Impairment of Consciousness (ACS)

1. Impairment of Consciousness (ACS) Dr. Boroumand

2. Consciousness Cortex: Awareness (HCF) Brain Stem: Awakeness = ARAS Posterior Fossa

3. Level of Consciousness (awakness)(means : ARAS) • Full Awake(alert) • Drowsiness • Stupor • Coma Acute Confusional States Or Delirious State

4. Coma Pathologic Sleep

5. Brain Stem and ARAS Brain Stem: 1-Awakeness 2-Respiration 3-Eye Fixation 4-Sleep Cycle 5-Weight gain 6-Yaupping 7-Cardiac Rhythm 8-Bilateral Long Tract Pathways (Hemi to Tetra paresis) Posterior Fossa

6. Vegetative State Means : Cortex (off) + Brain Stem (on) (cortical Death) Loss of Awareness Duration > 6 m/o = PVS

7. Locked in Syndrome • Localization : Bilateral Ventral Pontine Lesions • Quadriplegia + Lower Cranial Nerve Palsy • Causes: 1- Pontine Stroke 2- CPM 3- MS 4- ALS 5- Alzhiemer’s Disease 6- GBS 7- NMJ-Blockers Drugs 8- Brain stem lesions (Lymphoma-Glioma- TB- Syphilis)

8. Brain Death • Syn.: Irriversible Coma • Cortex off + Brain Stem off + Obvious Lesion + Irriversible Damage • Obvious Lesion Means: Bilateral Cortical Damage or Structural Lesion in BS • In Brain Death: EEG is flat

9. Brain Death Criteria • کرایتریای مرگ مغزی : • بیمار در کوما باشد • عدم وجود تنفس خودبخودی • فقدان رفلکس های ساقه مغزی • سکوت در EEG • فقدان جریان خون مغزی • فقدان هرگونه علت برگشت پذیر مغزی مانند مسمومیت با فنوباربیتال • Irriversible Coma = Brain Death

10. Phenobarbital Intoxication • Cortex Off • Brain Stem Reflexes off • EEG is completely Flat BUT: • Obvious lesion (-)  CT and MRI (NL)

11. Tx in Phen. Toxicity Forced Alkaline Diuresis

12. As a Rule: ↓ in LOC means: 1- Bilateral Cortical Damage 2- Brain stem Structural Damage 3- Unilateral Supratentorial Damage extending toward the brain stem or the other Side

13. Level of Consciousness (awakness) • Full Awake(alert) • Drowsiness (Normal Stimulation) • Stupor (Painfull/Forcefull Stimulation) • Coma (Unresponsiveness) or Loss of Verbalization

14. ↓LOC & EEG • EEG ∝ ↓LOC • EEG can determine the level of consciuosness

15. Note: • Attention • Concentration • Acute ConfussionalState(↓LOC) : No At. + No Con. • Dementia : Attention Ok + No Concentration • Dementia: ↓ in COC ( not: ↓ in LOC)

16. Temporary loss of consciousness • caused by: • impaired cerebral perfusion (syncope, fainting), • cerebral ischemia, • migraine, • epileptic seizures, • metabolic disturbances, • sudden increases in intracranial pressure • sleep disorders.

17. Syncope • Syncope may result from: • Cardiac, • Noncardiac • Undetermined causes

18. Cardiac Causes of Syncope • decreased cardiac output secondary to cardiac arrhythmias, • outflow obstruction, • hypovolemia, • orthostatic hypotension, • decreased venous return

19. cerebral ischemia • Cerebrovascular disturbances due to: • transient ischemic attacks of the posterior or anterior cerebral circulations, • cerebral vasospasm from migraine, • subarachnoid hemorrhage • hypertensive encephalopathy

20. epileptic seizures • Absence seizures • Generalized tonic-clonic seizures • Complex partial seizures

21. Seizure or syncope ?

22. metabolic disturbances • Cardiac encephalopathy, • hepatic encephalopathy, • uremia, • hypoglycemia, • hypoxia, • hyponatremia, • hypo-/hypercalcemia, • hypo-/hypermagnesemia, • other electrolyte disturbances • toxic and industrial exposures (carbon monoxide, organic solvent, lead, manganese, mercury, carbon disulfide, heavy metals)

23. Step by step managment • LOC Detection • 6 Step Assessment • IV-Line x2 • TNG • ECG • Dizepam • Refer to Specialist

24. موفق باشید

25. Headache Dr. Boroumand

26. Useful questions • تعداد و نوع سردرد • نحوه شروع سردرد • فرکانس و پریودیسیتی سردرد • چقدر طول می کشد تا سردرد به اوج خود برسد • عوامل تریگر سردرد کدامند • درد از کجا شروع می شود و چگونه پیشرفت میکند. • مداوم است یا ضرباندار • آیا پیش درآمدی برای شروع سردرد هست یا خیر • عوامل تشدید کننده سردرد • عوامل تخفیف دهنده سردرد کدامند. • خود بیمار چه ایده ای از علت سردرد خود دارد.

27. Recent onset • Definition: • American Academy of Neurology guidelines as a one-month interval. • a 6- to 12-month interval.

28. “worst ever” headache • An increasingly severe headache, • Change for the worse in an existing headache pattern all means the possibility of an expanding intracranial lesion.

