Apallic syndrome

What is a coma, or a coma, know, perhaps, everything. But such a term as "apallic syndrome" is not familiar to many. Apallic syndrome is usually called a kind of coma - a vegetative state, in which there is a deep breakdown in the function of the cortex of the brain.

[1], [2], [3], [4], [5],

Epidemiology

The term "apallic syndrome", as a nosological variant of the pathology of the nervous system, is still not sufficiently used by domestic doctors. At present, diagnostic diagnoses such as "decortication status", "state of decerebration", "state of decortic rigidity" are used at diagnosis. All these terms only remotely determine the degree of damage to the nervous system that is present in the apallic syndrome.

Due to the archaic attitude of most medical specialists to the pathological condition called apallic syndrome, it is not necessary to talk about any epidemiological facts on the disease.

According to foreign sources, aphallic syndrome occurs in 2-15% of patients who are in a state of prolonged traumatic coma, as well as in 11% of patients who have a coma of non-traumatic character. In this case, the longer the coma turns out, the more likely the appearance of an apallic syndrome.

In patients under 35 years of age, the chance to recover from the aphallic syndrome is almost 10 times higher than in older patients (after age 65).

[6]

Causes of the apallic syndrome

Apallic syndrome can be a consequence:

• traumatic brain injury;
• brain damage as a result of surgical interventions;
• viral brain damage (eg, meningoencephalitis);
• ischemic stroke;
• severe intoxication of the body;
• hypoxia of the brain.

The majority of patients with aphallic syndrome go to medical institutions after severe craniocerebral injuries - while the syndrome is one of the stages of regeneration of consciousness after a coma.

[7], [8],

Risk factors

Risk factors are not causes of the syndrome, but can serve as an impetus to its development. Among such factors, the greatest threat to the development of the aphallic syndrome is represented by:

• senile and pre-puberty;
• head trauma;
• severe poisoning;
• severe infections;
• the state of severe hypoxia and the violation of trophic processes in the brain.

Apical syndrome in a child often develops after infections with brain damage (for example, after meningitis), after complicated resuscitation or craniocerebral trauma.

[9], [10],

Pathogenesis

The degree of preservation of consciousness and the severity of behavioral reactions largely depend on the state of the cerebral cortex, the thalamus and the ascending reticular formation, and are of great importance in the mechanism of the development of the syndrome.

The efficiency of the cortex in combination with the reticular formation determines the degree of conscious and cognitive behavior.

Violations of organics and the functionality of the cortex lead to loss of consciousness and may be a consequence:

• widespread bilateral injuries and exchange disorders;
• unilateral damage with further compression of the other side (swelling or swelling);
• pronounced lesions of the cortex simultaneously with the white matter, with further compression of the brain stem.

In order for the coma to pass into the apallic syndrome, the function of the reticular formation of the midbrain must necessarily be preserved.

[11], [12], [13], [14], [15]

Symptoms of the apallic syndrome

The patient with the apallic syndrome is in a visible consciousness: his eyes are open, however the sight is not fixed on the objects of the surrounding situation. There is no reaction to the name, voice, tactile touch and other annoying factors. The patient does not show signs of attention, does not show emotion, does not speak and does not perform any actions.

Apallic syndrome is characterized by dissociative symptoms: with apparent clarity of consciousness, its content is absent, expressed in mental processes. There are no reflexes in the form of protective reactions, arms and legs are immobilized and retain any position given to them passively.

There is a reaction to pain, often even a hyperreaction, which is manifested by convulsive muscle contractions or uncoordinated movements.

The swallowing reflex is saved.

The first signs of the transition of a comatose state to an apallic syndrome look like a specific impairment of consciousness, which is accompanied by "sleep-wake" cycles, regardless of the time of day. The pupils of the patient react to a light stimulus, but there is an uncoordinated movement of the eyeball (the so-called "pupal-eye phenomenon").

Often, the patient has seizures - muscle spasms, tonic seizures or myoclonus.

[16], [17], [18], [19], [20], [21]

Stages

A number of patients whose apallic syndrome has been triggered by head trauma may have a positive state of the disease. In this situation, the apallic syndrome passes into the stage of akinetic mutism, in which the cycle "sleep-wakefulness" occurs more clearly, the patient begins to respond to loud speech, can fix the sight, tries to concentrate attention on something. Nevertheless, the patient does not go to the contact.

The stage of akinetic mutism gradually turns into the next stage, which is characterized by the restoration of contact with the patient. Even with complete absence of movements in the limbs, the patient makes attempts to communicate: he nods his head, utters certain simple words, recognizes native people.

In the recovery stage, a gradual and slow regeneration of the psychomotor functions is possible.

