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Supratentorial mass lesions tend to affect brain function in an orderly way There may initially be signs of hemispheric dysfunction, such as hemiparesis As coma develops and deepens, cerebral function becomes progressively disturbed, producing a predictable progression of neurologic signs that suggest rostrocaudal deterioration Thus, as a supratentorial mass lesion begins to impair the diencephalon, the patient becomes drowsy, then stuporous, and finally comatose There may be Cheyne-Stokes respiration; small but reactive pupils; doll s-head eye responses with side-to-side head movements but sometimes an impairment of reflex upward gaze with brisk flexion of the head; tonic ipsilateral deviation of the eyes in response to vestibular stimulation with cold water; and initially a positive response to pain but subsequently only decorticate posturing With further progression, midbrain failure occurs Motor dysfunction progresses from decorticate to bilateral decerebrate posturing in response to painful stimuli; Cheyne-Stokes respiration is gradually replaced by sustained central hyperventilation; the pupils become middle-sized and fixed; and the oculocephalic and oculovestibular reflex responses become impaired, perverted, or lost As the pons and then the medulla fail, the pupils remain unresponsive; oculovestibular responses are unobtainable; respiration is rapid and shallow; and painful stimuli may lead only to flexor responses in the legs Finally, respiration becomes irregular and stops, the pupils often then dilating widely In contrast, a subtentorial (ie, brainstem) lesion may lead to an early, sometimes abrupt disturbance of consciousness without any orderly rostrocaudal progression of neurologic signs Compressive lesions of the brainstem, especially cerebellar hemorrhage, may be clinically indistinguishable from intraparenchymal processes A structural lesion is suspected if the findings suggest focality In such circumstances, a CT scan should be performed before, or instead of, a lumbar puncture in order to avoid any risk of cerebral herniation Further management is of the causal lesion and is considered separately under the individual disorders.

The definition of brain death is controversial, and diagnostic criteria have been published by many different professional organizations In order to establish brain death, the irreversibly comatose patient must be shown to have lost all brainstem reflex responses, including the pupillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and respiratory reflexes, and should have been in this condition for at least 6 hours Spinal reflex movements do not exclude the diagnosis, but ongoing seizure activity or decerebrate or decorticate posturing is not consistent with brain death The apnea test (presence or absence of spontaneous respiratory activity at a PaCo2 of at least 60 mm Hg) serves to determine whether the patient is capable of respiratory activity Reversible coma simulating brain death may be seen with hypothermia (temperature < 32 C) and overdosage with central nervous system depressant drugs, and these conditions must be excluded Certain ancillary tests may assist the determination of brain death but are not essential An isoelectric electroencephalogram, when the recording is made according to the recommendations of the American Electroencephalographic Society, may help in confirming the diagnosis Alternatively, the demonstration of an absent cerebral circulation by intravenous radioisotope cerebral angiography or by four-vessel contrast cerebral angiography is confirmatory

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Solution to Exercise 21-2. Use LINQ to SQL, but not the Object Relational Designer, to retrieve all the orders from the Order Details table where the quantity ordered is greater than 100. (You ll have to use a short type for the quantity, or else you ll get an error.) You re using LINQ to SQL here, but without the O/R Designer, there are some extra steps you ll need to take. First, be sure to add a reference to the System.Data.Linq namespace, and add the appropriate using statements.

Manno EM et al The declaration of death and the withdrawal of care in the neurologic patient Neurol Clin 2006 Feb;24(1): 159 69 [PMID: 16443137]

Patients with a metabolic cause of coma generally have signs of patchy, diffuse, and symmetric neurologic involvement that cannot be explained by loss of function at any single level or in a sequential manner, although focal or lateralized deficits may occur in hypoglycemia Moreover, pupillary reactivity is usually preserved, while other brainstem functions are often grossly impaired Comatose patients with meningitis, encephalitis, or subarachnoid hemorrhage may also exhibit little in the way of focal neurologic signs, however, and clinical evidence of meningeal irritation is sometimes very subtle in comatose patients Examination of the cerebrospinal fluid in such patients is essential to establish the correct diagnosis In patients with coma due to cerebral ischemia and hypoxia, the absence of pupillary light reflexes at the time of initial examination indicates that there is little chance of regaining independence; by contrast, preserved pupillary light

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