1/9. L-carnitine administration reverses acute mental status changes in a chronic hemodialysis patient with hepatitis c infection.A chronic hemodialysis patient presented with elevated serum ammonia concentration (189 micromol/l) and acutely altered mental status. He had been adequately dialyzed over the prior months and had no evidence of liver dysfunction, despite serological evidence for hepatitis c virus infection. His mental status deteriorated to coma despite vitamin replenishment, intensive hemodialysis, lactulose treatment, and blood pressure control over a 3-day period. Blood free L-carnitine concentration was depressed, and total carnitine concentrations was normal. Three hours after a single 2 g dose of L-carnitine was administered intravenously, the mental status reverted to normal. hyperammonemia resolved over a 5-week period. We suspect that subclinical liver dysfunction and dialysis status in tandem contributed to the carnitine deficiency, hyperammonemia, and confusion and that the L-carnitine administration reversed these biochemical and clinical abnormalities.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
2/9. consciousness disturbances in megalencephalic leukoencephalopathy with subcortical cysts.Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a genetic disorder featuring diffuse MRI white matter abnormalities and a discrepantly mild clinical picture. It is related to different mutations in MLC1 gene encoding a putative membrane protein of still unknown function. We report on a genetically proven MLC patient who presented with a peculiar clinical course characterized by a prolonged comatose state following a minor head trauma at 12 years of age. The disturbance of consciousness lasted for over four months and then gradually improved. Proton MR spectroscopic imaging studies showed a moderately severe depletion of N-acetylaspartate restricted to the white matter with sparing of the cortical grey matter. The full recovery from coma suggests a transitory functional impairment of the structures implicated in the maintenance of consciousness.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
3/9. Stormy onset with prolonged loss of consciousness in benign childhood epilepsy with occipital paroxysms.In nine of 62 children with benign occipital epilepsy (BOE) the onset was stormy and alarming. The first and often only seizure was characterised by prolonged loss of consciousness lasting up to 12 hours, suggesting an acute cerebral insult. In all but one case there was a tonic aversion either of eyes alone or of both head and eyes which was interpreted as conjugate deviation. The other accompanying ictal motor phenomena were either partial or generalised convulsions. In five patients the seizure was heralded by a headache, and in five cases was accompanied by vomiting. The seizure began with visual symptoms in only one patient. The seizure occurred while awake in seven and during sleep in two. The age at onset was from 3 1/4 to 10 years. Interictal EEGs showed occipital discharges typical of BOE, and the clinical course was benign. In four cases a few partial or complex partial seizures recurred during subsequent anticonvulsant therapy, but in five cases seizures never recurred. anticonvulsants were discontinued in five patients who remained free from seizures for one to 11 1/2 years after withdrawal of treatment. Sudden coma in a child associated with focal features such as tonic deviation of the head or eyes or both may represent a benign seizure disorder.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
4/9. A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation.This is a longitudinal validation study that is Part II of a two-part series. Part I focuses on the methods used to construct the neurobehavioral measure derived from the Disorders of consciousness Scale (DOCS) as well as the evidence of reliability and validity. Part II illustrates, through a series of selected case reports, the clinical use of repeated DOCS measures to enhance and complement medical rehabilitation management. The use of repeated DOCS measures in scientific investigations of mechanisms of injury is also described. Participants included patients at rehabilitation hospitals who were 18 years of age and older and unconscious after severe brain injury. Medical decision making regarding short-term effects of pharmacological intervention was augmented and improved through the examination of individual neurobehavioral recovery patterns. We identified medications to treat secondary medical complications and successfully determined effective dosage, presumably improving prognosis for recovery. We facilitated and enhanced development and refinement of individualized rehabilitation programs. Two investigations of treatment effectiveness during coma recovery and examination of the relationship between behavioral changes and neural adaptation are also described. By systematically tracking and mapping individual patterns of neurobehavioral recovery, we show that medical and rehabilitation management after coma can be enhanced. In addition, we also show that by examining the relationship between the DOCS neurobehavioral measure with mechanistic indicators of neurological recovery such as functional magnetic resonance imaging, scientific investigations of treatment and rehabilitation effectiveness can be enhanced.- - - - - - - - - - ranking = 6keywords = coma (Clic here for more details about this article) |