[22], [23], [24], [25], [26], [27]

Forms

Apallic syndrome is usually divided into two types:

• syndrome of traumatic etiology;
• syndrome of non-traumatic etiology.

[28], [29], [30], [31],

Complications and consequences

In patients of senile or prehospital age, the growing processes of atrophy can lead to the development of decerebral rigidity - a condition accompanied by convulsions.

With a serious brain damage with a decrease in its performance, the patient may die or remain disabled.

Consequences may not always be negative, as there are cases of recovery of patients who survived to whom and the apallic syndrome. The outcome of the syndrome is determined by several factors:

• the severity of the patient's condition;
• timeliness and quality of assistance;
• general health of the patient;
• duration of coma.

With prolonged stay in a coma, secondary complications can occur:

• muscle tone disorders;
• contractures;
• infectious complications;
• venous thrombosis;
• heterotopic ossification.

[32], [33], [34], [35], [36], [37], [38], [39], [40]

Diagnostics of the apallic syndrome

Apallic syndrome is diagnosed on the basis of a specific clinical picture of this condition. If necessary, doctors can use other types of diagnostics - laboratory and instrumental.

Analyzes:

• general blood analysis;
• general urine analysis;
• blood chemistry.

Instrumental diagnostics:

• Ultrasound of the main and peripheral arterial and venous network of regional head basins, as well as internal organs, upper and lower extremities;
• capillaroscopy - the study of capillary function;
• electrocardiography with monitoring of ischemic changes in the cardiac muscle;
• electroencephalography - the study of the functional capacity of the brain.

Additionally, an examination and consultation of a neurologist, rehabilitation specialist and psychiatrist is prescribed.

[41], [42], [43], [44], [45], [46]

Differential diagnosis

Differential diagnosis is carried out with a coma. The main signs of difference are that the aphallic syndrome is not characterized by deep depression of consciousness, and the "sleep-wake" cycle can proceed without disturbances.

Also, the syndrome is differentiated from dementia, in which there is no disruption of the functionality of the cortex, but there is a slow deterioration in mental activity, or the cessation of certain mental functions.

Treatment of the apallic syndrome

In the apallic syndrome, patients should receive full-scale treatment with 24-hour medical supervision and medical care. The doctor must keep the respiratory and cardiac functions under control, and take the necessary measures to support them.

Parenteral nutrition is additionally provided.

Medications that are used in the apallic syndrome usually belong to the following groups:

• nootropics (nootropil, aminalon, piracetam, pantogam);
• amino acids (prephizone, cerebrolysin);
• vitamins of group B;
• drugs that improve cerebral circulation (trental, Cavinton).

	Dosing and Administration	Side effects	Special instructions
Nootropil	Assign from 30 to 160 mg per kilogram of the patient's weight.	Hyperkinesis, drowsiness, asthenia, dyspepsia, weight gain.	Apply with caution in case of problems with blood coagulability.

	Dosing and Administration	Side effects	Special instructions
Pantogam	Assign from 250 mg to 1 g 3-4 times a day.	Allergies, neurological disorders.	Avoid taking the drug at night.

	Dosing and Administration	Side effects	Special instructions
Cerebrolysin	Assign 25-50 mg three times a day, with a possible increase in dosage to 75 mg three times a day.	Drowsiness, extrapyramidal disorders, dyspepsia, increased sweating.	Long-term use of Cerebrolysin should be combined with control of kidney and liver function.

	Dosing and Administration	Side effects	Special instructions
Cavinton	Assign 15-30 mg per day for three doses.	Changes on the ECG (extrasystoles, palpitations), redness of the skin, sleep disorders, allergies, sweating.	Cavinton tablets contain lactose, which must be taken into account when treating patients with lactose intolerance.

	Dosing and Administration	Side effects	Special instructions
Cyanocobalamin (vitamin B¹²)	Assign an amount of 200-500 mcg per day.	General condition of excitation, heart pain, allergy.	Use with caution in angina pectoris.

	Dosing and Administration	Side effects	Special instructions
Pyridoxine (vitamin B6)	Assign 50-150 mg to 4 times a day.	Allergy, increased secretion of hydrochloric acid in the stomach.	With caution use Pyridoxine in the stomach ulcer and duodenal ulcer, as well as coronary heart disease.

Physiotherapeutic treatment

Physiotherapy can be appropriate only at the stage of restoration of contact with the patient, when his chances of recovery become obvious. Usually used:

• general UFO-exposure in combination with oxygen baths, iodide-bromine baths, carbonic and salt baths;
• electrophoresis of calcium with effect on the collar zone;
• manual therapy and massage.

