Disorders of consciousness
Jan Kočica, Blanka Adamová
Neurology – lecture (aVLNE9X1p)
Neurology – lecture (aVLNE9X1p)
Consciousness disorders
̶ Consciousness is awareness of the internal and external world = a state in
which the individual is fully aware of him/herself and his/her surroundings
and is able to act according to his/her free will and respond adequately
to external and internal stimuli.
VIGILANCE (vigility, wakefulness)
The ability to adequately respond to stimuli from an external environment.
CONSCIOUSNESS
LUCIDITY (awareness)
The ability to be aware of one's own existence in the waking state and to correctly
interpret perceptions from one's surroundings. Vigility is therefore a condition of lucidity.
Neurology – lecture (aVLNE9X1p)
Consciousness disorders – physiology
̶ To maintain consciousness, proper reticular formation (RF) of the brainstem and
its connection with diencephalic structures (thalamus, hypothalamus) and
cerebral cortex (temporo-parieto-occipital border and frontal medial cortex) is
necessary.
̶ The ascending reticular activation system (ARAS), sometimes also described as RAS or
extrathalamic reticular control modulatory system, functions as an afferent system for the control of
predominantly alertness.
̶ RF is a group of interconnected neurons throughout the brainstem (from the midbrain to the medulla
oblongata). Continuing in the spinal cord like the reticulospinal tract.
Consciousness disorders – pathophysiology
̶ However, extracerebral/systemic causes are more common (such as
hypo/hyperglycaemia, intoxication, hypotension or any conditions generally leading to
decreased brain perfusion).
̶ For impaired consciousness as part of a structural (focal) impairment of the brain, the
patient must have:
̶ Brain stem lesion or
̶ affected both hemispheres,
̶ Unilateral hemispheric lesions do not lead to a disorder of consciousness unless the other
hemisphere is affected at the same time/secondarily (e.g. by overpressure of midline
structures due to oedema).
Neurology – lecture (aVLNE9X1p)
Consciousness disorders – basic concept
VIGILANCE (vigility, wakefulness) – QUANTITATIVE CONSCIOUSNESS DISORDERS
Inability (affects arousal) to respond adequately to a stimuli of an external environment.
CONSCIOUSNESS
LETHARGY (DROESINNESS)
STUPOR
COMA
Neurology – lecture (aVLNE9X1p)
Consciousness disorders – basic concept
CONSCIOUSNESS
LETHARGY (DROESINNESS)
STUPOR
COMA
There is no spontaneous level of vigilance, increased drowsiness. Patient can be awakened by addressing or
touching – reacts with latency/slowly, inaccurately. If the impulse to maintain vigilance disappears, the
patient falls asleep. Somnolence can be caused, for example, by sleep deprivation.
No spontaneous level of vigiliance. The patient can not be awakened addressing, but only by strong
stimulation (algic/nociceptive stimulus). It usually answers in one word or makes incomprehensible sounds.
Does not respond to stimuli at all (deep coma) or responds non-specifically / very limited / imperfectly to
strong algic/nociceptive stimulation.
Neurology – lecture (aVLNE9X1p)
VIGILANCE (vigility, wakefulness) – QUANTITATIVE CONSCIOUSNESS DISORDERS
Consciousness disorders – basic concept
CONSCIOUSNESS
LUCIDITY (awareness) – QUALITATIVE CONSCIOUSNESS DISORDERS
Inability to be aware of one's own existence and to correctly interpret perceptions from
one's surroundings. Vigility is a condition of lucidity.
DELIRIUM
Non-specific response to various somatic disorders (e.g., metabolic or infectious) or intoxication. Organic
mental disorder.
• Sudden onset (max. in days) and fluctuating course (often with a sleep-wake cycle disorder).
• Attention and perception disorder (disorientation by time, place and person) and acute cognitive
dysfunction (usually all domains - i.e., memory, attention, concentration, executives (planning,
organization, working memory), speech, spatial orientation) dominate.
• Often accompanied by psychiatric manifestations (restlessness, agitation, hallucinations, delusions and
aggression). It may be accompanied by motor restlessness (e.g. tremor), sweating and tachycardia.
Neurology – lecture (aVLNE9X1p)
Consciousness disorders – basic concept
Consciousness – physical examination
̶ What questions should a physician ask when examining a patient
with impaired consciousness?
1) What is the severity and character of the disorder of consciousness?
2) Where can be an expected location of the disability?
3) What is the cause of the disability?
How serious is the situation?
Neurology – lecture (aVLNE9X1p)
Consciousness – physical examination
̶ Examination usually takes place on emergency department with
little anamnestic data (paramedic‘s report, relatives, witnesses).
