The state of arousal or the degree of variation from normal alertness as judged by the appearance of facial muscles, fixity of gaze, and body posture.
Level of consciousness
The state of patient’s awareness of self and environment and his responsiveness to external stimulation and inner need
Is by far the more important and dramatic aspect of disordered consciousness
Loss of normal arousal
The condition of person when awake; fully responsive to a thought or perception and indicates by his behavior and speech the same awareness of self and environment as that by the examiner
An inability to think with customary speed, clarity and coherence; marked by some degree of inattentiveness and disorientation; implies a degree of imperceptiveness and distractibility.
An inability to sustain a wakeful state without tye applicationof external stimuli; inattentiveness and mild confusion are the rule both improving with arousal. Indistinguishable from light sleep.m
Results most often from a process that influences the brain globally; can also be from focal __________ in various locations.
Confusion. Cerebral disease.
An inability to sustain a wakeful state without the application of external stimuli. Inattentiveness and mild confusion are the rule both improving with arousal. Indistinguishable from __________.
Drowsiness. Light sleep.
A state in which the patient can be roused only by vigorous and repeated stimuli but the state of arousal cannot be sustained without repeated external stimulation.
In stupor, responses to spoken commands are either ___________ and ________.
In stupor, this is common and there is a reduction or elimination of the natural shifting of body positions.
Restless/Stereotyped motor activity
In stupor, when left ________, these patients quickly drift back into a sleep-like state. The eyes move ______ & ______.
Unstimulated. Outward. Upward.
The patient appears to be asleep and is at the same time incapable of being aroused by external stimuli or inner need.
no reaction of any kind is obtainable: corneal, pupillary, pharyngeal, tendon and plantar reflexes are in abeyance and tone in the limb muscles is diminished.
Deepest stage of coma
Pupillary reactions, reflex ocular movements and corneal and other brainstem reflexes are preserved in varying degree, and muscle tone in the limbs may be increased; respiration may be slow or rapid, periodic, or deranged.
Lesser degrees coma
In lighter stages, sometimes referred to by the ambiguous and unhelpful terms ________ or _______, most of the reflexes can be elicited, and the plantar reflexes may be either flexor or extensor ( ______ sign)
Semicoma/Obtundation. Babinski sign.
Shares a number of other features with the pathologic states of drowsiness, stupor or coma. Include yawning, closure of the eyelids, cessation of blinking and swallowing, upward deviation or divergence or roving movements of the eyes, loss of muscular tone, decrease/loss of tendon reflexes, and even the presence of Babinskinsigns and irregular respirations, sometimes ________ in type.
Upon being awakened from deep sleep, a normal person may be _______ for a few moments.
Sleeping persons may still respond to unaccustomed stimuli and are capable of some mental activity in the form of _______ that leave traces of _______, thus differing from persons in stupor or coma.
The most important difference in relationship of sleep to coma: persons in sleep, when stimulated, can be roused to normal and ________.
Does not decrease during sleep, as it usually does in coma.
Cerebral oxygen uptake
Recordable electrical activity- _____ and cerebral evoked responses- and spontaneous motor activity differ in two states.
The patient remains totally inattentive, does not speak, and shows no signs of awareness of the environment or inner need; responsiveness is limited to primitive postural and reflex movements of the limbs. There is loss of sphincter control. There may be arousal or wakefulness in alternating cycles as reflected in partial eye opening, but the patient regains neither awareness nor purposeful behavior of any kind.
Persistent Vegetative State
In PVS, there is a lack of _______ visual following of objects.
Syndrome of unconscious awakening lasting _______ after nontraumatic and ______ after traumatic injury.
Persistent Vegetative State. 3months. 12months.
In Persistent Vegetative State, most common pathologic bases are _______________ as a result of _________, widespread necrosis of the cortex after cardiac arrest, and thalamic necrosis from a number of causes.
Diffuse Cerebral injury. Closed head trauma.
In Persistent Vegetative State, the most common prominent pathologic changes are usually in the
Thalamic & Subthalamic nuclei
In traumatic cases of PVS, the pathologic findings are of diffuse ___________ ( described as diffuse __________), prominent thalamic degeneration, and ischemic damage in the cortex.
Subcortical white matter degeneration. Axonal injury.
