Disturbances of consciousness, wakefulness and sleep

Short anatomical and physiological data.

Consciousness is the highest form of reflection of reality, it combines the mental processes that allow
people to orient themselves in the outside world, time, self and participate in public life. Consciousness
ensures the normal functioning of the cerebral cortex of the brain, reticular formation of midbrain and
thalamus, as well as the persistence of the bilateral relations between them. Any pathological process
that diffusely damages cortex or locally damages reticular formation of the middle and the midbrain,
may cause impairment of consciousness.

Sleep and wakefulness are intimately related to functional status, which alternation occurs throughout
life. Sleep - is not only a period of rest and recovery of lost power when awake, but an active process of
information processing. Night Sleep has two phases: the phase of REM sleep (sleep with rapid eye
movements, during which dreams occur) and the phase of slow sleep (sleep without rapid eye
movements). Phase of slow sleep consist of about 80% of sleep time, it is divided into 4 stages
(depending on depth of sleep and related physiological and electroencephalographic changes). Phases of
fast and slow form of sleep cycle, which lasts 70-100 min and is repeated 4-6 times during the night. The
duration of sleep has considerable individual differences, on average it is 16-20 h in the newborn, 9-12 h
childhood and adolescence, 7-9 h in young and middle-aged and usually somewhat reduced in old age.
Sleep and wakefulness change is mainly regulated by midbrain and brain stem reticular formation.

Forms of consciousness disturbances. Examination of patients with impaired consciousness

Disturbance of consciousness can be divided by the severity of confusion, sopor and coma.
Confusion is characterized by partial or complete loss of orientation, the difficulty of verbal contact, loss
of coherence of thought and action, a delayed execution of instructions while maintaining wakefulness.
Sopor. If the patient can not fully return to a state of clear consciousness, but he can still respond poorly
to vigorous verbal instructions, opens his eyes and purposefully respond to pain stimuli.
In coma states, deep suppression of consciousness occur with lack of purposeful response to external
stimuli, although in superficial stages of coma, there is possible unconscious behavioral response to pain
stimulation; coma is accompanied by a disorder of the regulation of vital functions.

While examining a patient with impaired consciousness, it is important to make sure that the airways are
free, no signs of vascular collapse, internal bleeding or cranial trauma. Examination conducted together
with therapy to maintain vital functions.
In neurological examination, if there is no data of cervical spine fracture, examine for meningeal
symptoms, the presence of which indicates the inclination of pathological process of brain membranes.

Hemihypestesia pain is expected in cases when there are none or weakened reaction (as pain mimics,
groan) to pain stimuli of one side. Symptom of hemiparesis is one-sided absence or weakening of
movements in the limbs (spontaneous or reflexatory in response to pain stimulation). In the absence of
movements on both sides, it’s possible that hemiparesis only shows unilateral changes (decrease or
increase) muscle tone and reflexes, Babinski's sign, internal rotation of feet.

At the paralyzed side, there can be smoothed nasolabial fold, lowered angle of mouth, "sailing”
phenomenon of respiratory rhythm cheeks. The defect of the brain stem or cranial nerves maybe
indicate by disturbance of breath, increase or decrease in pupil size, anisocoria, absence of reaction
pupils to light, squint, the absence of the phenomenon of "Eye of Doll" - eye movements in the opposite
to passive head rotation toward the patient.
The severity and prognosis of disorders of consciousness are assessed using the Glasgow Coma Scale
(Table 8.1), where each index corresponds to a certain point. the total number of points is 3-8, then the
probability of death of the patient is on average of 60%, if 9-12, then only 2%. If in a day, the patient GSC
point remains 3-8 points, even if patient survives, disability is very likely due to the motor and / or
intellectual defect.

Table 8. 1 Glasgow Coma Scale

Indicator Points
Opening of eyes:
spontaneous 4
during speech 3
when pain 2
absence 1
Speech:
fully preserved 5
confuse 4
understandable words 3
inarticulate sounds 2
absent 1
Motor reaction:
Follow instructions 6
purposeful reaction to pain stimulation 5
leg lift to pain stimulation 4
flexion response to pain stimulation 3
extensor response to pain stimulation 2
absent 1

Additional investigative methods in a coma.

The standard examination of coma patient includes a general analysis of blood and urine tests, blood
chemistry (electrolytes, glucose, calcium, phosphate, sodium, creatinine, urea, liver function tests,
osmolarity of the plasma), electrocardiography, chest X-rays.. If you suspect a brain lesion, it is shown a
computer or MRI of the head, if it is not possible, then run X-ray of the skull, echoencephaloskoy, lumbar
puncture, unless contraindicated - electroencephalography. If you suspect infections of the brain and the
membranes, lumbar puncture and cerebrospinal fluid study is very useful. If you predict intoxication,
screen for toxic substances (ethanol, barbiturates, tranquilizers, etc.) in the blood and urine of a patient.

