Coma due to stroke: causes, symptoms, treatment and prevention methods

Find out more about diseases starting with the letter “K”: Causalgia, Brain cyst, Cluster headache, Tick-borne encephalitis, Kozhevnikov epilepsy, Colloid cyst of the third ventricle, Coma, Compressive myelopathy, Balo concentric sclerosis, Radicular syndrome, Corticobasal degeneration, Craniovertebral anomalies, Craniospinal tumor, Craniopharyngioma, Myasthenia gravis crises, Hemorrhage into the ventricles of the brain.

Coma is a pathological disorder of consciousness, borderline between life and death, and poses a certain danger to human life. Translated from Greek “deep sleep”. It occurs through damage to special areas of the brain and is determined by the patient’s complete lack of connection with the surrounding reality. Occurs due to metabolic or organic root causes.

Characterized by a lack of consciousness and reflexes of the pupils of the eyes to the brightest stimuli. Computed tomography and magnetic resonance imaging and laboratory blood tests have a key role in diagnosing coma. All therapeutic measures are focused on eliminating the factors of the pathological process

general information

During a comatose state, the patient completely loses contact with others. A profound impairment of consciousness is determined by the complete absence of mental activity. Even intense stimulation cannot bring the patient out of this state. Coma is different in that the patient is always in a supine position with his eyes closed, which he does not open when exposed to sound stimuli or pain.

Clinical symptoms depend on the cause of occurrence and the severity of suppression of the nervous system - absence or presence of spontaneous movements, extinct or preserved reflexes, spontaneous breathing, dependence on life-supporting equipment.

The origin is due to extensive damage to special brain areas responsible for wakefulness.

Main consequences of the condition

There are several outcomes that can result from coma after a stroke. Firstly, the patient will return from a dangerous condition with (in rare cases, complete) restoration of vital functions. Secondly, death as a result of brain death, which can occur due to severe hypoxia.

Thirdly, a way out of the situation without restoration of functions, with preservation of paralysis and paresis, as well as with impaired memory and intelligence. Fourthly, the transition to a vegetative state with the preservation of limited reactions to stimuli, while the person cannot speak or think.

Proven fact: full restoration of health is possible only in 10% of cases.

Causes

The occurrence of coma is always caused by damage to the nerve pathways caused by severe pathologies of the central nervous system. A coma cannot be an independent disease.

The reticular formation is a mesh-like structure that runs throughout the brain. All signals from the surrounding reality pass through it, filtered and systematized. When the cells of this unique system are damaged, the nervous system's connection with the outside world is lost.

The causes of damage to the reticular pharmacy system are divided into:

• Physical: cerebral hemorrhages, injuries, bruises, bullet wounds, strokes.
• Chemical, in turn, are divided into external and internal. Poisonous compounds coming from outside can be narcotic substances, sleeping pills, neurotropic poisons, toxic toxins in infectious diseases. Internal chemical compounds are formed as a result of metabolism and diseases of internal organs. These include ammonia (severe liver pathologies), abnormal levels of glucose and acetone (diabetes mellitus), and insufficient oxygen in the blood (hypoxia).
• The most severe is the combination of physical and chemical effects on the reticular formation. The result is a worsening of intracranial pressure indicators. This case occurs with tumors of the central nervous system and traumatic brain injuries.

Coma due to intoxication of the body

It stands out as a separate group, since it is provoked by endogenous intoxications accompanying toxoinfections, various infectious diseases, pancreatitis, renal and liver failure, or exposure to chemical poisons on the body: organic phosphorus compounds, alcohol, drugs belonging to the group “barbiturates”, and other medicines.

In addition to this strict classification, there are comas of unknown or mixed etiology for which one clear cause cannot be identified, for example, in the case of thermal coma caused by overheating of the entire human body. Although some sources classify it as a neurological group.

Below we will consider individual types of comatose states that are more common than others.

Classification

Comatose states are classified according to groups of criteria:

• the reason that caused it;
• degree of depression of consciousness.

