BackgroundWhether the Glasgow Coma Scale (GCS) can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component (GCS-M)/Simplified Motor Score (SMS) to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients.

MethodsA retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit (NCU). Outcomes were death and unfavorable prognosis (modified Rankin Scale: 5-6) at NCU discharge. The receiver operating characteristic (ROC) curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves (AUCs) was performed using the Z- test.

ResultsOf 106 patients included in the study, 41 (38.7%) patients died, and 69 (65.1%) patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale's predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h (0.721 vs. 0.717, Z = 0.135, P = 0.893) and 72 h (0.730 vs. 0.765, Z = 1.887, P = 0.060), in predicting poor prognosis at 0 h (0.827 vs. 0.819, Z = 0.395, P = 0.693), 24 h (0.771 vs. 0.760, Z = 0.944, P = 0.345), 48 h (0.732 vs. 0.741, Z = 0.593, P = 0.590), and 72 h (0.775 vs. 0.780, Z = 0.302, P = 0.763). AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death (0.964 vs. 0.964, P = 1.000) and poor prognosis (1.000 vs. 1.000, P = 1.000) for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M (<0.700), in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). The SMS AUCs (<0.700) in predicting outcomes were poor.

ConclusionsThe GCS-M approaches the same test performance as the GCS in assessing the prognosis of intubated acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.

Adolescent ; Adult ; Coma ; diagnosis ; etiology ; Glasgow Coma Scale ; Humans ; Intubation, Intratracheal ; Prognosis ; Retrospective Studies ; Stroke ; complications

Since the first grading system of the subarachnoid hemorrhage was introduced by Botterell in 1956, various grading systems have been presented-mostly based on Botterell's or Glasgow Coma Scale-and studied for their universal validity. At the beginning, management plan for the patients solely depended on the grade of the applied grading system but after introduction of CT and microscope into the diagnosis and surgery for the aneurysmal subarachnoid hemorrhage and better understanding and management of vasospasm, the role of grading system has been changed to emphasize more on the predictability of the postsurgical outcome. The author reviewed the most popular and widely used grading systems to figure out their significance in predicting outcome and clinical applicability.
Classification ; Coma ; Diagnosis ; Humans ; Intracranial Aneurysm ; Subarachnoid Hemorrhage*

Coma ; diagnosis ; etiology ; Female ; Humans ; Hyperparathyroidism, Primary ; complications ; diagnosis ; Male ; Middle Aged

Cerebral dural sinus thro-bosis(DST) has been described as a rare and severe disease, clinically characterized by headache, papiliedema, seizures, focal deficits,progressive coma and even to death With the, advances ih diagnostic tools particularly MRI, DST is more commonly detected and index of suspicion is being increased. In order to characterize clinical features of DST that has been rarely reported in this country, we investigate a series of 14 patients with radiologically cerebral dural sinus thrombosis. It showed a highly variable mode of onset, diverse causes and unpredictable clinical courses. DST consists of heterogenous disease entities, with more broad spectrum of clinical presentation. Outcome was felt to be rather favorable than previously thought. Therefore, early consideration of the possibility, proper neuroimaging diagnosis and appropriate therapeutic trial on individual basis is recommended in the management of DST.
Coma ; Diagnosis ; Headache ; Humans ; Magnetic Resonance Imaging ; Neuroimaging ; Seizures ; Sinus Thrombosis, Intracranial*

Brain death is a clinical diagnosis. The three cardinal findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. The clinical examination of the brainstem includes testing of brainstem reflexes, determination of the patient's ability to breath spontaneously, and evaluation of the motor response to pain. Spontaneous and reflex movements originating from the spinal cord neurons may occur in brain-dead patients. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis. In some countries including Korea, our country, confirmatory tests are required by law when determining brain death. However, a confirmatory test is not usually mandatory except for patients in whom specific components of clinical testing cannot be evaluated reliably.
Apnea ; Brain Death* ; Brain Stem ; Brain* ; Coma ; Diagnosis ; Humans ; Jurisprudence ; Korea ; Neurons ; Reflex ; Spinal Cord