X-ray CT of the head allows you to get the image of the skull and brain in the horizontal plane at different
levels. CT of the head is the main method of research for further examination of coma patients with
suspected damage of brain. To increase sensitivity of this method, we can used with CT with contrast
amplification (urotrast, verografin or others).

MRI of the head allows us to obtain image slices of the brain in different planes at different levels. The
method of MRI is more sensitive to changes in tissue and is better than CT, allows us to visualize the
structure of the posterior cranial fossa. However, MRI needs a longer time to perform it thus limits its
use in urgent situations, particularly during the examination of coma patient. Since the MRI uses
powerful magnetic fields, it is contraindicated in implanted pacemakers, micropump for insulin delivery,
metal fragments in other organs. To increase the sensitivity of the method, MRI with contrast
(gadolinium) can be used.
Radiography of the skull (craniography) is usually carried out in direct and lateral projections, sometimes
in the special projections. In recent years, it is used less frequently with the introduction of CT and MRI,
which is much more informative. X-ray of the skull is used to identify a set of fractures and skull base,
pathological calcification within the skull, hyperostosis of the skull bones, and their destruction,
malformations of the skull.

Electroencephalography (EEG) - a method study of brain activity. In the period of wakefulness in humans
normally occur predominantly α-rhythm (8-12 Hz) and (β-rhythm (14-40 Hz). Pathology can appear as
slow rhythms (θ-rhythm and δ-rhythm) and epileptic activity (spikes , sharp wave complexes peak-slow
wave). To increase the sensitivity of the method, provocative tests (photic stimulation, hyperventilation,
etc.) can be used. EEG is used in the diagnosis of brain death.

Echoencephaloscopy (EchoES) is a method of ultrasound examination of the brain, based on regstration

of reflections of the echo signals from the brain structures. Main value is signal marks which are
reflected from middle structures (M-echo). In major process of cerebellar hemisphere of the brain,
middle structures of the brain can shift which leads to a shift of M-echo at 2 mm n more from the middle
position, but the lack of displacement M-echo, does not rule out brain damage.

Causes of impaired consciousness. Destructive and metabolic coma. Medical tactic.

Disturbance of consciousness may be caused by both organic brain damage (destructive coma), and its
dysfunction due to toxic and metabolic disorders (metabolic coma). Destructive coma is possible in
extensive lesions of the cerebral hemispheres, and with a small lesion of the upper parts of the brain
stem and midbrain, exciting reticular activating system. The main causes of destructive coma - brain
injury, stroke, intracranial infection (meningitis, encephalitis), brain tumor, status epilepticus. Metabolic
coma may develop during hypoglycemia or hyperglycemia, diabetic ketoacidosis, uremia, hepatic failure,
hyponatremia, hypothyroidism, hypercalcemia or hypocalcemia , severe heart and/or pulmonary
disease, Gaye-Wernicke encephalopathy, acute hypertensive encephalopathy, as well as poisoning
(alcohol, drugs, drugs, heavy metals, carbon monoxide, etc.), thermal injury (heat stroke, hypothermia).

Determining the causes of coma is important to give information about the features of its development,
prior to injuries and diseases, alcohol, drugs and medicines. Acute impairment of consciousness is more
often observed in stroke, brain trauma, or hypoglycemia, gradually develops over several hours - with
intracranial infection, brain tumors, metabolic disorders, and poisoning.

Unilateral widening of the pupil is typical in major process (intracranial hematoma, tumor), although it
should be borne in mind that anisocoria is noted in the mild, almost 10% of healthy individuals and may
be the result of injury or operations on the eye. Narrow pupils (less than 1 mm) observed at
hemorrhagesof the pons, barbiturate or narcotics poisoning. Preservation of pupillary reactions in deep
consciousness is characteristic of metabolic disorders. Vertical exotropia and float movement of the
eyeballs are observed in destructive lesions of the upper parts of the brain stem.

Urgent therapeutic measures in a coma include providing airway and adequate ventilation of the lungs,
circulatory system stabilization, the introduction of IV 30-50 ml of 40% of the first glucose (for suspected
hypoglycemia) and 100 mg of thiamine (for suspected acute encephalopathy Gaye - Wernicke),
normalization of body temperature. Then determine the cause of impaired consciousness and carry out
measures (control of blood pressure and respiration, skin care, parenteral nutrition and bowel
movements, bladder control, etc.), warning of multiple complications of coma. After determining it, treat
the causes of coma, such as antibiotic therapy for meningitis, dehydration with cerebral edema caused
by cranial trauma or tumor.
Brain Death. Chronic vegetative state.