In Persistent Vegetative State, anatomic findings suggest that the ________ is either diffusely injured or effectively disconnected and isolated from the _______ or the ________ are destroyed.
Cortex. Thalamus. Thalamic nuclei.
In either the traumatic or anoxic types of PVS, atrophy of the cerebral white matter may lead to _________ enlargement and thinning of the _______.
Ventricular. Corpus Callosum.
The patient is capable of some rudimentary behavior such as following a simple command, gesturing, or producing single words or brief phrases, always in an inconsistent way from one examiner to another.
Minimally Conscious State
In MCS, there is preservation of the ability to carry out basic _________ that demonstrate a degree of ______, at least at some times.
Motor behaviors. Alertness.
In Minimally Conscious State, the causes and pathologic changes are identical to those of vegetative state, including frequent finding of __________ and __________.
Thalamic. Multiple cerebral lesions.
There is little or no disturbance of awareness but only an inability of the patient to respond adequately. Is most often caused by a lesion of the _________ as a result of basilar artery occlusion.
Locked-in syndrome. Ventral pons (basis pontis).
In Locked-in Syndrome, such an infarction spares both _________ pathways and the ___________ responsible for arousal and wakefulness, as well as certain midbrain elements that allow the eyelids to be raised and give the appearance of wakefulness.
Somatosensory. Ascending neuronal systems.
The lesion in Locked-in syndrome essentially interrupts the _________ & _________ pathways, depriving the patient of speech and the capacity to respond in any way except by _______ & _______.
Corticobulbar. Corticospinal. Vertical gaze. Blinking.
Patients who are silent and inert as a result of bilateral lesions usually of the anterior parts of the _________, leaving intact the motor and sensory pathways. The patient is profoundly apathetic, lacking to an extreme degree the psychic drive or impulse to action (_______)
Akinetic mutism. Frontal lobe. Abulia.
The patient appears unresponsive, in a state that stimulates stupor, light coma, or akinetic mutism. There are no signs of structural brain disease such as pupillary or reflex abnormalities.
In catatonia, these are preserved, as in the awake state; there is usually resistance to eye opening, and some patients display a waxy flexibility of passive limb movement that gives the examiner a feeling of bending a wax rod; there is also the retention for a long period of seemingly uncomfortable limb postures.
Retention for a long period of seemingly uncomfortable limb postures.
Display a waxy flexibility of passive limb movement that gives the examiner a feeling of bending a wax rod.
Absence of all cerebral & brainstem functions, including spontaneous respiratiin. Irreversibility of the state.
Absence of cerebral function: presence of __________ and total lack of __________ and of motor and vocal responses to all visual, auditory, and cutaneous stimulation.
Deep coma. Spontaneous movement.
Absence of cerebral function: may persist, and the toes often flex slowly in response to plantar stimulation. But a well developed _______ is unusual.
Spinal reflexes. Babinski sign.
Absence of cerebral function: is seen from time to time as a transitional phenomenon just after brain death becomes evident.
Extensor or flexor posturing
Absence of Brainstem function: loss of spontaneous eye movements, midpoint of the eyes, and lack of response to _______ and ________ testing. The presence of dilated or midposition fixed pupils (not smaller than ___ mm).
Oculocephalic & Oculovestibular (Caloric). 3mm.
Absence of Brainstem function: paralysis of _________, no facial movement or gag, cough, corneal or sucking reflexes.
Absence of Brainstem function: an absence of ______ & ______ responses to noxious stimuli. And absence of ___________.
Motor & Autonomic. Respiratory movements.
Absence of Brainstem function: clinical findings should show ___________ of brain function, not an ________.
Complete absence. Approximation.
To demonstrate unresponsiveness of the medullary centers to a high carbon dioxide tension.
Serves both as a stimulus to breathing and a confirmation that spontaneous ventilation has failed. If no ________ is observed and examination of blood gases shows that an adequate level of _____ has been attained, the presence of this component of brain death is corroborated.
Loss of consciousness of certain conditions parallels the reduction in
Acetone bodies are present in high concentration
There is probably an accumulation of dialyzable small molecular toxins, notably phenolic derivatives of the aromatic amino acids.
