Structural and functional connectivity of the ascending arousal network for prediction of outcome in patients with acute disorders of consciousness.

To determine the role of early acquisition of blood oxygen level-dependent (BOLD) signals and diffusion tensor imaging (DTI) for analysis of the connectivity of the ascending arousal network (AAN) in predicting neurological outcomes after acute traumatic brain injury (TBI), cardiopulmonary arrest (CPA), or stroke. A prospective analysis of 50 comatose patients was performed during their ICU stay. Image processing was conducted to assess structural and functional connectivity of the AAN. Outcomes were evaluated after 3 and 6 months. Nineteen patients (38%) had stroke, 18 (36%) CPA, and 13 (26%) TBI. Twenty-three patients were comatose (44%), 11 were in a minimally conscious state (20%), and 16 had unresponsive wakefulness syndrome (32%). Univariate analysis demonstrated that measurements of diffusivity, functional connectivity, and numbers of fibers in the gray matter, white matter, whole brain, midbrain reticular formation, and pontis oralis nucleus may serve as predictive biomarkers of outcome depending on the diagnosis. Multivariate analysis demonstrated a correlation of the predicted value and the real outcome for each separate diagnosis and for all the etiologies together. Findings suggest that the above imaging biomarkers may have a predictive role for the outcome of comatose patients after acute TBI, CPA, or stroke.

Disorders of Consciousness: Practical Management in an Emergency Room

Lowering of the level of consciousness is a very common presentation at the emergency room, often without any history that helps finding an etiology. This emergency requires quick empirical measures to reduce neuronal mortality, with additional protection against sequelae. According to the Advanced Cardiac Life Support (ACLS) guidelines, there are current emergency neurological support protocols, such as the Emergency Neurological Life Support (ENLS) created by the Neurocritical Care Society. The present paper shows how to approach unconscious patients, highlighting possible etiologies and proposed treatments.

Autonomic impairment of patients in coma with different Glasgow coma score assessed with heart rate variability.

PRIMARY OBJECTIVE: The objective of this study is to assess the functional state of the autonomic nervous system in healthy individuals and in individuals in coma using measures of heart rate variability (HRV) and to evaluate its efficiency in predicting mortality. DESIGN AND METHODS: Retrospective group comparison study of patients in coma classified into two subgroups, according to their Glasgow coma score, with a healthy control group. HRV indices were calculated from 7 min of artefact-free electrocardiograms using the Hilbert-Huang method in the spectral range 0.02-0.6 Hz. A special procedure was applied to avoid confounding factors. Stepwise multiple regression logistic analysis (SMLRA) and ROC analysis evaluated predictions. RESULTS: Progressive reduction of HRV was confirmed and was associated with deepening of coma and a mortality score model that included three spectral HRV indices of absolute power values of very low, low and very high frequency bands (0.4-0.6 Hz). The SMLRA model showed sensitivity of 95.65%, specificity of 95.83%, positive predictive value of 95.65%, and overall efficiency of 95.74%. CONCLUSIONS: HRV is a reliable method to assess the integrity of the neural control of the caudal brainstem centres on the hearts of patients in coma and to predict patient mortality.

[Myxedema coma]. / Coma mixedematoso.

Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

Coma mixedematoso / Myxedema coma

El hipotiroidismo es una enfermedad frecuente, de diagnóstico y tratamiento simples. Si no es detectada a tiempo puede progresar a la forma más grave conocida como coma mixedematoso. El término "coma mixedematoso" es considerado generalmente engañoso, ya que la mayoría de los pacientes no se presenta inicialmente en estado de coma. La progresión típica es la letargia, evolucionando al estupor y eventualmente al coma, con insuficiencia respiratoria e hipotermia. Es relativamente infrecuente, afecta fundamentalmente a mujeres ancianas, y a menudo ocurre en invierno. Esta entidad debe ser considerada una forma de hipotiroidismo descompensado, desencadenada a partir de una variedad de enfermedades o condiciones no tiroideas que provocan un compromiso sistémico generalizado de extrema gravedad, con desenlace fatal de no mediar un diagnóstico precoz y un tratamiento intensivo.

Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

The impact of acute brain dysfunction in the outcomes of mechanically ventilated cancer patients.