̶ Glasgow Coma Scale (GCS) - a simple reproducible and fast
method to assess the level of consciousness (quantitative
impairment of consciousness, vigility).
̶ Widely used scale to assess the initial severity of traumatic brain injury.
1) What is the severity and character of the disorder of consciousness?
Neurology – lecture (aVLNE9X1p)
Glasgow Coma Scale (GCS)
BEST EYE RESPONSE (E)
Spontaneously. + 4 body
To verbal command. + 3 body
To pain. + 2 body
No eye opening. + 1 bod
BEST VERBAL RESPONSE (V)
Oriented. + 5 bodů
Confused. + 4 body
Inappropriate words. + 3 body
Incomprehensible sounds. + 2 body
No verbal response. + 1 bod
BEST MOTOR RESPONSE (M)
Obeys commands. + 6 bodů
Localizes pain. + 5 bodů
Withdrawal from pain. + 4 body
Flexion to pain (decortication). + 3 body
Extension to pain (decerebration). + 2 body
No motor response. + 1 bod
Coma
8 or less Severe
9 – 12 Medium
13 + Light
Neurology – lecture (aVLNE9X1p)
Consciousness – physical examination
̶ Evaluation of lucidity/awareness:
̶ We usually evaluate the orientation of a patient by person, place and time.
̶ What is your name? What is the day today? What is the current year? Where are we? In
which city are we? Try to describe what I'm wearing right now. Point to a nurse – Do you
know what her/his job is?
̶ If the patient responds appropriately and correctly, only then can a valid
anamnesis be taken.
̶ If the patient has a qualitative disorder of consciousness, we must not forget
to record this fact in the documentation when taking the anamnesis!
1) What is the severity and character of the disorder of consciousness?
Neurology – lecture (aVLNE9X1p)
1) What is the severity and character of the disorder of consciousness?
Consciousness – examination record
Normal findings:
Objective examination:
Patient conscious/vigil, oriented, cooperating,…
Lucid, cooperating,…
Pathological findings:
Objective examination:
Deep stupor, GCS 9 (E2V3M4),…
Neurology – lecture (aVLNE9X1p)
Consciousness – physical examination
2) Where can be an expected location of the disability?
• Evaluation of vital functions (respiration, blood pressure, heart activity)
• Blood samples are usually taken in parallel (incl. Acid-base balance or toxicology)
ASPECTION
• Overall appearance? Posture? Spontaneous movements? Response to external stimuli? Asymmetry
of a limb movement? Involuntary movements?
SOMATIC EXAMINATION
• It is usually performed in parallel by an emergency physician.
• Signs of trauma, bleeding, examination of the heart, abdomen,…
Neurology – lecture (aVLNE9X1p)
Consciousness – physical examination
2) Where can be an expected location of the disability?
NEUROLOGICAL EXAMINATION
• Assessment of a level of consciousness disorder.
• Determination of whether the brain stem functions are intact.
• Examination of eye symptoms (position of bulbs, movements, pupillary reactions).
• Muscle tone test and examination of focal symptoms.
• The nature of breathing.
Neurology – lecture (aVLNE9X1p)
Consciousness – physical examination
EYEBALLS POSITION
• Are they in an asymmetrical position?
• Wandering movements of bulbs?
EYEBALLS MOVEMENT
• Spontaneous movements?
• Are oculomotor nerves intact?
Conjugated left deviation of bulbs – both bulbs turn to „see
the leasion“ (destructive lesion).
Skew deviation – Abnormal horizontal-torsional
position of the left bulb.
Divergent position of bulbs. Often accompanies
severe impairment of consciousness.
Consciousness – physical examination
EYEBALLS MOVEMENT - OCULOCEFALIC REFLEX
OCULOCEFALIC REFLEX (horizontal/vertical)
• The positive is manifested by
conjugate deviation/twisting of both
eyeballs to the opposite direction to
the position of the head.
• If positive, integrity of the pons Varoli
(if horizontal) is maintained.
• The manoeuvre also tests the
intactness of the oculomotor nerves,
vestibular nuclei and fasciculus
longitudinalis medialis (FLM).
Positive = Intact
Negative = non-intact
Consciousness – physical examination
EYEBALLS MOVEMENT – OCULOCALORIC REFLEX
OCULOCALORIC REFLEX
• 10-15 ml of physiological solution is applied
to the ear canal, while the reflex is equipped
with a deviation of bulbs to the application
side.
• In general, hot water (room
temperature) leads to the deviation of
the bulbs to the opposite side and cold
water to the application side.
• If the movement is only with one bulb, then
it is still true that there is probably a brain
stem lesion.
