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23 - Alterations of level of consciousness related to stroke

Published online by Cambridge University Press:  10 October 2009

By
Marc D. Reichhart
Edited by
Olivier Godefroy  and
Julien Bogousslavsky
Marc D. Reichhart
Affiliation:
Xigen Enterprises and CHUV, Lausanne, Switzerland
Olivier Godefroy
Affiliation:
Université de Picardie Jules Verne, Amiens
Julien Bogousslavsky
Affiliation:
Université de Lausanne, Switzerland
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Summary

Introduction

Alteration of level of consciousness (ALC), which comprises deficient arousal, stupor, and rarely deep coma, is frequent at the acute stage of stroke. These conditions may cause fluctuating, fixed, or fast decrease of consciousness level, which in turn interferes with a detailed bedside neurological examination and neuropsychological assessment. Conversely, ALC constitutes a useful complementary sign both for the localization (syndrome) and cause (etiology) of cerebrovascular diseases (Adams, 1997). A typical example is the examination of a stuporous old patient with high blood pressure (220/120 mmHg), showing an ataxic hypesthetic hemiparesis with asterixis, bilateral Babinski signs, whereas neuro-ophthalmological evaluation of his (forced open) eyes reveals an upgaze palsy with downward gaze deviation: this stroke pattern suggests a contralateral large thalamic (syndrome) hemorrhage (etiology), as illustrated in Figure 23.1.

Patients who develop ALC, ranging from somnolence to stupor and coma, need immediate admission to the intensive care unit (ICU), particularly those without upper airways protection, absent gag reflex, and/or a Coma Glasgow Scale (CGS) below or equal to 6 (see later). Indeed, endotracheal intubation is mandatory in these cases before further CT-scan or MR imaging (MRI) studies, EEG and laboratory tests – i.e. hematocrit, electrolytes with quick capillary glucose, osmolality; renal, hepatic, arterial blood gases (pH, PCO2, PO2, HCO3, HbCO, lactate), coagulations tests (aPTT, INR, platelets, smear, fibrinogen with fibrin degeneration products, d-dimer), blood and urine toxic screening, thyroid and hypophyse functions screening.

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The Behavioral and Cognitive Neurology of Stroke , pp. 455 - 488
Publisher: Cambridge University Press
Print publication year: 2007

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