1. Write out the Glasgow Coma Scale (GCS) and indicate the score assigned to each point on the scale.

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a. eyes

     i. e_____

4 spontaneous

     ii. y_____

3 to speech

     iii. e_____

2 to pain

     iv. s_____

1 nil

b. verbal

     i. v_____

5 oriented

     ii. o_____

4 confused

     iii. i_____

3 inappropriate

     iv. c_____

2 incoherent

     v. e_____

1 nil

c. motor

     i. m_____

6 obeys

     ii. o_____

5 localized

     iii. v_____

4 withdrawal

     iv. i_____

3 decorticate

     v. n_____

2 decerebrate

     vi. g_____

1 nil

2. True or False. A patient with a GCS score E2 V1 M2 (GCS 5) is in a coma.

false (Whereas 90% of patients with GCS ≤ 8 are in a coma, coma is defined as inability to obey commands, speak, or open the eyes even to pain.)

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3. Define coma.

A GCS less than 8 is a generally accepted operational definition of coma.

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4. List the three locations of brain lesions that produce coma.

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a. u_____ p_____ and m_____

upper pons and midbrain

b. d_____

diencephalic

c. b_____ c_____ h_____

bilateral cerebral hemisphere

5. Disinhibition by removal of the corticospinal pathways above the midbrain typically results in_____ posturing.

decorticate

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6. Complete the following about coma in general:

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a. Decorticate lesion is at_____.

midbrain

b. Decerebrate lesion is at_____.

intercollicular level between vestibular nuclei and red nucleus

c. Locked-in syndrome lesion is at _____.

ventral pons

7. Complete the following about coma in general:

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a. In decorticate posturing

     i. The upper extremities are in _____.

flexion

     ii. The lower extremities are in _____.

extension

b. In decerebrate posturing

     i. The upper extremities are in_____.

extension

     ii. The lower extremities are in _____.

extension

8. Decorticate and decerebrate posturing have what lower extremity movements in common?

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a. e_____

extension

b. i_____ _____

internal rotation

c. p_____ _____

plantar flexion

9. A patient is brought to the emergency room in a coma after being found down. Pupils are equal and reactive. Painful stimulus elicits no movement. No signs of trauma are evident. Studies show Na⁺ 130, K⁺ 4.9, C 1—100, HCO₃ 2—15, BUN 30, Cr 1.2, Glu 440. The likely cause of coma is _____ _____.

diabetic ketoacidosis

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10. What stroke syndromes can lead to coma?

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a. b_____ c_____ i_____

bilateral cortical infarcts

b. b_____ d_____ i_____

bilateral diencephalic infarcts (i.e., top of basilar)

c. b_____ s_____

brain stem

11. A patient in coma eventually arouses with apathy, memory loss, and vertical gaze paresis. The most likely etiology for the coma was_____ _____ _____.

bilateral diencephalic infarcts

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12. Indicate the effect of midline shift on level of consciousness.

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a. 0 to 3 mm_____

alert

b. 3 to 4 mm_____

drowsy

c. 6 to 8.5 mm_____

stuporous

d. 8 to 13 mm_____

comatose

13. The three categories of disorders in the differential diagnosis of pseudocoma are

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a. l_____-i_____s_____ and v_____ p_____ i_____

locked-in syndrome and ventral pontine infarction (EEG normal)

b. p_____d_____,c_____, and c_____ r_____

psychiatric disorders, catatonia, and conversion reaction

c. n_____w_____ and m_____g_____, G_____-B_____ s_____

neuromuscular weakness and myasthenia gravis, Guillain-Barré syndrome

14. A patient presents with coma. Your first move is to assess and secure the _____.

airway

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15. Complete the following about approach to the comatose patient:

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a. What percent of patients with Wernicke encephalopathy present with coma?

3%

b. You would initially treat those patients with_____.

thiamine

16. True or False. The following breathing pattern is most likely to be observed in a comatose child with fulminant hepatic failure after acetylsalicylic acid (ASA) use during a viral infection:

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a. Cheyne-Stokes

true (Seen with diencephalic lesions or, as in this case, bihemispheric dysfunction. The child has a toxic/metabolic encephalopathy as a result of hepatic failure due to Reyes syndrome.)

b. hyperventilation

false

c. cluster

false

d. false

false

17. What is the significance of equal, reactive pupils in a comatose patient?

indicates toxic metabolic cause

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18. What is the most useful single sign in distinguishing metabolic from structural coma?

the light reflex (Equal and reactive pupils indicate toxic/metabolic cause with few exceptions.)