The goal of physiotherapeutic treatment in the apallic syndrome is stabilization and regression of the pathological process, prevention of atrophy and degenerative changes.

Alternative treatment

Apallic syndrome is a resuscitative condition in which medical specialists take all possible measures to ensure the life of the patient. Of course, in this period there can not be any alternative treatment. Some alternative recipes can be useful only at the stage of recovery and establishing contact with the patient.

So, tea from hips of a dogrose will help the patient to recover faster and will fill a lack of vitamins in an organism.

It is useful to cook compotes and kissels based on blackberries, currants, raspberries, blueberries: berries contain many useful substances that will facilitate the work of all organs and systems of the patient.

Drinks from cranberries will help in cases where the development of the aphallic syndrome is associated with a strong intoxication of the body. Berries can be rubbed with honey - this will improve the functional capacity of the liver and urinary system.

A lot of vitamins, pectin and trace elements are contained in apple juice. Apples help to cope with anemia, accelerate the elimination of toxic substances and tissue regeneration.

[47], [48], [49], [50], [51]

Herbal Treatment

Treatment of the aphallic syndrome with herbal remedies is performed only after the patient begins to make contact, and gives clear signs of improvement. He can already eat and drink on his own - the parenteral nutrition is canceled. Do not start herbal medicine without consulting the doctor.

• A strawberry leaf - 10 g, a nettle leaf - 10 g, a birch leaf - 20 g, a flaxseed - 50 g. Two tablespoons of the mixture pour 250 ml of boiling water, insist 60 minutes. Take several times a day, half an hour before a meal.
• Chamomile and lily of the valley flowers - 10 grams, fennel fruits - 20 grams, mint leaves - 30 grams and valerian root - 40 grams. Infuse one tablespoon of the mixture in 1 liter of boiling water, take 50 ml 5 times a day.
• The herbage of the motherwort is 15 grams, herbage grass - 10 g, hawthorn - 10 g, leaves of mint - 5 g, leaves of birch - 5 g, oregano - 5 g, sweet clay - 5 g. L. Mixture of 500 ml of boiling water. In the morning, filter and take 180 ml three times a day, half an hour before meals.

Improve the recovery will also help preparations based on ginkgo biloba in combination with red clover. You can buy a ready-made drug in the pharmacy, or prepare the tincture yourself: in a clean jar 0,5 l tightly stack dry grass and pour vodka, stand 4 weeks in the refrigerator, filter. Take 1 tsp. Before meals three times a day.

Homeopathy

The advantage of homeopathic treatment in the apallic syndrome is often questioned, because the syndrome is a complex condition that requires relentless medical supervision and medical support. Sometimes, in the recovery phase, the use of homeopathic preparations is allowed, but only against the background of the main traditional treatment.

The following preparations are possible:

• Cerebrum compositum - this drug is prescribed for 1 ampoule intramuscularly 1-3 times a week. Allergy to Cerebrum compositum happens rarely, and no other side effects after application of the drug have been observed.
• Gotu kola - take 2 capsules twice a day with food. The drug can cause allergies, so it should be used with great care.
• Nervocheel - a sedative homeopathic remedy, which is prescribed for 1 tablet three times a day under the tongue, half an hour before meals. The drug is almost safe, since the only possible side effect of its use - allergy - is very rare.
• Vertigocel - take 10 drops three times a day for dizziness and frustration of consciousness. The drug in rare cases can cause an allergic reaction, therefore should be taken only under the supervision of a doctor.

Operative treatment

Operative treatment for apallic syndrome can be prescribed in two cases:

• with head and neck injuries, which provoked the development of the syndrome;
• with hematomas of meninges.

Surgery is performed by a surgeon or neurosurgeon, depending on the problem found.

In other situations, there is no need for surgical treatment.

Prevention

Prevention of the aphallic syndrome consists in avoiding, if possible, the initial provoking factors that can cause its appearance. For this purpose it is recommended to undergo periodic medical examinations at medical specialists, which will allow to discover and eliminate the causes of the syndrome development in advance.

[52], [53], [54], [55], [56]

Forecast

The prognosis is determined by the initial painful process that led to the development of the apallic syndrome.

If the syndrome is accompanied by atrophic processes, the prognosis can be considered unfavorable: there is a state of decerebral weakness (rigidity) with the transition into a state of agony.

With posttraumatic apallic syndrome, the patient can have a positive dynamics on an increasing schedule, for several months, until complete release into the psychoorganic syndrome with a chronic course. In rare cases, a relative recovery is observed.

Apallic syndrome can be called one of the options for the patient to exit from a coma, so in many ways his outcome depends on the completeness and quality of resuscitation.

[57], [58]