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Disorders of consciousness
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7
TVBS
2002 05 20 17:04
1 3
CT
2002 08 16
.Consciousness
the
Content of consciousness
Orientation
percepbility
attitudes
emotions
active
Structural basis
1.ascending
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
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
differential diagnosis
(1) Abulia
(2) Locked-in
syndrome
abulia
The
Locked-in syndrome
Lesion
brain death
Harvard medical school committee 1968
1. Absence
of cerebral function
2. Absence of brainstem function
Brain death
1. Absence
Section
aphasia
A loss
classification
Broca aphasia
Primary
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
Subcortical aphasia
Thalamic
aphasia
Basal ganglion aphasia: nonfluent,
dysarthric, paraphasic
apraxia
The
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
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7
TVBS
2002 05 20 17:04
1 3
CT
2002 08 16
2002 09 07
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8 18
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
1. Optic nerve:
uniocular blindness
2. Optic chiasm:
bitemporal hemianopia
seen in pituitary tumor,
craniopharyngioma
3. Optic tract:
homonymous hemianopia
4. 5. Optic radiation:
quadrant anopia
6. Visual cortex:
homonymous
hemianopia with
macular sparing
anatomy
2. Trochlear nerve:
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
Vertigo
To maintain
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
May be prolonged
Nystagmus horizontal
May be vertical
Other 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
no
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