29. Headaches of instantaneous onset • Means an intracranial hemorrhage, usually in the subarachnoid space but also can be caused by : • intracerebral hemorrhage, • cerebral venous thrombosis, • Embolic cerebellar infarction • arterial dissection, • pituitary apoplexy, • spontaneous intracranial hypotension, • benign angiopathy of the central nervous system (CNS), (reversible cerebral vasoconstriction syndrome) • acute hypertensive crisis, • idiopathic “primary thunderclap headache”

30. sah • Explosive • Severe • Exertinal • Resistant • Usually with no focal neurological signs (unless 3th nerve plasy, …) • Papilledema and subhyaloid hemorrhage. • Neck stiffness

31. Cvt (cerebral vein thrombosis) • Female • Hypercoagulability state (dehydration, OCP, pregnancy, delivery) • Gradual increasing headache but sometimes suddenly onset. • Resisitant to treatment • May have focal neurological signs.

32. Attention! A history of antecedent head or neck injury should be sought; even a relatively minor injury can be associated with: • the subsequent development of epidural, subdural, subarachnoid, or intraparenchymal hemorrhage • posttraumatic dissection of the carotid or vertebral arteries

33. Exertional headache and headache associated with sexual activity both are worrisome • A primary headache disorder unassociated with structural disease • can be associated with migraine BUT These must be excluded with the first occurrence of such headaches. • Subarachnoid hemorrhage • Arterial dissection, which

34. Carotid artery dissection Commonly manifests with: • Neck, face, and head pain ipsilateral to the dissection, • Frequently is associated with an ipsilateral Horner's syndrome, • Often follows head or neck trauma • May cause CRA or Ophthalmic Occlusion and finally Blindness. • Tenderness

35. Location and Triger zones • Asking the patient to show the location of his or her pain with a finger often is helpful. • Trigeminal neuralgia is confined to one or more branches of the trigeminal nerve. • Lancinating face pain triggered by facial or intraoral stimuli occurs with trigeminal neuralgia. (CBZ) • Glossopharyngeal neuralgia typically is triggered by chewing, swallowing, or talking, although cutaneous trigger zones in and about the ear occasionally are present.

36. Headache and Focal neurological signs • Aura in Migraine Headache • Intracranial Hemorrahges • Carotid Dissection • Neuralgias • Basialr Type Migraine • GCA

37. Migraine with Focal Neurological Signs Aura in Migraine Headache: • Some patients with migraine have premonitory symptoms that precede a migraine headache by hours. • These can include: • psychological changes, such as depression, euphoria, or irritability, or • somatic symptoms, such as constipation, diarrhea, abnormal hunger, fluid retention, or increased urination.

38. Migraine with Focal Neurological Signs–Aura • focal cerebral symptoms associated with a migraine attack. • most commonly last 20 to 30 minutes but can last 1 hour. • Aura symptoms usually have a gradual onset and increase over minutes. • usually precede the headache. But At other times, the aura may continue into the headache phase or arise during the headache phase. • Visual symptoms are most common and may consist of either positive or negative phenomena or both. • Other hemispheric symptoms, such as somatosensory disturbances (numbness and/or tingling) or language dysfunction, may occur with or without visual symptoms. • If more than one symptom occurs (e.g., visual plus somatosensory), the onsets usually are staggered and not simultaneous.

39. 3 findings which can differentiate maigraine induce aura from cva • Positive symptoms • the slow spread of symptoms, • staggered onsets help

40. Basilar type migraine Symptoms originating from the brainstem or both cerebral hemispheres simultaneously, such as: • vertigo, • dysarthria, • ataxia, • auditory symptoms, • diplopia, • bilateral visual symptoms in both eyes, • bilateral paresthesias, • decreased level of consciousness,

41. CVA • The location of the pain is a poor predictor of the vascular territory involved. • cortical infarction > deep cerebral hemisphere infarctions. • either steady or throbbing and is rarely as explosive or as severe as the headache of subarachnoid hemorrhage. • the pain is usually of at least moderate size, • TIAs transient head pain in up to 40% of patients. • carotid distribution ischemia  frontotemporal head pain • vertebrobasilar ischemia  occipital headache.

42. Pseudotumorcerebri • Female/ Obesity/Visual blur.) • Drugs (/COPD/hirsutism/PCO • Papilledema • 6thcarnial nerve paresis • No special focal neurological signs • No other findings in routin lab • No special finding in neuroimagining • LP/Prednisone/Acetazolimide

43. Giant cell artritis (TA) • Most common feature: headache of an unknown cause. • most common symptom headache (72%) • The headache is most often • throbbing + scalp tenderness. • often generalized • focal tenderness on the affected superficial temporal > occipital artery. • Fisrt step: ESR

44. Red flag of headache • New Headache • Explosive headaches • Worsening headaches • Focal neurological sings • Neck regidity • Fever • Trauma • Inceasing pain with valsalva maneuver • Confusion and decrease LOC • AIDS • Papilledema • Old age • Tenderness on the scalp • Seizure • Vomiting

45. Yellow flags of headache • بیدار کردن بیمار از خواب • سردردی که همیشه در یکطرف سر باشد • تأثیر واضح تغییر پوسچر در تشدید سردرد.

46. Vertigo Dr. Boroumand

47. Dizziness • Dizziness is a term patients use to describe a variety of symptoms including: • spinning or movement of the environment (vertigo), • lightheadedness, • presyncope, • Imbalance • visual distortion, • internal spinning, • nonspecific disorientation • anxiety

48. Vertigo sensation of spinning of the environment, indicates a lesion within the vestibular pathways, either peripheral or central

49. Vertigo Associated ear symptoms such as hearing loss and tinnitus can suggest a peripheral localization, to the inner ear or eighth nerve.

50. Useful questions and signs • Associated ear symptomes • Positional dependency • Onset pattern • Focal neurological signs • Risk factors