A pontine lesion on the opposite side to the eye deviation. ‘Wrong way eyes’ may also be seen in thalamic hemorrhage.A frontal lobe lesion on the same side as the eye deviation, commonly a stroke. This can also be a result of a Todd’s paralysis following a seizure (whereas during the seizure the eyes deviate in the opposite direction - away from the origin of the ‘irritative’ focus).thus dysconjugate gaze is difficult to interpret in the stuporous or comatose patient.Most individuals have a degree of exophoria when drowsy for any reason and any underlying strabismus tends to worsen.ICH, PCOM aneurysm or raised ICP (parasympathetic nerves are in the superficial parts of the nerve, so tend to be more vulnerable to compressive lesions – ptosis and ‘down and out’ eye positioning tends not to occur due to sparing of the more central motor fibers) One dilated pupil suggests CN3 compression – e.g.fixed mid-sized pupils occur in midbrain lesions.pinpoint pupils occur in pontine lesions and certain overdoses (e.g.Different sized pupils correspond to different types of lesions.We need to assess the pupils for size, asymmetry and reactivity to light.Look for spontaneous breaths in the ventilated patient (may be suppressed if hyperventilated).Also look for deep rapid Kussmaul breathing, secondary to a metabolic acidosis, as in diabetes ketoacidosis.Central hyperventilation, or prolonged inspiratory pauses or irregular ataxic breathing indicates various brainstem lesions as does apnea.Cheyne-Stokes Respiration is not specific but is seen in lesions above the brainstem.Other scores such as the Richmond Agitation-Sedation Score (RASS) are used to titrate sedation (see Sedation in the ICU)īreathing pattern is often forgotten in intubated patients, but is important as the pattern of breathing correlates with the level of the lesion, and may suggest other causes.GCS is most commonly used (see Glasgow Coma Scale (GCS)).ventilator (evidence of spontaneous breaths?).cranial scars, drains, ICP monitors and VP shunts.consider the neurological findings in light of the vital signs, evidence of trauma, acute or chronic illness, and/or drug ingestion.Todd’s paresis, hemiparesis due to hypoglycemia) Remember that systemic causes can sometimes have focal signs! (e.g. Metabolic - check COATPEGS (CO2, O2, ammonia, temperature, pH, electrolytes, glucose, serum osmolality).Systemic causes without focal signs (TOMES) meningism - meningoencephalitis, subarachnoid haemorrhage (SAH). tumor, hemorrhage, abscess), injury, inflammation no meningism - stroke, space occupying lesions (e.g.In particular, assessment of asymmetry for the presence of focal neurological deficits is vital. meningism and signs of the underlying cause.motor responses (tone, reflexes and posturing).eye movements and oculovestibular responses.level of consciousness (Glasgow Coma Score - list the components e.g.The key components of the neurological examination of the comatose patient are: Coma is a state of unconsciousness caused by temporary or permanent impairment of the ascending reticular system in the brainstem, or both cerebral hemispheres.
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