1. Case Report 78 year old female presents to clinic with progressive “worsening function”. History reveals that she has been growing more confused and inappropriate over the past few weeks, or possibly even months, and recently has begun stumbling. 4 days ago she fell and fractured her humerus. She was treated in the ER with Vicodin for pain, arm sling for traction, head CT for liability, Ceftriaxone because it is standard of care, and given a follow up with orthopedics. Two days ago she became somewhat delirious, this morning she is agitated and only saying inappropriate words.

2. GCS tool.. The Glasgow Coma Scale is the most widely used scoring system used in quantifying level of consciousness following traumatic brain injury. It is used primarily because it is simple, has a relatively high degree of interobserver reliability and because it correlates well with outcome following severe brain injury.

3. The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : – Best Eye Response. (4) – No eye opening. – Eye opening to pain. – Eye opening to verbal command. – Eyes open spontaneously.

4. – Best Verbal Response. (5) – No verbal response – Incomprehensible sounds. – Inappropriate words. – Confused – Orientated – Best Motor Response. (6) – No motor response. – Extension to pain. – Flexion to pain. – Withdrawal from pain. – Localising pain. – Obeys Commands Our Patient (at her worst): GCS - 9 Eyes - 3Motor - 4Speech - 2

5. Disorders of Mental Status - From DSM IV ConsciousnessCognitionMoodPsychosis Delirium1°  2°  2°  2°  Dementianl 1°  2°  2°  Mood Dx 1°  Psychotic Dx 1° 

6. Kindling Theory of Delirium Predisposing Factor + Insult Predisposing Factors: (1) Elderly. (2) Post-Operative. (3) Severe Burns. (4) Brain Injury/Dementia. (5) Drug Withdrawal Insult: “I WATCH DEATH”

7. Delirium DDX - “I WATCH DEATH” (I) Infectious - meningitis, encephalitis (W) Withdrawal. (A), Acute metabolic - acidosis electrolyte disturbance, renal failure. (T) Trauma. (C), CNS disease - CVA seizures. (H) Hypoxia. (D) Deficiencies - B12, niacin, thiamine. (E) Environmental - Hypo/hyperthermia. (A) Acute vascular - cerebral hemorrhage, vasculitis. (T) Toxins - drugs, poisons. (H) Heavy Metals - Hg, Pb.

8. Case 2 An 85 year old female patient was demonstrating an expressive aphasia over a period of several weeks. The neurological examination did not demonstrate any other significant motor or sensory signs.

9. Which one of the following lesions does this patient have?

10. An MRI of this patient showed small bilateral hemorrhages in branches of the middle cerebral arteries supplying the parietal lobes. They interrupt the deep (arcuate) fibers passing from Wernicke's area to Broca's motor speech area and account for the aphasic speech.

11. A woman in her mid-50's complained of headache and poor coordination on her left side. Neurologic examination revealed papilledema, weakness, and loss of sensation of the left face. There was also a mild hearing loss on the left, cerebellar ataxia of the left extremities, and mild corticospinal tract signs (spastic hemi paresis) on the right side. Case 3

12. Which one of the following lesions does this patient have?

13. The MRI showed a mass (benign epidermoid cyst) in the left cerebellopontine angle. This tumor invaded the cerebellum, stretched the 5th, 7th, and 8th cranial nerves, and was putting pressure on the basis pontis with it's corticospinal tracts.

14. Over a period of time, a 40 year old son visiting his mother noticed that she was having increased difficulty speaking. Her neurologic exam revealed an expressive aphasia, spastic paresis of the right upper extremity, and right facial weakness. Other motor and sensory functions were unremarkable. Case 4

15. Which one of the following lesions does this patient have?

16. An MRI indicated a white matter mass in the posterior part of the left inferior frontal gyrus involving Broca's speech area and the lower precentral gyrus. The glioblastoma was treated by surgical excision and local irradiation but the neurologic symptoms were not improved.

17. A 44 year old woman complained of headaches. Neurologic examination revealed papilledema and she could not follow a finger in upward gaze. Her pupils were dilated, did not react to light, and her eyes could not converge when viewing a near object. Case 5

18. Which one of the following lesions does this patient have?

19. The MRI showed an enlargement in the tectum which closed the cerebral aqueduct and caused increased intracranial pressure and resultant headache and papilledema. Damage here to the gaze and pupillary light centers also involve occipitomesencephaic fibers affecting pupillary reflexes, vertical gaze and convergence.