In case of coma, when the brain is irreversibly damaged and cardiac and respiratory activities are
maintained artificially, the state is regarded as brain death. Diagnosis is based on an irreversible
persistent absence of consciousness, disrupting stem functions - swallowing, respiration, systemic
hemodynamics, absence of pupillary, pharyngeal and other reflexes. Brain death is established only in
the identification of the disease, which causes irreversible brain damage, and excludes the influence of
drugs, hypothermia, metabolic and endocrine disorders. To confirm brain death, investigation such as:
EEG is used which allow identifying absence of bioelectrical activity of the brain, and angiography or
ultrasound Dopplerography, which can show stopping blood circulation in the brain. The diagnosis of
brain death is put only with consultation of specialists - intensive care, neurology and others.

After coming out of coma, patient may develop a chronic vegetative state, characterized by the
restoration of waking at a total loss of cognitive (cognitive) functions. In these cases, the brain stem is
saved, but there is extensive destruction of the cerebral cortex. Patients have normal cyclic change of
sleep and wakefulness, normal breathing and heart activity, but at the same time there are no
purposeful movement, speech and reactions to verbal stimuli. If the duration of vegetative state is
within 2-4 weeks, recovery is unlikely.

When come out of a coma, patient sometimes develops akinetic mutism, in which the patient lies
motionless with eyes open and consider all that surrounds him, but does not begin contact, and do not
respond to commands. In recovery, the patient does not remember happening in this period. Akinetic
mutism usually develops in lesion prefrontal parts of the frontal lobes.

Table 8.2
Major syndromes of impaired consciousness, sleep and wakefulness

Major syndromes Manifestations of syndrome

Disturbances of 1. Partial or complete loss of orientation, difficulty of verbal contact, loss of
consciousness: coherence of thought and action, slow execution of instructions while
1. Confusion of maintaining wakefulness
consciousness 2. Patient can not be returned to a state of clear consciousness, he was poorly
2. Sopor responsive to verbal instructions but opens her eyes and respond purposefully to
painful stimuli
3. Coma 3. The deep depression of consciousness from lack of purposeful response to
external stimuli, impairment of the regulation of vital functions
Insomnia (subjective Dissatisfaction with sleep, difficulty of falling asleep, frequent waking up at night,
insufficiency of sleep) early morning awakening, daytime fatigue, often emotional disorders, decreased
performance
Sleep apnea Repeated long-term (more than 10 s) episodes of stop breathing during sleep, often
heavy snore, increased motor activity during night sleep, daytime sleepiness
Narcolepsy Forced daytime sleep (occasionally irresistible need to sleep in any environment) on
average 3.5 per day (from several minutes to an hour), often marked cataplexy,
hypnagogic hallucinations, and "sleepy paralysis”.
Parasomia Sleeptalking , sleepwalking, night terrors, nocturnal enuresis, etc.
Sleep Disorders
Insomnia is the feeling of lack of sleep, defined by patients as "can’t sleep". It happens permanently in
about 10% of the population, and in another 15% occasionally experienced lack of sleep. Insomnia is
more common in women and in old age. It is subjective in nature, as rule of sleep is very inconsistent,
and its objective assessment is difficult. Some patients believe that they have very few (1-3 h) sleeps or
no sleep, but objective observation (electrophysiological registration or sleep polysomnography) shows
duration of their sleep significantly increase, or almost normal. Patients complain of insomnia as
dissatisfaction of sleep, difficulty to fall asleep, frequent waking up at night, early morning awake. In the
daytime, many reveal bad concentration, fatigue, short temper. Period of insomnia vary, in some people
it occurs only once or periodically, while others suffers different individual disturbance for whole life.

Insomnia is often develops on a background of acute and chronic stressful situations in a neurotic
disturbances, depression, alcohol abuse and psychotrophic substances, rarely primary (idiopathic)
insomnia. But it can occur in infectious diseases, acute and chronic somatic (cardiovascular, pulmonary,
gastrointestinal, renal, etc.), endocrine, neurological and psychiatric illness. Therefore, patients with
insomnia need to undergo examination to exclude these diseases. Specific methods of examination of
patients with sleep and wakefulness disorders are polysomnography – register the range of total sleep
parameters – electroencephalogram, movements of eyes, electromyogram, respiration, etc. These allow
us to objectively assess the quality of sleep.

