TOPIC : A STUDY OF OUTCOMES IN PATIENTS IN ALTERED SENSORIUM WITH FOCAL NEUROLOGICAL DEFICIT

PROBLEM STATEMENT :

Altered mental status (AMS) is a symptom complex that continuously poses a great challenge in the ICU management. The causes may range from easily reversible (such as hypoglycemia) to relatively permanent (such as stroke), and from benign (such as intoxication) to potentially life threatening (such as meningo-encephalitis) etiologies.

AMS is defined as a state of drowsiness, unresponsiveness, sudden behavioural change, disorientation or confusion, agitation or hallucination.

This is a study based on patients who present in altered sensorium due to a neurological deficit such as hemiparesis, hemiplegia, slurring of speech, stroke secondary to seizures etc and their outcomes.

A focal neurologic deficit consists of a set of symptoms or signs in which causation can be localized to an anatomic site in the central nervous system. The site of the pathologic abnormality is typically deduced through the history and physical examination before imaging. The clinical localization of a suspected lesion is extremely useful in that it assists the radiologist in directing the imaging portion of the evaluation. Focal neurologic deficits may develop suddenly or may evolve slowly. Once a deficit occurs, it may remain stable, may continue to worsen in a continuous or steplike fashion, or may resolve. Resolution may be partial or complete.

Additionally, deficits may be unifocal, implying a single lesion, or multifocal, suggesting multiple discrete lesions. A patient presenting with a focal neurologic deficit should be considered for imaging of the entire neuroaxis whenever appropriate. The presentation may suggest causation.

AIM :

THIS STUDY AIMS TO KNOW THE OUTCOMES IN PATIENTS IN ALTERED SENSORIUM WITH FOCAL NEUROLOGICAL DEFICIT.

OBJECTIVES :

· To study about the aetiology of Altered sensorium.

· To study the clinical features and risk factors of patients in altered sensorium with focal neurological deficits.

METHODOLOGY :

All patients who fulfilled the inclusion and exclusion criteria were included in this study. A Proforma was prepared which included detailed history, clinical examination and requisite investigations available in our hospital.

History includes all symptoms pertaining to in detail with emphasis on all the risk factors attributable to altered mental status with focal neurological deficits. A detailed clinical examination was done and neurological deficits were identified. Relevant investigations like haemoglobin, total white cell count, erythrocyte sedimentation rate, routine urine analysis, blood glucose, blood urea, serum creatinine, serum lipid profile, Chest X-ray, CT scan, MRI scan, electrocardiography, echocardiogram, and outcomes are assessed based on Modified Rankin scale (mRS) were done for all patients.

Clinical and laboratory data was collected from all the patients and descriptive analysis done for risk factors.

All data was entered into Microsoft office excel 2019 version.

The Modified Rankin Scale (mRS)

The scale runs from 0 to 6, running from perfect health without symptoms to death.

0, No symptoms.

1, No significant disability. Able to carry out all usual activities, despite some symptoms.

2, Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

3, Moderate disability. Requires some help, but able to walk unassisted.

4, Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

5, Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

6, Death.

PLACE OF STUDY : Department of General medicine,
Kamineni institute of medical sciences

STUDY PERIOD : November 2020 - October 2022

STUDY DESIGN : A prospective observational study

SAMPLING SIZE : Convenient sampling Proposed number
of cases to be studied = 50

INSTITUTIONAL ETHICAL COMMITTEE CLEARANCE & PATIENTS OFFERING VOLUNTARY WRITTEN INFORMED CONSENT TO PARTICIPATE IN THIS STUDY

INCLUSION CRITERIA :

• All patients with Signs and Symptoms of focal neurological deficits in altered sensorium.

• All ages more than 18 yrs.

EXCLUSION CRITERIA :

• Patients in altered sensorium without focal neurological deficit.

• Age less than 18 years.

• INVESTIGATIONS :

• Complete blood picture

• Complete urine examination

• Chest X-ray

• ECG

• MRI brain/CT brain

• Fasting blood sugars

• Lipid profile

• 2D ECHO

• RFT

PROFORMA :

NAME :

•I.P/O.P.NO:

•AGE : yrs.

