Motor function

As part of the assessment of Glasgow Coma Scale it may have been appreciated that there is lateralisation in the individual patient which implies a focal cause for the coma. The observation of involuntary movement affecting the face or limbs and asymmetry of reflexes will help to support this possibility. Focal seizures are an important indicator for a focal cause for the coma, and the observation of more generalised

Box 1.1 Clinico-anatomical correlation in coma

Bilateral hemisphere damage Symmetrical signs Fits or myoclonus Normal brain stem reflexes

Normal oculocephalic and oculovestibular responses Normal pupils

Supertentorial mass lesion with brain stem compression Ipsilateral third nerve palsy Contralateral hemiplegia

Brain stem lesion Early eye movement disturbance Abnormal oculocephalic or vestibular responses Asymmetrical motor responses

Toxic/metabolic Reactive pupils

Random eye movements until late in coma

Absent oculocephalic and oculovestibular responses

Extensor or flexor posturing

Hypertonicity

Hypotonicity

Multifocal myoclonus.

seizure or of multifocal myoclonus raises the possibility of a metabolic or ischaemic-anoxic cause for coma with diffuse cortical irritation. The testing of tone as part of the assessment of muscle function can be useful in the comatose patient where it is possible to detect asymmetry of tone, not only in the limbs but also in the face. There are recognisable patterns of signs associated with the site of pathology (Box 1.1).21

By this stage it should be possible to identify those patients who are unconscious with focal signs, those who are unconscious without focal signs but with meningism, and those who have loss of consciousness without either focal signs or meningism (Box 1.2).

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