The insulinoma is a rare tumor, usually small, solitary and benign with no prediction for any part of the pancreas. It is amendable to surgical cure but approximately 10percent are malignant and the peak incidence is encountered between ages 40~60. Surgery has been established as the treatment of choice. The reason for electing to operate rather than treat symptomatically is prevention of complications, such as increasing obesity, or prolonged and irreversible episodes of hypoglycemic coma with resultant permanent central nervous damage. During the anesthesia for a patient with insulinoam, the important problems are to recognize and treat hypoglycemia. This is a case report of a patient with insulinoma who underwent surgical treatment. Two years age, under the diagnosis of insulinoma, she was underwent distal pancreatectomy with splenectomy. But 3 months ago, hypoglycemic attacks recurred during fasting periods surgical intervention was performed under the diagnosis of recurrent insulinoma. She was anesthetized with thalamonal-nitrous oxide-oxygen, pancuronium, and 10 percent dextrose solution was administered throughout the operation. We monitered the level of blood sugar intermittently by using a rapie sugar analyser(Glucometer, Ames, Japan). No hypoglycemic episode during anesthesia was observed. We report the case of our anesthetic experience withan insulinoma and review the anesthetic choice and the management of the patient.
Anesthesia* ; Blood Glucose ; Coma ; Diagnosis ; Fasting ; Glucose ; Humans ; Hypoglycemia ; Incidence ; Insulinoma* ; Obesity ; Pancreas ; Pancreatectomy ; Pancuronium ; Splenectomy

Livedo reticularis is a mottled bluish discoloration of the skin which occurs in a netlike pattern and is not a diagnosis in itself, but is a nonspecific reaction pattern. It may be classified as idiopathic and secondary livedo reticularis. Decompression sickness can occur during decompression after diving into deep sea water or during a rapiid ascent from sea level, and is one of the many causes of the secondary livedo reticularis. We report a case of livedo reticulris which developed in a patient with decompression sickness. A biopsy from the purpuric patch revealed an unusual histopathologic finding that resembles those of bullae and sweat gland necrosis in drug induced coma.
Biopsy ; Coma ; Decompression Sickness* ; Decompression* ; Diagnosis ; Diving ; Humans ; Livedo Reticularis* ; Necrosis ; Seawater ; Skin ; Sweat Glands

PURPOSE: The comatose mentality can be catastrophic, especially if the condition is severe or the duration is prolonged. Therefore, delayed diagnosis can result in a poor outcome or death. The best radiologic modality to differentiate from cerebral lesions in patients suffering from cerebral diseases is magnetic resonance imaging (MRI) rather than computed tomography (CT). Special apparatuses with metal materials such as ventilators, and cardiac pacemakers belonging to patients cannot be located in the magnetic field. We aimed to exhibit the possibility of examining MRI, maintaining ventilation at a relative long distance by means of modified Ambu(R). METHODS: Self-inflating bags as a sort of a manual ventilator, connected with relatively long extension tubes instead of mechanical ventilators, were adopted to obtain MRI. PVC (polyvinyl chloride) extension tubes had different lengths and diameters. Lengths were 1, 2, and 3 cm and diameters were 15, and 25 mm. The work of breathing and expiratory changes of expiratory tidal volume (TVe), minute volume of expiration (MVe), peak inspiratory pressure (PIP) were measured by use of the mechanical ventilator, Servoi(R), as the alteration of TVi (inspiratory tidal volume), extension tube lengths and diameters with other values fixed. RESULTS: Measured TVe and MVe by ventilator were the same values with control at every TVi, regardless of extension tube lengths and diameters, but PIP were increased with the rise of TVi, tube lengths, with decline of tube diameters, these were statistically significant. CONCLUSION: MRI examination can be carried out with a self-inflating bag connected with an extension tube at a long distance in patients who need artificial ventilation.
Coma ; Delayed Diagnosis ; Humans ; Magnetic Fields ; Magnetic Resonance Imaging ; Tidal Volume ; Ventilation* ; Ventilators, Mechanical ; Work of Breathing

The electroencephalogram exhibits continuous epileptiform discharges in many advanced coma stages, described as comatose nonconvulsive status epilepticus (NCSE). Comatose NCSE might represent an irreversible brain damage, but its causal role remains unclear. We experienced a comatose patient with continuous generalized 3 Hz spike-and-wave discharges after cerebral anoxia, which is a quiet similar electroencephalographic pattern of typical absence status epilepticus. This case indicates that NCSE in comatose patients may be overdiagnosed if the diagnosis is based on electroencephalographic alterations alone.
Brain ; Coma* ; Diagnosis ; Electroencephalography ; Heart Arrest* ; Humans ; Hypoxia, Brain ; Status Epilepticus

The electroencephalogram exhibits continuous epileptiform discharges in many advanced coma stages, described as comatose nonconvulsive status epilepticus (NCSE). Comatose NCSE might represent an irreversible brain damage, but its causal role remains unclear. We experienced a comatose patient with continuous generalized 3 Hz spike-and-wave discharges after cerebral anoxia, which is a quiet similar electroencephalographic pattern of typical absence status epilepticus. This case indicates that NCSE in comatose patients may be overdiagnosed if the diagnosis is based on electroencephalographic alterations alone.
Brain ; Coma* ; Diagnosis ; Electroencephalography ; Heart Arrest* ; Humans ; Hypoxia, Brain ; Status Epilepticus