5/9. Chronic renal disease patients with severe star fruit poisoning: hemoperfusion may be an effective alternative therapy.We report a case of star fruit intoxication in a 60-yr-old male patient with a past medical history of diabetes mellitus and chronic renal failure. Clinical effects included hiccups, hearing impairment, urine retention, and disturbed consciousness. Star fruit intoxication was also the suspected cause of hypothermia, an unusual symptom. The patient remained comatose after receiving two sessions of hemodialysis. However, after a 6 h session of charcoal hemoperfusion following the second hemodialysis treatment, his consciousness returned to normal within 1 day. While no previous study on hemoperfusion therapy in star fruit intoxication has been reported, in view of the fatal outcome of star fruit intoxication in uremic patients, hemoperfusion may be an alternative therapy if intensified hemodialysis fails.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
6/9. The spectrum of presentations of venous infarction caused by deep cerebral vein thrombosis.The classic features of thrombosis of the deep cerebral venous system are severe dysfunction of the diencephalon, reflected by coma and disturbances of eye movements and pupillary reflexes, resulting in poor outcome. However, partial syndromes without a decrease in the level of consciousness or brainstem signs exist, which may lead to initial misdiagnoses. The spectrum of clinical symptoms reflects the degree of venous congestion, which depends not only on the extent of thrombosis in the deep veins but also on the territory of the involved vessels and the establishment of venous collaterals. For example, thrombosis of the internal cerebral veins with (partially) patent basal veins and sufficient collaterals may result in relatively mild symptoms. Deep cerebral venous system thrombosis is an underdiagnosed condition when symptoms are mild, even in the presence of a venous hemorrhagic congestion. Identification of venous obstruction has important therapeutic implications. The diagnosis should be strongly suspected if the patient is a young woman, if the lesion is within the basal ganglia or thalamus, and especially if it is bilateral.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
7/9. hyperammonemia in multiple myeloma.Two patients with multiple myeloma who appeared to be producing ammonia are reported. Both patients showed hyperammonemia and amino acid disturbances, such as a low Fischer ratio. One patient had bence jones protein (lambda) type myeloma and became comatose, but the hyperammonemia and disturbance of consciousness were improved by chemotherapy for the myeloma. The other patient had IgA kappa type myeloma and somnolence and died of malignant pleurisy despite intensive chemotherapy. autopsy showed widespread multiple myeloma and an almost normal liver. ammonia levels in the supernatant of cultured myeloma cells from the patient's pleural effusion increased almost linearly from the time of cell seeding. These observations showed that ammonia was produced at a high level by these human myeloma cells. We also found that one of the common myeloma cell lines, RPMI 8226, could produce ammonia as well.- - - - - - - - - - ranking = 1keywords = coma (Clic here for more details about this article) |
8/9. Electroencephalographic monitoring in the emergency department.EEG is the single most important test in diagnosing epilepsy and related conditions. We urge immediate EEG for patients with persistent, unexplained, altered consciousness. In our prospective study, 37% of patients referred for emergency EEG had combined EEG and clinical evidence of SE that was not tonic-clonic that would have gone undetected without EEG. In some cases, EEG provides useful diagnostic information or clarifies the severity of brain dysfunction in comatose patients. Finally, EEG is essential in monitoring patients who require pentobarbital coma for refractory SE.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |
9/9. Impairment of consciousness induced by valproate treatment following neurosurgical operation.Eight patients, who underwent neurosurgery for various supratentorial lesions presented unexplained impairment of consciousness during the first post-operative days. These states ranged from stupor to deep coma, and two patients had an emergency re-exploration. All these patients were receiving the usual dosage (1000 to 1500 mg per day) of valproic acid (VPA). The treatment had been initiated either several weeks or months previously in 4 cases, and was thus well tolerated, or the day before surgery in the 4 other cases. EEG recordings displayed diffuse abnormalities, delta waves and/or high voltage triphasic complexes, that led to the diagnosis of VPA intolerance and drug withdrawal. Then full clinical recovery and EEG clearing occurred within 1 to 5 days. VPA intolerances are wellknown but remain exceptional, about 1 case per 100.000. In our neurosurgical population, however, the rate was higher, approximately 2%. Wide areas of blood brain barrier destruction may contribute to the higher frequency of this easily reversible cause of post-operative stupor or coma.- - - - - - - - - - ranking = 2keywords = coma (Clic here for more details about this article) |