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19. The only metabolic causes of fixed/dilated pupils are

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a. a_____e_____

anoxic encephalopathy

b. g_____t_____

glutethimide toxicity

c. a_____u_____

anticholinergic use (i.e., atropine)

d. b_____t_____p_____

botulinum toxin poisoning

20. True or False. The following is a metabolic cause of fixed, dilated pupils:

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a. atropine

true

b. glutethimide toxicity

true

c. hypermmonemia

false

d. anoxic encephalopathy

true

e. botulinum toxin poisoning

true

21.In a third nerve palsy

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a. the pupil is_____

dilated

b. and the eye looks_____and _____.

down and out

22. True or False. The following ocular findings can be seen in comatose patients with pontine lesions:

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a. pinpoint pupils

true

b. periodic alternating gaze

false (Periodic alternating gaze usually indicates bilateral cerebral dysfunction.)

c. ocular bobbing

true

d. bilateral conjugate deviation to cold calorics

false

23. In frontal lobe lesions patient looks toward

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a. the_____side

moving

     i. in destructive lesions that is_____

away from hemiparesis, toward the moving extremities

     ii. in irritative lesions (seizures) that is_____

away from seizure focus, toward the jerking extremities

b. lesion is in the f_____c_____for_____c_____g_____

frontal center for contralateral gaze

24. In a pontine lesion the eyes deviate toward the_____ side.

nonmoving

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25. True or False. The eyes “look toward the side of the destructive lesion” in all destructive supratentorial lesions causing bilateral conjugate gaze deviation.

false (Whereas the above is true for lesions affecting the frontal gaze center, medial thalamic hemorrhage can result in gaze deviation away from the lesion, “wrong way gaze,” i.e., toward the nonmoving side.)

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26. Name three causes of bilateral downward gaze deviation in a comatose patient.

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a. t_____ l_____

thalamic lesion

b. m_____ p_____ l_____

midbrain pretectal lesion

c. b_____

barbiturates

27. Complete the following concerning internuclear ophthalmoplegia:

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a. Lesion is in the_____ _____ _____.

medial longitudinal fasciculus

b. Fibers are interrupted that go to the_____ _____ _____ _____.

contralateral third nerve nucleus

c. Results in

     i. loss of_____

addcution

     ii. of the_____ eye

ipsilateral

     iii. on_____ _____ _____

spontaneous eye movement

     iv. or in response to_____ _____

_____

reflex movement (doll’s, calorics)

     v. and convergence_____

is not impaired

28. True or False. The ciliospinal reflex is indicative of

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a. parasympathetic pathways

false

b. spinothalamic pathways

false

c. integrity of the periaqueductal gray

false

d. sympathetic pathways

true

29. True or False. Subfalcine herniation is of concern because:

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a. Anterior cerebral artery territory infarcts may occur

true

b. Transtentorial herniation may occur

true

c. There is no obvious concern.

false

30. True or False. Decreased consciousness occurs early in uncal herniation.

false (It occurs late in uncal herniation early in central herniation.)

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31. True or False. Uncal herniation syndrome rarely gives rise to decorticate posturing.

true

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32. Upward cerebellar herniation

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a. Can occlude the_____,

SCAs

b. resulting in_____ infarction.

cerebellar

33. Central herniation

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a. can occlude the_____,

PCA

b. resulting in_____ _____.

cortical blindness

c. It can shear basilar artery_____ and cause D_____ hemorrhages.

perforators, Duret

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34. True or False. This stage of central herniation is reversible.

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a. medullary stage

false

b. diencephalic stage

false

c. lower pons false

false

d. upper pons

false

35. List the distinguishing features of the pupils and respiratory pattern for the following injuries:

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a. injury at the diencephalon

     i. pupils_____

react to light

     ii. respiratory pattern is_____

Cheyne-Stokes

b. injury at the midbrain

     i. pupils_____

midposition

     ii. respiratory pattern is_____

hyperventilation

c. injury at the pons

     i. pupils_____

pin-point

     ii. respiratory pattern is_____

apneustic

d. injury at the medulla oblongata

     i. pupils are_____

dilated, fixed (markedly open)

     ii. respiratory pattern is_____

ataxic

36. True or False. Internuclear ophthalmoplegia is prominent at the “lower pons” stage of central herniation.

false (at the upper pons stage)

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37. Matching. Use the numbered options to complete the following statements:

Parasympathetics are lost; Sympathetics are lost; Both are lost.

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a. Why does injury to the pons result in pinpoint pupils?

b. Why does injury of herniation result in dilated fixed pupils?

(i.e., bilateral third nerve palsy)

38. Matching. Use the numbered options to complete the following questions:

3%; 9%; 15%; 18% What percentage of patients who had symptoms of central herniation had:

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a. good outcome?

b. functional outcome?

39. True or False. Regarding uncal herniation:

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a. The earliest consistent sign is

     i. impaired consciousness

false

     ii. unilateral dilated pupil

true

40. What shape is the suprasellar cistern?

pentagonal

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41. True or False. Unilateral dilated pupil in early third nerve stage of uncal herniation is seen in the following percentage of patients ipsilateral to the lesion:

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a. 65%

false

b. 75%

false

c. 85%

true

d. 95%

false

42. Complete the following statements concerning anoxia. Pathological lesions seen in

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a. cortex

     i. _____ cortical laver

third

     ii. _____ horn

Ammon

b. basal ganglia

     i. g_____ p_____

globus pallidus

     ii. c_____

caudate

     iii. p_____

putamen

c. cerebellum

     i. P_____ cells

Purkinje

     ii. d._____ nucleus

dentate

     iii. i_____ o_____

inferior olive

d. What tissue is more sensitive to anoxia—gray or white matter?

gray (It has a greater requirement of O₂.)

e. Are steroids useful after cardiac arrest?

no

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