Elevation of blood NH3 (ammonia) to 5 to 6 times normal levels corresponds roughly to the level of coma.
Drugs such as general anesthetics, alcohol, opiates, barbiturates, phenytoin, antidepressants and diazepines induce _____ by their direct effects on _________ in the cerebrum and _____ or on neurotransmitters and their receptors.
Coma. Neuronal membranes. RAS.
May affect the brain by lowering arterial blood pH to less than _____.
Lactic acidosis. 7.
The impairment of consciousness that accompanies pulmonary insufficiency that is related mainly to
In acute hyponatremia (Na
Act by producing metabolic acidosis
Methyl alcohol & Ethylene glycol
The sudden and excessive neuronal discharge that characterizes an _________ is another common mechanism of coma; presumably because the spread of the seizure discharge to ___________ paralyzes their function; In other types of seizures, in which consciousness is interrupted from the very beginning, a _______ origin has been postulated.
Epileptic seizure. Deep central neuronal structures. Diencephalic.
There is an enormous increase in intracranial pressure.
Closed head injury
In concussion, it is likely that the sudden __________ of the brain induced by the acceleration and deceleration from blow to the head produces a rotation (_______) of the cerebral hemispheres around the axis of the upper brainstem. Disruption of the function of the neurons in some unknown way is the proximate cause of __________.
Swirling motion. Torque. Loss of consciousness.
Is produced by one of two broad groups problems: clearly morphologic, consisting either of discrete lesions in the upper ________ and lower ________ or of more widespread changes throughout the hemispheres. Metabolic or submicroscopic, resulting in suppression of neuronal activity.
Coma. Brainstem. Diencephalon.
3 types of lesion: A large mass in the ________ - chiefly a tumor, abscess, massive edematous infarct, or intracerebral, subarachnoid, subdural or epidural. Cause coma by compression of the _______ & ______ region of the RAS.
Cerebral hemisphere. Midbrain & Subthalamic region.
Pathologic Anatomy of Coma, a destructive lesion is located in the _______ or _______, in which case the neurons of the RAS are damaged directly. Characterizes brainstem stroke from the _______, _______ and __________ hemorrhages, as well as some forms of traumatic damage.
Thalamus. Midbrain. Basilar artery occlusion. Thalamic. Upper brainstem.
In pathologic coma, there is widespread bilateral damage to the _______ & ________, the result of traumatic damage (contusions, diffuse axonal injury), bilateral infarcts or hemorrhages, encephalitis, meningitis, hypoxia or global ischemia. Coma in these cases results from interruption of ___________ impulses of from generalized destruction of cortical neurons.
Cortex. Cerebral white matter. Thalamocortical.
Process raw sensory signals into complex concepts that can be remembered and used to create new ideas that can be formulated into action. It is the part of the brain which is for example converts a sound (_______) into a word then into a sentence. Integrates (______) i to ideas/memory.
Higher Cortical Functions. Sensation. Conception.
Involves many interaction among may cortical subcortical regions, and often between both hemispheres. __________ is most responsible for language and motor control such as writing. _______ is dominant in 95% of right handed and ____ of left handed individuals.
Higher cortical functions. Dominant hemisphere. Left hemisphere. 70%.
Region in the cerebral cortex that deals with visual, auditory and somatosensory.
Primary sensory cortex
Region in the cerebral cortex that refines single sensory information.
Unimodal association cortex
Region in the cerebral cortex that receives input from all sensory modalities and handles complex intellectual functions.
Multimodal association cortex
Responsible for problem solving, self-monitoring, planning, mental tracking and abstract thinking.
Participates in memory and emotion.
Limbic association cortex
The setting for language, space orientation, complex movement, and recognition of self and the world.
Parietal association cortex
Clinical dysfunction occurs when damage is fairly large and involves both sides of this structure. (Trauma) Damage can produce such reflexes as grasp, snout, suck and rooting.
In prefrontal lobe damage, patients often demonstrate _________ without _______ to the consequences, inability to perform several tasks simultaneously, lack of _______ to work or complete tasks, and tendency to appear _______ or half-dressed.
High impulsivity. Forethought. Drive. Disheveled.
Consolidates long term memories from immediate memory and short term memory. No single brain location appears responsible for the repository of long-term memories. Thus no single brain lesion can eradicate well-formed long term memories.
