CONSCIOUSNESS

Definition:
• A state of awareness of the self and environment

Two components:
• Wakefulness
(arousal)
• Awareness
(content)
Altered consciousness
• Coma
• Vegetative state
• Akinetic mutism
• Locked-in syndrome
• Brain death
 COMA
no eye opening, not utter a word, not
obey command (GCS <= 8)
Sustained, not arousable

? Transient unconscious:
Syncope, concussion
 Glasgow Coma Score
• An objective method to assess severity of HI
• To assess progress of patient
• Limitation: developing mass lesion may not
have deterioration until the lesion is critical.
Approach

Methods of painful stimulation

advantages and
disadvantage

Describe your finding

 GCS
Limitation
• swollen eye,
• intubation
• aphasia
• language barrier
• baby
(1)Adult Vs Child, (2) motor 6 Vs 5, (3) Motor: most important

Adult Infants & Children

Eye opening Spontaneous ------
to command to sound
to pain ------
None ------
Speech Oriented Appropriate for age, social smile
Disoriented Cries but consolable
Inappropriate Persistently irritable
Incomprehensible Restless, lethargic
None ------
Motor Obeys commands Spontaneous
Localized pain ------
Withdraws ------
Spastic flexion ------
Extension ------
None ------
 Vegetative state
Arousal but no awareness
– Often have sleep-wake cycles.
– May yawn, swallow food placed in the mouth.

– May move the trunk or limbs in meaningless ways.

– May occasionally smile, and a few may even shed tears;
– Some utter grunts or, on rare occasions, moan or
scream.
 Vegetative state
1. No evidence of awareness of self or environment and an inability t
o interact with others,
2. No evidence of sustained, reproducible, purposeful, or voluntary b
ehavioral response to visual, auditory, tactile, or noxious stimuli,
3. No evidence of language comprehension or expression,
4. Intermittent wakefulness manifest4d by the presence of sleep-wake
cycles,
5. Sufficiently preserved hypothalamic and brainstem autonomic func
tions to permit survical with medical and nursing care,
6. Bowel and bladder incontinence,
7. Variably preserved cranial nerve reflexes (pupillary, oculocephalic
, corneal, vestibulo-ocular and gag) and spinal reflexes.

The Multi-Society task Force on PVS (N eng L Med 94;330:1499-508)

N Engl J Med 1994: 330:1573
Persistent and permanent
Vegetative State (VS)
Persistent VS Permanent* VS
Trauma >1month >12 months
Nontrauma >1month >3 months

Permanent: in trauma case, not prelude recovery but rare and

almost always severely disabled.
 UNCONSCIOUSNESS
Unawareness
– Coma
– Vegetative state
 LOCKED-IN SYNDROME
• Consciousness and cognition are retained but
movement and communication are impossible
because of severe paralysis of the voluntary motor
system.
• Abnormalities in the descending corticospinal
pathways at or below the pons
• Neuromuscular blocking agents.
• Limited communication through eye movements
signals is preserved.
 AKINETIC MUTISM
• Pathologically slowed or nearly absent bodily
movement and loss of speech.
• Wakefulness and self-awareness is preserved but
the level of mental function is reduced.
• Bilateral damage to the paramedian
mesemcephalon, basal diencephalone or inferior
frontal lobe. E.g. bilateral ACA or its branches
infarction.
 BRAIN DEATH
Permanent absence of all brain function.
– Brainstem function test: all absence
BRAIN DEATH
Deeply comatose and
unresponsive patients with
severe brain damage who are
maintained on artificial
ventilation and circulation
supports:
alive or dead?
BRAIN DEATH

Life :

Heart Vs Brain
BRAIN DEATH

Brain function is the final determination of

life, not the beat of the heart.

The brain and mind are the essence of the

mankind; they constitute meaningful life and
their absence defines human death

(C. Miller Fisher 1991)

BRAIN DEATH
An individual who was sustained either
(1) irreversible cessation of circulatory and
respiratory function, or
(2) irreversible cessation of all function of the
entire brain, including the brain stem,
is dead.

(Guideline for the determination of death, JAMA 1981)

BRAIN DEATH
Two practical concerns
– Resources
– Organ donation

? Criteria
BRAIN DEATH
Key points for determination of brain death

“ irreversible cessation of all function of the entire

brain, including the brain stem,”

• Etiology
• Observation and Clinical Tests
• + Confirmatory Tests
BRAIN DEATH
ETIOLOGY

Reversible causes to be excluded

• Drug effect (intoxication, Depressant, muscle relaxants)
• Hypothermia (temperature <320C)
• Metabolic or endocrine disturbances
• Shock (SBP>90)
BRAIN DEATH
CLINICAL TESTS

...irreversible cessation of all function of the entire brain,

including the brain stem,...

Entire brain Vs brain stem

Death of the brain occurs when the organ irreversibly loses its
capacity to maintain the vital integrative function regulated
by the vegetative and consciousness-mediating centres of
the brainstem.
 BRAIN DEATH
CLINICAL TESTS

• No motor response to pain

• fixed pupils
• Absent corneal reflex
• Absent oculovestibular
reflex
• Absent gag reflex
• No respiration to apnea
test
BRAIN DEATH
CLINICAL TESTS

• WHO and WHEN

• Two doctors who are not involved in the
organ donation
• Two examination in separate time
BRAIN DEATH
CONFIRMATORY TESTS

Neuronal function:
• Electroencephalogram (EEG)
• Evoked potentials
Intracranial blood flow
• Cerebral angiography
• Transcranial Doppler
BRAIN DEATH
CONFIRMATORY TESTS

• EEG:
• electricocerebral silence
• Most frequently cited in the establishment of brain death
• Activity of cortical neurons: not brain stem
BRAIN DEATH
CONFIRMATORY TESTS

Cerebral angiography
• 4 vessels: Absent cererbal blood flow
• Most certain available means for documentation of brain
death.
• Most useful in cases complicated by metabolic / drug /
hypothermia factors
BRAIN DEATH
CHILDREN (< 5 years-old)

• Greater potential for recovery: more strict criteria than

adult
• longer period between the two clinical examination (at
lease > 24 hours)
• Confirmation test is required
DIAGNOSIS OF BRAIN DEATH:
AN ACTIVE PROCESS

• A clear understanding of brain death helps the patient’s

family and friends to recognized the reality of their loss,
spares them from the prolonged anguish that uncertainty
promotes.
• The health care team, can direct its energies to the care of
patients who benefit from intensive therapy, thereby
focusing human and material resources.
• The potential availability of organs provides hopes to
patients whose lives depend on successful transplantation.
“ the creation of new hope from tragedy…. a gift to the
future ”

Ganger GE, Brain death and Organ donation,

In: Neurosurgical Intensove Care