[...]... fingers After 2 several jerks, the movements disappear, only to reappear a few seconds later Differential diagnosis The four conditions that are most often “confused with confusion” are aphasia, neglect, transient global amnesia, and psychosis Aphasia Aphasia is an acquired disorder of language resulting from brain damage (Chapter 3) It may be difficult to distinguish some patients with aphasia, particularly... head trauma sufficient to cause coma almost always have abnormal head CT scans In addition to skull fractures, abnormalities following trauma include epidural, • • • • subdural, intraparenchymal, and subarachnoid hemorrhages Some patients have no clear evidence of fracture or hemorrhage, but the CT scan (or, more likely, an MRI) shows evidence of diffuse axonal injury Intracranial mass lesion Bilateral... may include encephalopathy, headaches, seizures, increased intracranial pressure, diplopia, dysarthria, radicular pain, and weakness The most common tumors that produce neoplastic meningitis are primary CNS tumors, carcinomas of the lung and breast, melanoma, lymphoma, and leukemia.15 Although neoplastic meningitis usually accompanies advanced cancer, it may be the first sign of disease in some cases... Bilateral frontal or brainstem lesions including tumors, abscesses, and intracranial hemorrhages may all lead to coma Subarachnoid hemorrhage Aneurysmal rupture leading to subarachnoid hemorrhage is an important cause of coma that may be detected with a CT scan (Chapter 19) Hypoxic–ischemic injury Whether due to anoxia following cardiac arrest or to severe hypoxia secondary to pulmonary disease, irreversible... nonneoplastic, autoimmune process Common antibodies associated with limbic encephalitis include: • anti-Hu (ANNA-1) associated with small-cell lung cancer19 • anti-Ma2 associated with testicular cancer in young men19 • anti-CV2/CRMP5 associated with small-cell lung cancer20 • voltage-gated potassium channel antibodies20 • N-methyl-D-aspartate (NMDA) receptor antibodies associated with ovarian teratoma20,21... decerebrate posturing In the final stage of transtentorial herniation, medullary compression produces irregular breathing, flaccidity, and eventually death Chapter 2 Coma Management of increased intracranial pressure The first step in managing increased intracranial pressure is to improve cerebral venous drainage by placing the head of the patient’s bed at a 45° angle Next, intubate the patient and hyperventilate... become cavalier and dismiss the possibility of focal structural lesions as a source of confusion Subdural hematoma is the diagnosis that is most often missed Usually caused by traumatic tearing of the bridging subdural veins, subdural hematoma may result in a wide variety of neurological presentations including hemiparesis, seizures, headaches, and confusion The head trauma that produces a subdural hematoma... metabolic encephalopathies, generally those that produce metabolic acidosis Central neurogenic hyperventilation is rare, and is usually seen in the context of brainstem glioma or lymphoma.5 Apneustic breathing is characterized by 2- or 3-second pauses that occur at the end of inspiration and expiration, and reflects pontine damage Ataxic breathing has an irregular, gasping quality, and is secondary to lower... three phases based on the frequency of the responsible causes and the ease of obtaining diagnostic testing: Phase 1: history, examination, and basic studies By the time a neurologist is consulted, a basic metabolic workup and CT scan of the brain is usually available Combined with a careful history and physical examination, these data help to establish one of the following coma diagnoses: • Trauma Patients... clinical practice My students have encouraged me to put my approach into writing, and the basic text of Neurology: A Clinician’s Approach reflects our case conference format Each of the problems that face a neurologist requires a different approach In general, however, the technique of Neurology: A Clinician’s Approach is to start by defining the chief complaint, move to techniques concerning how to take .