Treatment of insomnia - it is the therapy of main illness and/or elimination of the triggering factors, if
possible. It is very important to keep going to bed hygiene by going to sleep and waking up at one and
same time, exclusion of daytime sleep, usage of alcohol, smoking, eating and intense mental work
before sleeping, comfortable sleeping environment. In some cases, dative substances help: valerian root,
motherwort grass, etc. Hypnotic drugs are effective, zopiclone (imovan) on 7,5-15 mg, zolpidem (ivadal),
but 10-20 mg, nitrazepam (radedorm) 5-10 mg, and a number of other medications before bedtime. It is
recommended not to take these medications in long-time (more than 3 weeks) and consistently, if it is
required in long-term use, patient should have drug-break from treatment.

Sleep apnea syndrome manifested repeating long episodes (more than 10 sec) respiratory arrest in a
period of sleep. Obstructive (peripheral) sleep apnea is due to the closure of the respiratory center.
Central sleep apnea is a disturbance of the central regulation of respiration. Most patients have mixed
apnea, combining obstructive and central components. Sleep apnea occur in 2% women and 4% men of
the population.

In patients with peripheral or sleep mixed apnea, usually (in 80% of cases) there are strong snoring,
increased motor activity during night sleep and daytime sleepiness. They are more likely in people with
marked obesity, short and thick neck, crooked nasal septum, a disproportionately large tongue, chronic
vasomotor rhinitis, an increase in the tonsils, hypertension, headache, insomnia, impotence in men.
Central apneas occur in lesions of the brain stem, polyradiculoneuropathy, myopathy, myasthenia gravis
and other neurological diseases. For an accurate diagnosis, we requires an overnight sleep study of
polysomnography with registration of respiration, which can detect periods of apnea lasting from 10 to
180 and determine the frequency of their occurrence. Sleepy apnea increases risk of stroke, myocardial
infarction, death during sleep and mortality from cardiovascular disease.

Treatment of sleep apnea is aimed at ensuring the airway during sleep, which in some cases can be
achieved by surgery to restore normal nasal breathing, removal of hypertrophied tonsils, etc. The degree
of sleep apnea usually decreases with a decrease of excess body weight. In recent years, it is suggested
that a special device for the treatment of sleep apnea, whereby the air in the respiratory rhythm the
patient is fed into the respiratory tract, thus overcoming the obstruction of the upper respiratory tract.

Narcolepsy - a disease that often begins at a young age in the form of enforced daytime sleep, disrupts
the normal way of life (see Table. 8.2). Patients occasionally feel an irresistible need to sleep in any
environment. The frequency of daytime sleep differs, on average, 3-5 in the day. The duration varies
from several minutes to an hour or more. Drowsiness is most pronounced during the day, in the
afternoon and diminishes in the evening. Patients often develop a sudden and short-term (seconds,
minutes) loss of muscle strength and tone, with the full preservation of consciousness (cataplexy) in
emotional responses - joy, laughter, anger, etc. Before night sleep, patient may have vivid visual or
auditory hallucinations (hypnagogic hallucinations). Sometimes immediately after waking up or falling
asleep when the patient is unable to effect movement or utter a word (“sleepy paralysis”) within
seconds or minutes.

Increased daytime sleepiness is the main complaint of patients and not significantly changed in range
during entire life, other disturbances (cataplexy, hypnagogic hallucinations, and sleepy paralysis) often
decreases with age. Polysomnography is used in the diagnosis of sleep, which identifies the signs of sleep
with rapid eye movement immediately after falling asleep.

Several small (15-20 min) intervals for a short nap significantly improve the condition of the patient. To
eliminate daytime sleepiness, during the first half of the day, do not used drugs with pychostimulating
action (indopan, sydnocarb, modafinil). To prevent cataplexy and paralysis of sleep, we may use Tricyclic
antidepressants lacking sedative action (imipramine, melipramin, clopipramin).

Increased daytime sleepiness (hypersomnia) may also be caused by disorders of sleep at night, sleep
apnea syndrome, drug administration with hypnotic effect, depression, rarely - brain tumor or
encephalitis with lesions of the hypothalamus and brain stem.

Parasomnia - a group of disorders associated with sleep talking, sleepwalking, night terrors, nocturnal
enuresis, etc. sleepwalking occurs in 5-10% of children and usually disappears at about 7-14 years. It
often occurs in the first 1-2 hours of sleep is often accompanied by sleep talking. During sleepwalking
period, we must prevent injury to the child, in severe cases, you can use benzodiazepines (2,5-5 mg dia
zepam at night) or antidepressants (10-25 mg amitriptiline at night). Night terrors occur in 1-3% of
children, sometimes combined with sleepwalking. They are characterized by sudden incomplete
awakening, fear, crying, tachycardia, and diaphoresis. In frequent severe attacks, it is advised to take
short-acting benzodiazepines or antidepressants. Night enuresis outlined in the section on pelvic
disorders.