasm: fibers
from the nasal retinas
cross over

reduced vision

1. One eye
Central retinal artery occlusion
Amaurosis fugax
Retro-bulbar optic neuritis
multiple sclerosis, neuromyelitis optica
Foster-Kennedy syndrome
anosmia, optic atrophy on one side
Papilledema on the other side , seen in frontal lobe
tumor

reduced vision
2. Two eyes
Cortical blindness :
dilated pupil, light reflex is preserved
Toxic: methyl
Deficiency: pernicious anaemia

visual field defect

1. Optic nerve:
uniocular blindness

visual field defect

2. Optic chiasm:
bitemporal hemianopia
seen in pituitary tumor,
craniopharyngioma

visual field defect

3. Optic tract:
homonymous hemianopia

visual field defect

4. 5. Optic radiation:
quadrant anopia

visual field defect

6. Visual cortex:
homonymous
hemianopia with
macular sparing

visual field defect


1.

Optic nerve: uniocular blindness


2. Optic chiasm: bitemporal hemianopia
seen in pituitary tumor, craniopharyngioma
3. Optic tract: homonymous hemianopia
4. Optic radiation: quadrant anopia
5. Visual cortex: homonymous hemianopia with
macular sparing

B. Disorder of ocular movement


anatomy
1. Oculomotor nerve:

levator of lid

superior rectus

inferior rectus

inferior oblique

medial rectus

pupillary sphincters

ciliary muscle

anatomy
2. Trochlear nerve:

superior oblique muscle


3. Abducens nerve:

lateral rectus muscle

ocular paralysis
1. Ocular motor nerve paralysis
Ptosis
Lateral deviation of the eye
Inability to rotate the eye
upward, inward and
downward
Diplopia
Dilated non-reactive pupil,
paralysis of accommodation

ocular paralysis
2. Trochlear nerve
Can not rotate down and outward
The patient complains of special difficulty
in reading or going downstairs

ocular paralysis
3. Abducens nerve
Paralysis of outward movement
Eye deviates medially
Diplopia

ocular paralysis
4. Nuclear ophthalmoplegia
Brain stem lesion: infarction, MS
Accompanied by ipsilateral cranial nerve
paralysis, contralateral hemiplegia

ocular paralysis
5. Internuclear ophthalmoplegia (INO)

ocular paralysis
5. Internuclear ophthalmoplegia (INO)
Gaze:frontal lobe
paramedian pontine
reticular formation
abducens
medial longitudinal
fasciculus ocular
motor

ocular paralysis
5.1 Anterior internuclear
ophthalmoplegia
With a lesion of the
left MLF, the left eye
fails to adduct when
the patient looks to the
right, this condition is
referred to as left
internuclear
ophthalmoplegia.

ocular paralysis
5.2 One-and-a-half
syndrome
Pontine center for gaze
and ipsilateral MLF
One eye lies fixed in the
midline for all
horizontal movements;
the other eye can make
only abducting
movements.

ocular paralysis
6. Superanuclear ophthalmoplegia
Middle frontal gyrus
No diplopia
Two eyes are equally affected
Reflex movements are spared

alterations of the pupils

1. Pupillary light reflex


Optic nerveoptic chiasmoptic tract
Pretectal areabilateral E-W nuclei
Oculomotor nervepupillary sphincter

alterations of the pupils


2. Horner sign
Miosis
Ptosis
Retraction of eye-ball
Loss of sweating on the
same side of face
Due to interruption of
the sympathetic fiber.

Section 4 vertigo and deafness

cranial nerve: vestibular nerve


cochlear nerve
. Vertigo
All subjective and objective illusion of
motion or position, usually rotational.

Vertigo
To maintain

balance: visual system


proprioceptive system
vestibular system
Vestibular system: labyrinth
vestibular nerve
central pathway to cerebellum,
MLF, autonomic center

Vertigo
Peripheral

Central

Location

Labyrinth, vestibular
nerve

Brain stem,
cerebellum, cortex

Etiology

Labyrinthitis, menieres
disease, vestibular
neuronitis, otitis media

VBI, acoustic
neuroma, temporal
epilepsy

Vertigo

Severe, short attack

May be prolonged

Nystagmus horizontal

May be vertical

Other sign

Cranial nerve palsy,


contralateral
pyramidal sign

Deafness, tinnitus

deafness
Auditory system:
External auditory canaltympanic membrane
stapesoval window
organ of corti, hair cellcochlear nerve
ponsbilateral lateral lemniscusinferior
colliculusmedial geniculate bodytemporal
lobe

deafness
1. Conductive deafness
Otitis media, rupture of the tympanic
membrane, cholesteatoma
2. Sensorineural deafness
Menieres disease, drugsaminoglycosides,
acoustic neuroma, infarction, multiple
sclerosis
Exam: Auditory evoked potentials

Section 5 Syncope
. Syncope
an episodic loss of consciousness and
postural tone and an inability to stand,
due to diminished flow of blood to the
brain.

Section 5 Syncope
. Causes:
1. Reflex syncope
vasodepressor syncope, orthostatic
hypotention, carotid sinus hypersensitivity,
micturitional, vagoglosssopharyngeal,
associated with glossopharyngeal neuralgia

Section 5 Syncope
2. Cardiac syncope
arrythmia, myocardial, obstruction
3. Brain
TIA, arteritis
4. Other causes
anemia, hypoglycemia, hypoxia

Section 5 Syncope
clinical feature
1. Prodrome
dizziness, vertigo, pallor, sweating, dim
vision, tinnitus
2. Episode
loss of consciousness, fall to ground,
Bp<60mmHg, if more than 25 seconds may
have convulsion
3. Post episode
Regain consciousness, no sequela

Thank you for listening!

no
naojianfei@hotmail.com

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