Depending on the reasons, they are divided into the following types:

• traumatic - as a consequence of cranial and brain injuries;
• epileptic - as a worsening of epilepsy;
• apoplexy - the result of a stroke;
• meningeal - a consequence of meningitis;
• tumor - neoplasms in the skull;
• endocrine - during diabetes mellitus, a decrease in the properties of the thyroid gland;
• toxic - a consequence of renal and liver failure.

Causal classification does not reflect the patient’s actual well-being, and therefore is not used in neurology. Professionals in this field of medicine classify the case according to the severity of the person’s condition - the Glazko scale. The method is based on a general assessment of three indicators: the patient’s speech, the presence of body movements, and the opening of the eyelids. Depending on the severity of their violations, a certain number of points are assigned. The sum of the scores determines the patient’s degree of consciousness:

• 15 points - clear consciousness;
• 14-13 points - moderate stunning;
• 12-10 - deep stun;
• 9-8 - stupor;
• 7 or less - comatose state.

Based on these data, the severity of a person’s situation can be easily calculated, emergency treatment tactics can be quickly developed and the outcome of the disease can be predicted.

In intensive care circles, doctors divide coma into 4 degrees:

• I - stupor of consciousness;
• II - stupor;
• III - atonic;
• IV - beyond.

Biological brain death

➥ Main article: EEG in the diagnosis of brain death

A separate very complex issue, including from an ethical point of view, remains the problem of when the terminal stage of coma turned into biological death. It is now generally accepted that the clinical concept of the death of a subject is identical to the concept of the death of his brain. In conditions of deep areactive coma, when all clinical signs of brain functioning are absent, EEG becomes of particular importance as a direct and objective sign of the functioning of nervous tissue. Terminal coma corresponds to a constant absence of electrical activity of the brain, when in all mono- and bipolar leads the registration line coincides with the isoelectric line. The possibility of resuscitation and restoration of brain functions after electrical silence is determined by many factors; the absence of electrical activity of the brain means that cognitive functions will not be restored. In particular, if the cessation of phasic brain activity occurs under conditions of artificially regulated hypotension and hypothermia, the duration of the period during which the absence of electrical brain activity can be reversible increases significantly. Restoration of electrical activity after more than 0.5 hours of electrical silence can be expected with barbiturate intoxication. Most researchers believe that outside these conditions, practically irreversible changes in the brain, incompatible with life, correspond to the absence of electrical activity in the brain, which lasted continuously for 4-6 hours. Of course, death is determined based not only on the EEG, but also on the analysis of the entire complex of clinical data. Technical requirements for EEG recording in such patients must be met in full accordance with the International Standards of the Association of Clinical Neurophysiology. In any case, the isoelectric line on the EEG can only be interpreted taking into account the clinical picture. Formally, with a combination of clinical terminal coma, the absence of electrical activity of the brain and the absence of a toxic or hypothermic factor, the irreversibility of the condition is stated 24 hours after its onset. When deciding on organ donation, the French Electroencephalographic Society, for example, considers an interval of 10 hours sufficient13.

Clinical symptoms

The main clinical sign is the patient’s absolute lack of consciousness, deprivation of mental activity and contact with the outside world. All other manifestations of the disease are associated with the causes that caused brain damage:

• Body temperature indicators. Hypothermia occurs in case of poisoning with sleeping pills, alcohol (can decrease to 32-34 C⁰). An increase in temperature to 42-43 C⁰ and dry skin accompany a coma caused by general overheating.
• Respiratory frequency. Slow, shallow breathing is a sign of an overdose of morphine-containing drugs, sleeping pills, and a decrease in the level of thyroid hormones. Deep breathing is a distinctive feature against the background of infectious intoxication due to pneumonia. This symptom occurs with kidney failure, brain tumors, uncontrolled sugar levels in diabetes in the form of acidosis.
• Pulse and blood pressure. A decrease in heart rate (bradycardia) signals coma due to heart pathologies. Frequent heartbeat - tachycardia, in combination with significant blood pressure numbers, indicate an increase in intracranial pressure. Hypertension, as a symptom, appears in patients in a coma after a stroke. Low blood pressure occurs in cases of poisoning with sleeping pills, heavy intra-abdominal bleeding, myocardial infarction, and diabetic coma.
• Skin color is also a significant diagnostic symptom. When intoxicated with carbon monoxide, the skin gradually acquires a dark red color. Suffocation is accompanied by a sharp decrease in the level of oxygen in the body’s blood, as a result of which the nail phalanges of the fingers and the nasolabial triangle turn blue. Bleeding from the ears and nose, bruises, bruises around the eyes (“a symptom of glasses”) correspond to a coma that manifested itself as a result of a traumatic brain injury. If the coma is caused by global blood loss, the skin becomes distinctly pale.
• Maintaining contact with others. A favorable encouraging sign is the ability of patients to utter some sounds. This is observed with mild coma or stupor. The more severe the patient's condition becomes, the faster the ability to make sounds is lost. The mild form is also characterized by reflex movements of the limbs in response to pain, possibly causing grimaces.

Anatomical and functional features of the central nervous system

Being the central regulator of all processes occurring in the body, the brain operates in an active metabolic mode. Its weight is only 2% of body weight (about 1500 g). However, for the uninterrupted functioning of the brain, 14-15% of the total volume of circulating blood (700-800 ml) must flow into and out of the cranial cavity every minute. The brain uses 20% of all the oxygen the body consumes. It is metabolized only by glucose (75 mg per minute or 100 g per day).

So, the physiological functioning of brain tissue depends on adequate perfusion with its blood, the content of a sufficient amount of oxygen and glucose, the absence of toxic metabolites and the free outflow of blood from the cranial cavity.

A powerful autoregulation system ensures smooth functioning of the brain. Thus, even with significant blood loss, the perfusion of the central nervous system is not impaired. In these cases, a compensatory reaction of centralization of blood circulation with ischemia of less important organs and tissues is activated, aimed primarily at maintaining adequate blood supply to the brain. The body reacts to another pathological condition - hypoglycemia - by increasing blood flow to the brain and increasing the transport of glucose here. Hyperventilation (hypocapnia) reduces blood flow to the brain; hypoventilation (hypercapnia) and metabolic acidosis, on the contrary, increase blood flow, promoting the removal of “acidic” substances from tissues.

With significant damage to brain tissue, insufficient autoregulation or excessive manifestations of the compensatory reaction of the inflow and outflow of blood, the brain cannot voluntarily change its volume. The closed cavity of the skull becomes its trap. Thus, an increase in intracranial volume by only 5% (with hematomas, tumors, hyperhydration, liquor hypertension, etc.) disrupts the activity of the central nervous system with the patient losing consciousness. In another pathology, excessive growth of cerebral blood flow leads to overproduction of cerebrospinal fluid. The brain tissue is compressed between the blood and the cerebrospinal fluid, swelling develops, and functions are impaired.

Traumatic destruction of brain tissue, edema and swelling, increased intracranial pressure, impaired circulation of cerebrospinal fluid, circulatory disorders and other damaging mechanisms lead to hypoxia of CNS cells. It manifests itself primarily as a disturbance of consciousness.

Diagnostics

The diagnosis immediately establishes the causes of the comatose case. The conclusion differentiates the condition from other similar disorders of consciousness. The following diagnostic methods are used:

• Anamnesis collection. They find out from the patient's relatives or witnesses whether the patient took medications, and whether empty jars or blisters of medications were found nearby. You should ask about the presence of chronic diseases of blood vessels, endocrine glands, and heart. Clarify that the patient may have voiced complaints. An important factor is the age of the patient and the speed of development of symptoms. Young people more often fall into this state after poisoning with sleeping pills or narcotic drugs. In elderly patients, the formation of a coma occurs against the background of heart attacks, strokes, and other cardiovascular diseases.
• Inspection. During the examination, the possible root cause of the coma is determined. Respiratory rate, pulse rate, blood pressure, body temperature, injection marks, bad breath, bruises are indicators on the assessment of which the establishment of a correct diagnosis depends.
• The patient's position can also characterize the severity of brain damage. During hemorrhages and meningitis, the patient’s head is thrown back, the neck muscles have a pronounced tone - signs of irritation of the meninges. Convulsive attacks, cramping spasms of individual muscles indicate the patient’s status epilepticus, the condition of eclampsia in pregnant women. Unexpressed paralysis of the limbs indicates a stroke, a complete absence of reflexes indicates deep lesions of the cortex and spinal cord.
• A differential feature distinguishing it from other disorders of consciousness was the study of the patient’s function to open his eyes to irritation in the form of sound or pain. If the response to sound and pain stimulation in the form of involuntary opening of the eyes persists, then this is not a coma. If the eyes remain closed, the case is considered comatose by doctors.
• The doctor carefully evaluates the ability of the pupils to respond to light. Its quality makes it possible to determine the damaged area of ​​the brain, and also indicates the factor that provoked the coma. The clarity of the pupil's reaction to light indicates the future prognosis of the disease.

Pinpoint pupils that do not respond to bright light indicate alcohol or drug poisoning. If the pupils of the left and right eyes have different diameters, this is a sign of increasing intracranial pressure. Excessively wide pupils are a symptom of midbrain pathologies. If, when exposed to bright light, the reaction of the pupils is completely absent, their diameter remains wide, this is a very unfavorable symptom, which indicates imminent brain death.

The development of medicine makes it possible to use hardware methods for diagnostic purposes to examine patients with impaired consciousness immediately upon admission to a medical institution. Performing head computed tomography (CT), magnetic resonance imaging (MRI) makes it possible to detect changes in areas of the brain, lesions, tumor-like neoplasms, and signs of intracranial hypertension. The conclusions obtained as a result of the tomograph study serve as the basis for determining treatment tactics - surgical or conservative.

X-rays of the head and spine in several projections are performed if MRI or CT is not possible.

A biochemical blood test can confirm a metabolic failure. Tests for the level of glucose, urea, acetone, and ammonia in the blood are carried out very quickly. The ratio of the content of electrolytes and blood gases is determined. In addition, the blood is examined for insulin levels, adrenal and thyroid hormones, for the presence of narcotic substances, tranquilizers and other toxic drugs, and bacterial blood cultures are performed to identify a possible infectious agent.

During an electroencephalogram (EEG), electrical impulses from the brain are recorded, which make it possible to determine the type of coma and understand what caused it - hemorrhage, poisoning or a tumor.

Folk remedies

Photo: psychologies.co.uk

Coma is an emergency condition that requires immediate medical attention. Under no circumstances should one assume that there are any folk remedies that can help in this situation.

To prevent such a serious disturbance of consciousness, which entails dangerous changes in the body, it is necessary to follow some preventive measures. First of all, it is recommended to promptly consult a doctor if any disturbing symptoms appear. In turn, the doctor will not only diagnose the disease at an early stage, but will also prescribe the necessary treatment. These actions contribute to the timely correction of conditions that can cause the development of coma. In addition, it is important for people suffering from diabetes to carefully follow their diet and take glucose-lowering medications on time. Particular care should be taken with insulin preparations, since the administration of a large dosage of insulin exceeding the therapeutic dose can lead to the development of coma. In most cases, this problem may occur in elderly people who, due to their forgetfulness or blurred vision, may miss the time of taking the drug or use a large dose of the drug. Therefore, such people especially need outside help. It is important for people with chronic diseases of the cardiovascular system to carefully monitor their health and promptly contact a medical facility if their general health worsens.

The information is for reference only and is not a guide to action. Do not self-medicate. At the first symptoms of the disease, consult a doctor.