Consciousness – physical examination
EYE SLIT
• It is necessary to distinguish whether it is ptosis
of the eyelid or paresis of the facial nerve (watch
wrinkles, lagophthalmus).
PUPILLAR REFLEXES
• Evaluate symmetry, size (miosis/mydriasis),
shape, symmetry (anisocoria) and photoreaction.
Incomplete lesions of the oculomotor nerve (III) - Dilated (mydriatic)
fixed (non-reactive) pupil on the side of the lesion - can be caused by
swelling on the side of the lesion or the temporal conus.
Bilateral myotic (narrowed) reactive (unfixed) pupils.
They may be part of opiate intoxication or bilateral diencephalic lesions
(sympathetic) at the level of the thalamus and hypothalamus.
Bilaterally dilated (mydriatic) fixed (areaactive).
They can be severe hypoxemia or signs of death.
Normal or myotic responding pupil together with semiptosis
of the eyelid and possible anhidrosis of the forehead.
Part of the so-called Horner's syndrome (eg carotid dissection).
Consciousness – physical examination
BRAINSTEM REFLEXES
• They correspond to certain levels of the brainstem.
• NAZOPALPEBRAL REFLEX
(Diencephalo-mesencephalic junction)
= Hammering between the eyelids (at the level of
the eyebrows, glabella) leads to bilateral blinking
(syn. Fronto-orbicular). When repeated, it
extinguishes reflexively!
• OCULOCEFALIC VERTICAL REFLEX
(Diencephalo-mesencephalic junction)
Consciousness – physical examination
BRAINSTEM REFLEXES
• They correspond to certain levels of the brainstem.
• PHOTOREACTION (middle part of the mesencephalon)
• Direct (leads to equilateral miosis)
• Indirect (also contralateral miosis)
• CORNAL REFLECTION (pons Varoli, n. V, n. VII, n. III)
= Touching on the edge of the cornea leads to
blinking (straight to the same side and indirect to
the other side). Disorder indicates a serious
condition.
Consciousness – physical examination
BRAINSTEM REFLEXES
• OCULOCEFALIC HORIZONTAL (lower pons Varoli, n. VI)
• OCULOCARDIAL (lower pons - elongated spinal cord, n. V)
= by pressing on bulbs with figers, we cause a decrease in
heart rate (by at least 15BPM in the first 20 seconds).
We perform it only in patients on the monitor, if it is possible,
because with a reflex we can cause heart arrest in patients!
• GAG A COUGHING REFLEX
= Cough when intubating or when handling kanyla.
Consciousness – physical examination
MOVEMENT
DECORATION SYNDROME
• Disorders at the level of the thalamus and both
cerebral hemispheres.
• Brainstem functions are intact.
• Unconsciousness + decortication rigidity (reaction
to nociceptive stimulus)
• Upper limb/s flexion in elbows and wrists.
• Lower limb/s extension in the knees and
insteps.
DECORATION
DECEREBRATION
Consciousness – physical examination
MOVEMENT
DECEREBRATION SYNDROME
• Usually due to extensive brainstem involvement
(especially herniation)
• Unconsciousness + decerebral rigidity
• Upper limb/s extension in the elbows, flexion
with pronation in the wrist.
• Lower limb/s extension in the knees and
insteps.
DECORATION
DECEREBRATION
Neurology – lecture (aVLNE9X1p)
Consciousness – examination record
Objective examination:
̶ Deeply stuporous, GCS 9 (E2V3M4), spontaneous and regular breathing (BF
18/min, SpO2 95% without O2 supp.), 80 BPM, responds to an algic stimuli with an
unorganised defensive reaction/withdrawal, eyelid sym., Bulbs in the middle position,
pupils isocoric (4/4), not following, oculocephalic reflex intact, while bulbs moving in
all directions, the corneal reflex is present,…
Objective exam.:
̶ Stupor, GCS 9 (E2V3M4), breat.spont.,reg. (BF 18, SpO2 95%), HR 80BPM, eyelid
sym., bulbs midd., isocoric (4/4), not follow., oculoceph.r. +/+ with oculomot. intakt.,
corneal.r +, …
Consciousness – examination record
3) What is the cause of the disability?
̶ The diagnosis depends on the anamnesis, objective examination and
paraclinical examination (e.g., brain imaging or blood sampling).
̶ We should realize whether these are more:
̶ Diffuse - encephalopathy (e.g., metabolic, post-anoxic involvement, hypoglycemic coma,
uremic coma, etc.) and is therefore a generalized involvement of the brain (stem and
hemispheres), including the ARAS system.
̶ Supratentorial lesion (localized, focal symptoms) - a lesion above the tentorium cerebelli
(mesencephalon), which is usually accompanied by an increase in intracranial pressure
(e.g., swelling) and a possible impairment of consciousness is caused by oppression of the
brain stem (e.g., transtentorial herniation).
