Coma with focal signs

Except in those patients in whom an underlying and irreversible terminal disease is recognised, it is obligatory that CT or MRI be undertaken to identify the cause of the coma. This will define whether or not structural abnormality is present and in many instances give a clue to the underlying cause. If the CT scan is normal then the possibility of a non-structural focal abnormality antedating the onset of coma or being part of the coma, as occasionally happens with hypoglycaemic or hepatic encephalopathy, must be considered. If there is no focal structural abnormality on the CT scan then other investigations including metabolic and CSF examination should be carried out. Once the image has been obtained the question of more definitive therapy, be it neurosurgical, a reduction of intracranial pressure by the use of steroids and mannitol, the application of a specific antibacterial or antiviral agent, or the use of chemotherapy may be considered.

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