Treatment

Treatment is a complex, comprehensive process that must prevent death, maintain vital body functions, and at the same time combat the root cause of this condition.

The first resuscitation measures aimed at preserving a person’s life are carried out immediately upon the arrival of the ambulance team and during transportation of the patient, before all diagnostic procedures are carried out. First aid consists of fixing the patient's position, ensuring patency of the airway - straightening the tongue, clearing the nose and mouth of vomit, an oxygen mask, tracheotomy with the installation of a breathing tube. It is necessary to normalize blood circulation by administering medications that normalize cardiac activity and blood pressure. If necessary, indirect cardiac massage is performed.

In the intensive care unit, the patient is connected to an artificial respiration apparatus. Medicines are administered aimed at eliminating the pathological symptoms of the disease - anticonvulsants, antipyretics, hemostatics. Intravenous infusions of glucose and saline solutions are required. Measures are necessary to normalize body temperature. In case of hypothermia, the patient is covered and covered with hot water bottles. If there is a suspicion of poisoning with chemical or pharmacological drugs, gastric lavage is performed.

At the second stage, having detailed results of all types of examinations, the cause is eliminated. In case of hyperglycemic coma, measures are taken to normalize blood sugar and insulin levels. In case of renal failure, hemodialysis is performed. If an injury, hematoma or brain tumor is detected, urgent or planned surgical intervention is performed according to indications.

How to call a resuscitator

If you decide to go to our clinic in the center of Moscow for medical help, dial the ambulance number -. A team of our specialists will arrive at the address you specified to transport the patient to a medical facility and provide him with first aid.

All our specialists are highly qualified and have extensive medical experience. All diagnostic measures are carried out promptly. This is also due to the availability of modern equipment. Our doctors choose the most optimal treatment method, taking into account the characteristics of the disease and the patient’s body.

Our clinic is located at the address: Moscow, Central Administrative District, 2nd Tverskoy-Yamskaya Lane, building 10. The nearest metro station is Mayakovskaya (5 min walk).

Remember that if a person falls into a coma, he requires emergency assistance from specialists. The slightest delay can lead to the death of the patient.

Prognosis and possible prevention

Predicting the situation while a patient is in a coma is based on the degree of brain damage and the causes of the disease. The more severe the patient’s condition, the more likely an unfavorable outcome is possible. The patient's chances of recovery are assessed according to the following measures:

• precoma, coma I - the prognosis is favorable, complete recovery is possible without residual effects;
• coma II and III - an unreliable position that can lead to both recovery and death of the patient,
• coma IV - in most cases leads to the death of the patient, the prognosis is extremely unfavorable.

Early prevention is focused on timely diagnosis of major disorders of the cardiovascular system, various tumor pathologies and other conditions that can lead to coma.

Rehabilitation after a coma

To bring a patient out of a coma, doctors make many attempts, and this process takes an indefinite amount of time. If persistent efforts are successful, the person’s consciousness returns, the mood for recovery is formed, and rehabilitation is carried out under the supervision of specialists.

For this purpose, targeted centers with multifaceted rehabilitation programs are created. In the Minsk region, one operates in the Aksakov region. Those who require specialized assistance are there free of charge.

Hypoglycemic coma

In diabetic patients, sugar can not only rise sharply, but also fall. This happens due to long breaks between meals, excessive physical activity or when drinking alcohol. Hypoglycemic coma, the symptoms of which are described below, develops very rapidly.

Its harbingers may be:

• strong feeling of hunger;
• anxiety;
• irritable and restless state;
• low body temperature;
• shallow, rapid breathing;
• increased sweating;
• nausea, migraine;
• cardiopalmus;
• visual disturbances;
• inhibited consciousness;
• dilated pupils;
• muscle hypertonicity.

If all or part of the symptoms appear, emergency assistance is required, which consists of intravenous administration, if necessary, repeated, of glucose solution and subcutaneous administration of adrenaline.