INTRODUCTION: Delirium and coma are a frequent source of morbidity for ICU patients. Several factors are associated with the prognosis of mechanically ventilated (MV) cancer patients, but no studies evaluated delirium and coma (acute brain dysfunction). The present study evaluated the frequency and impact of acute brain dysfunction on mortality. METHODS: The study was performed at National Cancer Institute, Rio de Janeiro, Brazil. We prospectively enrolled patients ventilated >48 h with a diagnosis of cancer. Acute brain dysfunction was assessed during the first 14 days of ICU using RASS/CAM-ICU. Patients were followed until hospital discharge. Univariate and multivariable analysis were performed to evaluate factors associated with hospital mortality. RESULTS: 170 patients were included. 73% had solid tumors, age 65 [53-72 (median, IQR 25%-75%)] years. SAPS II score was 54[46-63] points and SOFA score was (7 [6-9]) points. Median duration of MV was 13 (6-21) days and ICU stay was 14 (7.5-22) days. ICU mortality was 54% and hospital mortality was 66%. Acute brain dysfunction was diagnosed in 161 patients (95%). Survivors had more delirium/coma-free days [4(1,5-6) vs 1(0-2), p<0.001]. In multivariable analysis the number of days of delirium/coma-free days were associated with better outcomes as they were independent predictors of lower hospital mortality [0.771 (0.681 to 0.873), p<0.001]. CONCLUSIONS: Acute brain dysfunction in MV cancer patients is frequent and independently associated with increased hospital mortality. Future studies should investigate means of preventing or mitigating acute brain dysfunction as they may have a significant impact on clinical outcomes.

Transdermal methyl alcohol intoxication cause of pain relief.

A 60-year old female patient was found comatosed at home and taken to the hospital's Emergency Department by her relatives. It was learnt that she wrapped her knees with spirit-impregnated cotton pad for pain for one week. On physical examination, only a colour change of purple violet on her knees was noted. Metabolic acidosis with increased anion gap was detected by arterial blood analysis. The patient underwent haemodialysis. She was discharged from the hospital with no complaints, alert and rational following five days of follow-up treatment, with the diagnosis of methyl alcohol poisoning.

Heart rate variability for assessing comatose patients with different Glasgow Coma Scale scores.

OBJECTIVE: To assess the autonomic nervous system (ANS) in coma by heart rate variability (HRV). METHODS: Sixteen comatose patients and 22 normal subjects with comparable ages and genders were studied. Patients were classified in two subgroups according to the Glasgow Coma Scale (GCS). Time, frequency, and informational HRV domain indices were calculated. RESULTS: A notable reduction of HRV was found in patients. Regarding the time domain indices, the triangular index, and the Delta_RRs, were significantly reduced in the subgroup with GCS=3. Absolute power for the whole frequency spectrum decreased whenever GCS scores were lower. A significant decrement was found for absolute power of the VLF and LF bands in the subgroup of GCS=3, and although it was lower for the HF band in these patients, those changes were not statistically significantly different. The LF/HF ratio and the Shannon´s entropy indices were significantly reduced in the subgroup with GCS=3. Our results are discussed regarding the progressive dysfunction the ANS networks when coma deepens. CONCLUSIONS: The HRV procedure is a powerful tool to assess the ANS in comatose patients. SIGNIFICANCE: HRV is a minimally invasive, low-cost methodology, suitable for assessing the ANS in coma.

Refractory nonconvulsive status epilepticus in coma: analysis of the evolution of ictal patterns.

OBJECTIVE: Nonconvulsive status epilepticus (NCSE) is currently considered as one of the most frequent types of status epilepticus (SE). The objective of the present study was to identify the natural history of the electrographical evolution of refractory NCSE and to establish the relationship between ictal patterns and prognosis. METHODS: We analyzed, retrospectively, 14 patients with loss of consciousness and NCSE. The ictal patterns were classified as discrete seizures (DS), merging seizures (MS), continuous ictal discharges (CID), continuous ictal discharges with flat periods (CID-F), and periodic lateralized epileptiform discharges (PLEDs). RESULTS: The ictal patterns were DS (n=7; 50.0%), PLEDs (n=3; 1.4%), CID (n=2; 14.3%), MS (n=1; 7.1%), and CID-F (n=1; 7.1%). CONCLUSIONS: NCSE electrographic findings are heterogeneous and do not follow a stereotyped sequence. PLEDs were related to a higher probability of neurological morbidity and mortality.