̶ Infratentorial lesions (localized, focal symptoms) - lesions of the brain stem (e.g., a stroke
in the posterior cerebral circulation, expansion process in the cerebellar corner, etc.)
Neurology – lecture (aVLNE9X1p)
Disorders of consciousness - syndromes
APALLIC SYNDROME (Coma vigile, vegetative state)
= impaired consciousness with preserved vigilance/vigility, but
without signs of lucidity (the patient opens his/her eyes
spontaneously or after stimulation, but does not realize him/herself,
does not perceive the surroundings, does not respond correctly)
̶ Usually with extensive cortico-subcortical brain damage (often after hypoxia after CPR,
extensive brain trauma), while the structures of the diencephalon and brainstem are
preserved.
̶ Patient breathes spontaneously, often wandering movements of bulbs that do not fix can be
seen, the brainstem reflexes are intact, lacking higher cortical functions, however KP
comp., There may be increased perspiration or other disorders of the autonomous system.
̶ Sometimes there may be vocalization or spontaneous limb movements.
Neurology – lecture (aVLNE9X1p)
Spinal examination
Jan Kočica, Blanka Adamová
Neurology – lecture (aVLNE9X1p)
SPINAL EXAMINATION
̶ We examine the cervical, thoracic and lumbar region.
SPINE POSITION AND POSTURE
The examiner assesses statics (ie spine posture - curvature (scoliosis (coronary), lordosis,
kyphosis)) and dynamics (ie spine development - forward and tilt (anteflexion and
retroflexion), inclination (side bends) and rotation). We mainly monitor the atypical
position of the spine.
ASPECTION
PALPATION AND PERCUSSION
The examiner palpates mainly paravertebral muscle spasms.
SPINAL EXAMINATION
SPINE POSITION AND POSTURE
In addition to birth defects (including eg
abbreviations the lower limb/s), scoliosis must
also be monitored in patients with hemiparesis
(eg demyelinating diseases or ischemic
diseases).
ASPECTION
STATICS DISORDERS
HYPEKYPHOSE (sag.)
HYPERLORDOSIS (sag.)
SCOLIOSIS (cor.)
SPINAL EXAMINATION
SPINE POSITION AND POSTURE
First, we observe the standing position (antalgic
posture? Defective rotation?)
We examine both with active patient movement
(upon request) and then passively (with the help
of the examiner)
ASPECTION
DYNAMICS DISORDERS
SPINAL EXAMINATION
CERVICAL SPINE EXAMINATION
CAVE: when traumatic changes are suspected!
• Best while sitting.
• Is the head at rest normal? (rotation to one side with lifting of the arm?)
• Blockages of the cervical spine in the upper section are more pronounced when the head rotates in the
forward bend.
• Blockages of the cervical spine in the lower section are more pronounced when the head rotates in the
backward bend.
• Paravertebral spasms? Percussion pain?
Rotation 80° Extension 80° Flection 50°Inclination 45°
SPINAL EXAMINATION
THORACIC SPINE EXAMINATION
• We also investigate sitting down a patient.
• Quantification tests („GREAT“ SCHOBER, STIBOR)
• SCHOBER TEST FOR CHEST MOBILITY (so-called "GREAT SCHOBER")
• We mark C7 + 30 cm caudally (use, for example, a tailor's tape), their distance will increase to 33-34
cm when bending forward and will decrease to 28-29 cm when bending backward.
SPINAL EXAMINATION
THORACIC SPINE EXAMINATION
• We also investigate sitting down a patient.
• Quantification tests („GREAT“ SCHOBER, STIBOR)
STIBOR TEST
• Mark C7 and L5 and measure the distance. When bending forward, it increases by 10 cm and more.
SPINAL EXAMINATION
LUMBAR SPINE EXAMINATION
• Examined best while standing.
• Among other things, the length of the lower limb/s and the position of the pelvis are evaluated.
SCHOBER TEST FOR LUMBAR SPINE MOBILITY (so-called "SMALL SCHOBER")
• Make a mark above the S1 and another 10 cm cranially, while in maximum forward bend, the marks
should move away by 5 cm, shortening by 1-2 cm at the backward bend.
SPINAL EXAMINATION
LUMBAR SPINE EXAMINATION
• Examined best while standing.
• Among other things, the length of the lower limb/s and the position of the pelvis are evaluated.
THOMAYER TEST
• In the maximum active forward bend, we measure the distance of the patient's fingertips from the
floor. We also monitor the development of the spine during this test.
Lékařská fakulta Masarykovy univerzity
2021