Limbic system. Hippocampal formation.
In limbic system, lesions that cause memory impairment are usually bilateral and may involve the
hippocampal formation, dorsomedial nuclei of the thalami, or mamillary bodies “HDM”
Part of limbic system that produce verbal memory deficits
Left temporal lobe damage
Part of limbic system that produce non-verbal memory deficits
Right temporal lobe damage
Stimulation of various sites in the limbic system may produce fear or sorrow through
Stimulation of various sites in the limbic system may produce pleasure through
Bilateral damage to the __________ or __________ may dramatically diminish emotional responses and produce an awake- appearing patient who is immobile, mute and unresponsive to his/her environment (__________)
Anterior cingulate gyri. Supplemental motor area. Akinetic mutism.
Is a higher order integration center.
Patients with lesions involving the ________, especially in the ___________, usually have intact perception of pain, touch, pressure, temperature and vibration but often have cortical sensory deficits. Astereognosis, Agraphesthesia & Loss of double simultaneous sensory stimulation.
Postcentral gyrus. Hand primary sensory area.
Cause lack of attention to the contralateral side of the body or to the contralateral visual space. Anosognosia, Anton’s syndrome, Dressing Apraxia, Constructional Apraxia, Ideational Apraxia & Ideomotor Apraxia.
For judgment, insight, foresight, ambition & sense of purpose.
For Short-term memory. Consolidation of long-term memory. Emotional response.
For perception of somatosensory input. Integration of all sensory data. Awareness of body and its relationship to external space. Language.
Nonfluent but content, understandable with truncated phrases containing mainly informational words. Good for simple one step commands but impaired for complex commands.
Mute or nonfluent. Poor to absent.
Fluent but noncomprehensible with excess non information words and paraphasias. Ability to comprehend is poor to absent.
A general mental capacity that includes reasoning, planning, solving problems, thinking abstractly, comprehending complex ideas, learning quickly and learning from experience.
Comes from dysfunction or damage of many bilateral areas of higher cortical function.
Neurologic changes of normal Aging: there is age related decline in ______ of central processing, Performance on _______, ______ memory retrieval and learning.
Cognition. Speed. Timed tasks. Recent.
Neurologic changes of normal Aging: cranial nerves most affected by aging are those for
Vision and hearing
Neurologic changes of normal Aging: visual loss diminishes due to the _______ becoming progressively smaller and less reactive to light and accomodation. Increasing opacity of the _____ & ______. Subtle ______ changes.
Pupils. Lens & Vitreous. Retinal.
Occurs and range of vertical eye movements diminishes with advanced age.
Is a progressive elevation of the auditory threshold, especially for higher frequencies.
Changes of aging more prominent in _____: loss of ______ hair cells. Degeneration of __________ neurons. Atrophy of the ___________.
Men. Cochlear. Spiral ganglion. Cochlear stria vascularis.
Neurologic changes of Normal Aging in Strength, Gait & Coordination: there is progressive decline in ________,________ and ________ of movement.
Muscle bulk. Speed. Coordination.
Neurologic changes of normal Aging in Sensation: the elderly have mild progressive loss of _______ & _______ sense, mainly in the feet, from a progressive loss of distal peripheral nerve sensory nerve axons resulting to _________. Diminishes ________.
Vibration & Position sense. Poor balance. Ankle jerk.
An acquired loss of intellect (IQ) that is sufficient to impair the individuals reasoning, planning and problem-solving skills, as well as the ability to think abstractly, comprehend complex ideas, learn quickly and learn from experience.
In dementia, final common pathway is __________ in one or more of the multimodal association cortices.
Loss of neurons
Used to describe the earliest signs and symptoms of dementia. The transitional zone between normal aging and dementia. These individuals complain of memory impairments but still lead relatively independent lives.
Mild cognitive impairment
Defined as occurring in patients who have adequate general cognitive functioning and perform normally in ADLs but show subjective memory impairment that is corroborated by a spouse or a friend and have objective memory impairment on standardized memory tests that is atleast 1.5 SD below the normal for age and educational status.
Mild cognitive impairment
A disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills
MR usually begins in ________ and before age ___.
Early life. 18.