Refractory nonconvulsive status epilepticus in coma: analysis of the evolution of ictal patterns / Estado de mal epiléptico não convulsivo refratário no coma: análise da evolução dos padrões ictais

OBJECTIVE: Nonconvulsive status epilepticus (NCSE) is currently considered as one of the most frequent types of status epilepticus (SE). The objective of the present study was to identify the natural history of the electrographical evolution of refractory NCSE and to establish the relationship between ictal patterns and prognosis. METHODS: We analyzed, retrospectively, 14 patients with loss of consciousness and NCSE. The ictal patterns were classified as discrete seizures (DS), merging seizures (MS), continuous ictal discharges (CID), continuous ictal discharges with flat periods (CID-F), and periodic lateralized epileptiform discharges (PLEDs). RESULTS: The ictal patterns were DS (n=7; 50.0%), PLEDs (n=3; 1.4%), CID (n=2; 14.3%), MS (n=1; 7.1%), and CID-F (n=1; 7.1%). CONCLUSIONS: NCSE electrographic findings are heterogeneous and do not follow a stereotyped sequence. PLEDs were related to a higher probability of neurological morbidity and mortality.

OBJETIVO: Estado de mal epiléptico não convulsivo (EMENC) é atualmente considerado uma das formas mais frequentes de estado de mal epiléptico. O objetivo deste estudo foi identificar a história natural da evolução eletrográfica do EMENC refratário, bem como estabelecer relações entre padrões ictais e o prognóstico. MÉTODOS: Foram analizados, retrospectivamente, 14 pacientes com comprometimento da consciência e EMENC. Os padrões ictais foram classificados em crises isoladas (CI), crises subintrantes (CS), descarga ictal contínua (DIC), descarga ictal contínua com períodos de atenuação (DIC-A) e descargas epileptiformes periódicas lateralizadas (PLEDs). RESULTADOS: Os padrões ictais observados foram CI (n=7; 50,0%), PLEDs (n=3; 1,4%), DIC (n=2; 14,3%), CS (n=1; 7,1%) e DIC-A (n=1; 7,1%). CONCLUSÕES: Achados eletrográficos no EMENC refratário são heterogêneos e não obedecem a uma sequência estereotipada. As PLEDs estão associadas à maior probabilidade de morbidade e mortalidade neurológica.

Non-epileptiform EEG abnormalities: an overview.

More than 80 years after its introduction by Hans Berger, the electroencephalogram (EEG) remains as an important supplementary examination in the investigation of neurological disorders and gives valuable and accurate information about cerebral function. Abnormal EEG findings may include ictal patterns, interictal epileptiform activity and non-epileptiform abnormalities. The aim of this study is to make an overview on the main non-epileptiform EEG abnormalities, emphasizing the pathologic findings and the importance of their recognition, excluding periodic patterns and EEG physiologic changes. Scientific articles were selected from MEDLINE and PubMed database. The presence of non-epileptiform EEG abnormalities provide evidence of brain dysfunction that are not specific to a particular etiology and may be related to a number of disorders affecting the brain. Although these abnormalities are not specific, they can direct attention to the diagnostic possibilities and guide the best treatment choice.

Non-epileptiform EEG abnormalities: an overview / Anormalidades eletrencefalográficas não epileptiformes: uma visão geral

More than 80 years after its introduction by Hans Berger, the electroencephalogram (EEG) remains as an important supplementary examination in the investigation of neurological disorders and gives valuable and accurate information about cerebral function. Abnormal EEG findings may include ictal patterns, interictal epileptiform activity and non-epileptiform abnormalities. The aim of this study is to make an overview on the main non-epileptiform EEG abnormalities, emphasizing the pathologic findings and the importance of their recognition, excluding periodic patterns and EEG physiologic changes. Scientific articles were selected from MEDLINE and PubMed database. The presence of non-epileptiform EEG abnormalities provide evidence of brain dysfunction that are not specific to a particular etiology and may be related to a number of disorders affecting the brain. Although these abnormalities are not specific, they can direct attention to the diagnostic possibilities and guide the best treatment choice.

Mais de 80 anos após sua introdução por Hans Berger, o eletrencefalograma (EEG) permanece como importante exame complementar na investigação de transtornos neurológicas e fornece informações valiosas e precisas a respeito da função cerebral. Achados eletrencefalográficos anormais podem incluir padrões ictais, atividade epileptiforme interictal e anormalidades eletrencefalográficas não epileptiformes. O objetivo deste estudo é fazer uma revisão das principais anormalidades eletrencefalográficas não epileptiformes, enfatizando os achados patológicos e a importância de seu reconhecimento, excluindo padrões periódicos e alterações eletrencefalográficas fisiológicas. Foram selecionados artigos científicos por meio de pesquisa nas bases de dados MEDLINE e PubMed. A presença de anormalidades eletrencefalográficas não epileptiformes fornece evidências de disfunção cerebral, as quais não são específicas para uma etiologia particular e podem estar relacionadas a uma série de desordens que afetam o encéfalo. Embora essas anormalidades não sejam específicas, elas podem direcionar a atenção para as possibilidades diagnósticas e guiar a escolha do melhor tratamento.