•GENDER :

•OCCUPATION :

•ADDRESS :

•GCS on D.O.A :

• CLINICAL PROFILE :

• CLINICAL H/O :

• PAST H/O STROKE :

• PAST H/O TIA :

• LOSS OF CONSIOUSNESS :

• SEIZURES :

• VOMITING :

• HEADACHE :

• URINARY CONTINENCE :

• APHASIA :

• VISUAL HALLUCINATIONS :

RISK FACTORS :

•SMOKING :

•ALCOHOL INTAKE :

•HYPERTENSION :

•DIABETES :

•PREVIOUS H/O CVA :

•H/O RENAL FAILURE :

ETILOGY :

• INFECTIVE :

• METABOLIC :

• STRUCTURAL :

• OTHERS :

• EXAMINATION FINDINGS

• BP :

• PR :

• GCS :

• CVS :

• RS :

• GIT :

• CNS :

1. Deficit :

2. Motor – Tone & Power :

3. Reflexes :

4. Sensory :

5. Cerebellar :

6. Cranial nerves :

PATIENT INFORMATION SHEET

• https://docs.google.com/document/d/1MJ0DZLGJtUdvyf-r-7qmS2BlcoNyB1uzX8RxaTZbiMs/edit - Telugu version

• https://docs.google.com/document/d/1h4tpj6YQVWshrlaE-hsTcNW7vn7NrDGBXnRE5xYgeuw/edit - English version

SUMMARY :

• From the study of outcomes in patients in altered sensorium with focal neurological deficits the following conclusions are made.

• In our study majority of patients were in age group of >70 years (n=12) followed by 40-49 and 60-69 years (n=11), 44% patients were in 4th to 6th decade, 24 % in age group more than 70 years.

• Out of 50 patients studied 34 were males and 16 were females which amounts to 68% for male and 32 % for female.

• Among the distribution of cases with risk factors major risk factor is alcohol amounting to 71% followed by smoking 28%.

• In our study patients with previous history of stroke, (n=7), males amounted to 8%(n=4), female 6%(n=3).

• Based on aetiology of structural causes, majority of cases presented with ischemic stroke(n=12) 24%, followed by haemorrhagic stroke(n=2), 4%.

• Based on aetiology of metabolic causes azotaemia(n=5) and hyponatremia (n=5). Most common aetiology was found to be metabolic (n=17) amounting to 34% followed by structural (n=15), 30% and multiple (n=13), 26%.

• Among study population based on clinical presentation 19 (38%) patients presented with seizures, hemiparesis, 12(24%), quadriparesis, 11(22%) and 7 (14%) presented with multiple clinical findings.

• Out of (n=50), Majority of patients, 72% has duration of altered mental status lasting for 2-5 days, followed by 16% falling under > 5days.

• In terms of mortality (n=12) Structural (n=5), 33% and multiple aetiologies(n=5), 33% showed worsening of outcomes.

• Among the study population (n=50) patients with Metabolic cause has good recovery compared to other patients, where as poor recovery is seen in patients with structural and multiple causes.

• In the study population (n=50) 16 cases recovered with normal function followed by 9 cases with mRS scale of one, followed by 2 and 5 with 7 and 5 cases respectively.

• Among the study population (n=50), patients with a duration of 2-6 days had more deaths, compared to the deaths occurred within one day and more than 6 days i.e. 3 respectively.

• Among the study population (n=50), most of the patients presented with mRS of 4 i.e 32 patients, mRS of 5 amounted to 18 patients, 9 patients presented with mRS of 5 on admission resulted in death showing worsening outcomes.

CONCLUSION :

The present study was concerned with the identification of the aetiology, risk factors and the minimal clinical data required to make a prediction of outcome in cases of altered sensorium with focal neurological deficit. The results show that with timely intervention and accurate management most of the aetiologies like metabolic and infective causes will show favourable outcome. Metabolic was the most common cause (34%) followed by Cerebrovascular accident (30%), infective (10%) and others (26%) in this study. Systematic clinical assessment like GCS and mRS score and can yield predictive information about the potential for recovery in cases of altered sensorium. So, this study concludes that empirically based estimates of prognosis in the neurologically severely ill provides great assurance to those involved in a decision-making process including patients, families and physicians. Knowledge of potentially favourable outcome greatly improves the morale and associated level of care on a cost-effective basis.

case 1 : A 41y old man with altered sensorium

case 2 : 35F with altered sensorium and involuntary movements

Case 3 - A 56 M with Pedal edema , SOB and Altered sensorium

case 4 : 26F altered sensorium headache

case 5 : A 60 YEAR OLD MALE WITH CVA

case 6 : 48M with unresponsiveness

case 7 : 45M altered sensorium

CASE 8 - A 48 YEARS OLD FEMALE WITH DKA AND CVA

case 9 : 75F Altered sensorium with motor weakness

case 10 : 48M Altered sensorium - meningoencephalitis

case 11 : 26M Altered Sensoriumand seizures

case 12 : 60F with Altered sensorium