Vestibulo-ocular reflex as predictor of cerebral death in comatose patients.

OBJECTIVE: Our goal was to establish the role of VOR - vestibular ocular reflex - in predicting cerebral death in comatose patients. PATIENTS AND METHODS: Prognosis study based on three concurrent cohorts of comatose patients of known etiology followed until the ultimate outcomes: recovery, vegetative state or death. Sixty comatose patients (Glasgow scale 8 or less) with known causes were studied: 49 males and 11 females; 7 to 83 years old. The cold water vestibular stimulation was performed at the bedside by irrigation with 0o Celsius saline in the external auditory canal during one minute. The reflex was considered present when both eyes deviated toward the stimulated side (19 patients group 1); present but abnormal for irregular unconjugated eye movements (11 patients group 2) or absent (30 patients, group 3). RESULTS: Group 1 had total recovery in 42%, partial recovery in 37% and cerebral death in 21%. These results were 9%, 18% and 73% for group 2, respectively and group 3 had 100% cerebral death. The difference was statistically significant between groups 1 and 2, 3 (p<0,05 Fischer exact test and X2 test). CONCLUSION: Absence of VOR predicted 100% of cerebral death and VOR present normal predicted 21% of cerebral death in the comatose patients we studied.

[Vital signs and facial expression of patients in coma]. / Sinais vitais e expressão facial de pacientes em estado de coma.

The objective was to check music and voice message influence on the vital signals and facial expressions of patients in physiological or induced comas. A randomized controlled clinical trial was done. The sample was consisted of 30 patients from Intensive Care Unit, being divided in 2 groups: Group Control (without auditory stimuli) and Experimental Group (with auditory stimuli). The patients were submitted to 3 sessions for consecutive days. Significant statistical alterations of the vital signs were noted (oxygen saturation - session 1; oxygen saturation - session 3; respiratory frequency - session 3) during the message playback and with facial expression, session 1, during both music and message. Apparently, the voice message is a stronger stimulus than the music in relation to the capacity of producing suggestive physiological auditory responses.

Sinais vitais e expressão facial de pacientes em estado de coma / Vital signs and facial expression of patients in coma / Signos vitales y expresión facial de pacientes en estado de coma

O objetivo foi verificar a influência da música e mensagem oral sobre os Sinais Vitais e Expressão Facial dos pacientes em coma fisiológico ou induzido. Realizou-se um Ensaio Clínico Controlado e Randomizado. A amostra consistiu-se de 30 pacientes de Unidade de Terapia Intensiva, que foram divididos em 2 grupos: Grupo Controle (sem estímulos auditivos) e Grupo Experimental (com estímulos auditivos). Os pacientes foram submetidos a 3 sessões, em dias consecutivos. Encontraram-se alterações estatisticamente significativas nos sinais vitais (saturação de O2 - sessão 1; saturação de O2 - sessão 3; freqüência respiratória - sessão 3) durante a mensagem e na expressão facial, sessão 1, durante a música e a mensagem. Aparentemente a mensagem foi um estímulo mais forte do que a música em relação à capacidade de produzir respostas fisiológicas sugestivas de audição.

The objective was to check music and voice message influence on the Vital Signals and Facial Expressions of patients in physiological or induced comas. A Randomized Controlled Clinical Trial was done. The sample was consisted of 30 patients from Intensive Care Unit, being divided in 2 groups: Group Control (without auditory stimuli) and Experimental Group (with auditory stimuli). The patients were submitted to 3 sessions for consecutive days. Significant statistical alterations of the vital signs were noted (oxygen saturation - session 1; oxygen saturation - session 3; respiratory frequency - session 3) during the message playback and with facial expression, session 1, during both music and message. Apparently, the voice message is a stronger stimulus than the music in relation to the capacity of producing suggestive physiological auditory responses.

El objetivo era verificar la influencia de la música y del mensaje verbal en los Señales Vitales y la Expresión Facial de los pacientes en coma fisiológico o inducido. Un Ensayo Clínico Controlado y Randomizado fue echo. La muestra fue consistida en 30 pacientes de Unidad de terapia Intensiva, que fueran divididos en 2 grupos: Grupo Control (sin estímulos auditivos) y Grupo Experimental (con los estímulos auditivos). Los pacientes fueran sometidos a las 3 sesiones, en días consecutivos. Los cambios estadísticamente significativos en las Señales Vitales fueran encuentrados (saturación del oxigeno - sesión 1; saturación del oxigeno - sesión 3; frecuencia respiratoria - sesión 3) durante el mensaje y en la Expresión Facial, sesión 1, durante música y el mensaje. Aparentemente el mensaje era uno estimulo más fuerte de qué la música en lo que refiere a la capacidad de producir respuestas fisiológicas de audición.

Alpha coma pattern in a child.

Alpha coma, an EEG pattern characterized by diffuse or widespread rhythmic activity in the alpha frequency band, is typically recorded in patients with profound coma and is frequently associated with severe neurological conditions. The most common etiologic factors of this pattern are hypoxic-ischemic encephalopathy, encephalitis, head trauma, metabolic disorders, and drug overdose. Reports of alpha coma pattern in children are relatively common. Clinical significance, both in children and adults, is variable, and highly dependent on etiology. The objective of this article is to report a clinical case of alpha coma pattern in a child with neuroblastoma. The EEG pattern was recorded during the evolution of treatment, secondary to complicating septic encephalopathy. The alpha coma pattern was replaced by a normal trace following a favorable outcome after sepsis resolution.

Coma e outros estados de consciência / Coma and other consciousness disorders

As alterações do nível de consciência podem variar entre dois extremos, desde uma desorientação têmporo-espacial até um estado de coma profundo. Na prática clínica é extremamente comum o médico se deparar frente a um paciente...

The alterations of the level of conscience can vary among two ends, from a mental confusion to a state of deep coma. In clinical practice it is extremely common a patient with alteration of the level of conscience without diagnosis. In general hospitals, studies indicate that the alcoholism, the brain trauma and the cardiovascular diseases are the main causes of coma (82%). Its necessary know how to recognize the main causes consciousness of and their differential diagnosis, aimed to identify the severe ill patient and to treat the possible emergency states that take to a secondary neurological damage. In this revision, we emphasized the key points in the neurological exam to determine the different alterations of the level of consciousness...

Auditory brainstem response: prognostic value in patients with a score of 3 on the Glasgow Coma Scale.

OBJECTIVE: To evaluate the prognostic value of auditory brainstem response (ABR) recorded in comatose patients presenting a score of 3 on the Glasgow Coma Scale (GCS = 3). PATIENTS: One hundred thirty-eight patients in coma at GCS = 3 due to various etiologic agents. INTERVENTION: To record and analyze tracings of ABR. MAIN OUTCOME MEASURE: Tracings from ABR were classified into four types (B1, B2, B3, and B4) on the basis of synchrony of waves. RESULTS: The Fischer's exact test used for comparison between death proportions revealed that B1 is different from B2, B3, or B4 and the association B2 + B3 + B4. CONCLUSION: Auditory brainstem response is a useful tool with prognostic value for patients in coma with GCS = 3. It was demonstrated in our series that once the patient presented an abnormal ABR (B2, B3, or B4), he had a greater probability of dying than a patient with a normal ABR (B1).

Capillary refill time as an independent prognostic indicator in severe and complicated malaria.

OBJECTIVES: To improve algorithms for the identification of children at risk of dying of malaria in endemic areas. STUDY DESIGN: In a prospective study of 2446 children with severe and complicated malaria admitted to a tertiary referral center in Ghana, West Africa, 12 clinical and laboratory signs were evaluated as indicators of death. RESULTS: A prolonged (> 2 seconds) capillary refill time (pCRT) was identified as an independent prognostic indicator of death along with acidosis, coma, and respiratory distress. Among the clinical signs, pCRT increased the risk of dying from 4-fold to 11-fold when present in addition to coma and respiratory distress. CONCLUSIONS: The recognition of pCRT as an independent indicator of death justifies its inclusion as a defining criterion of severe and complicated malaria and improves the use of clinical examinations in the triage of patients with malaria. As pCRT has been shown to reflect circulatory disturbances in children, it should be included in upcoming studies as a possible sign to indicate the need for intravenous fluid administration.