O The term “delirium” means “a going off the
ploughed track, a madness”.
O Acute or subacute syndrome
characterized by disturbance of
consciousness, global cognitive
impairment, disorientation, attention
deficits, disordered sleep-wake cycle, and
fluctuation in presentation.
O Neurologists and Internists prefer the term
“encephalopathy”, which literally means
“disease of the brain.”
O Mixed form (46%)
O Hyperactive (30%)
O Hypoactive (24%) – difficult type to
O Arousal – hyper – or hypovigilance.
O Sleep-wake cycle.
O Baseline cognition
O Use of IV lines, restraints, and bladder
O Is CNS involved itself?
O Drugs – Always ask!!!
O Withdrawal state
O A 36-year-old real estate agent was in the first
trimester of her first pregnancy when she
awoke with diplopia. She had not been well
for several days, feeling lethargic, off-balance
and slightly disoriented; symptoms that she
attributed to severe morning sickness during
the previous eight weeks. She was not taking
any medications and had been previously
healthy. Exam revealed bilateral ptosis,
limitation of gaze in all directions, slow upward
saccades, upbeat nystagmus and mild ataxia.
O Wernicke’s encephalopathy – triad of
ophthalmoplegia, ataxia, and confusion.
O Triad – minority of cases.
O Ocular findings – earliest and most
O About 30% have isolated or predominant
mental status changes ranging from
confusion to frank coma.
O Sometimes – sudden onset.
O Persistent vomiting of any cause.
O Chronic alcoholism.
O Prolonged IV alimentation.
O Bariatric surgery.
O Chronic renal dialysis.
O Low serum erythrocyte transketolase –
days to obtain.
O Treat on suspicion.
O MRI – specific (93%) but sensitivity is low.
O A 21-year-old primigravida with gestation age
of 33weeks whose first and second trimester
gestation was uneventful with no history of
hypertension and epilepsy before and during
pregnancy. She developed sudden onset of
headache, giddiness, vomiting, and
convulsions. Her blood pressure was 142/94
mmHg. Next day, the patient was taken into C
section for fetal distress. On 2nd day of post-
caesarean section she developed loss of
vision, headache, and vomiting. Her blood
pressure was 140/114 mmHg.
O Posterior Reversible Encephalopathy
O Variety of symptoms – headache, altered
mental status, visual disturbances, and
O Hypertension, Pre-eclampsia/eclampsia,
chemotherapy, collagen vascular disease,
and renal failure.
O Syndrome of neuropsychiatric dysfunction.
O Mental status changes ranging from subtle
psychologic abnormalities to profound coma.
O Clinical manifestations range from Stage I
(mild) to Stage IV (coma).
O Asterixis – flapping tremor – stage II (includes
personality change and inappropriate
O Posturing can be seen in stage IV.
O Focal signs and seizures – rare.
O EEG, Ammonia, and Imaging.
O Precipitating factors.
O Lactulose – enema v/s oral
O Oral antibiotics
O Protein restriction
O Sometimes there is cerebral edema in
O Fastest and briefest.
O Sudden muscle contractions – positive
O Muscle tone lapses – negative myoclonus.
O Almost always around a joint.
O Physiologic – hypnic jerks and hiccups.
O Provoked? Tactile? Or Auditory?
O Rapid onset: Renal failure, DDS, and
O Dementia/Neurodegenerative diseases.
O A 52-year-old woman presented with low-
grade fever, headache, disorientation,
amnesia, bad response to communication,
numbness in the right hand, blurred vision in
the right eye and tonic-clonic seizures in the
previous two weeks. Her previous
neurological history was unremarkable.
Physical examination revealed horizontal
nystagmus, bilateral Babinski signs, 4/5 of
limb power, and poor cooperation in mental
O Steroid responsive acute or subacute
encephalopathy associated with anti-
O Presenting features vary widely.
O Psychiatric symptoms around 60%.
O TPO and Thyroglobulin.
O TSH should be high but patients may be
euthyroid or hypothyroid.
O Myxedema coma – acute or subacute and
precipitated by stress.
O Hypothermic, Hypo ventilate, and
Hyper- and Hypoglycemia
O Diabetic ketoacidosis – pH doesn’t
correlate well with level of consciousness.
O Diabetic lactic acidosis.
O Sudden lowering of serum osmolality –
cerebral edema – can be fatal.
O Head trauma and Stroke patients –
O Stroke like illness.
Hypoglycemic Brain Injury
O Range from reversible focal deficits and
transient encephalopathy to irreversible
O Mean blood glucose was around 30mg/dl.
O White matter – more sensitive to ischemia
than previously thought.
O The duration of hypoglycemia may be
difficult to determine in many cases.
O A 26-year-old woman presented to the
emergency department with severe pleuritic
chest pain and dyspnea. While waiting for a
computed tomographic scan in the radiology
department, she had an asystolic cardiac
arrest. The resuscitation lasted 20 minutes,
after which she was found to have reactive
pupils. Three days later the family is
considering withdrawing care because she is
still comatose. On examination, her pupils are
now unreactive and she has no motor
response or brainstem reflexes. The nurse
reports that the patient had myoclonus 12
O Brainstem reflexes – important to check.
O Pupillary reaction absent at Day 3 after
cardiac arrest – poor outcome.
O Caution – motor response especially if
hypothermia protocol was used.
O Corneal reflex.
O Cold caloric testing.
O Myoclonic status epilepticus – likely poor
O Neuroimaging – MRI is preferred.
O EEG – looking for reactivity.
O Lance-Adams syndrome.
O Action myoclonus associated with ataxia,
postural imbalance, and very mild
O Asthma attack – typically.
O Post-hypoxic or Post-hypercapnic.
O The level of BUN can vary widely.
O Tremor, Asterixis, and Delirium.
O May have hemiparesis.
O Some patients free of cerebral symptoms with
values of BUN over 200 mg/dl.
O Uremic patients – deficient in Thiamine.
O Neurologic recovery does not immediately
follow effective dialysis.
O Uremia and hypertensive encephalopathy –
difficult to diagnose.
O Speech impairment
O High aluminum content
O Muscle cramps
O 3-4 hours after dialysis may be 24 hours later
O Self limited – within days
O First hemodialysis, severe uremia, metabolic
O The degree of carbon di-oxide retention
correlates the most.
O Duration of the condition.
O Headache, confusion, and somnolence.
O PCo2 should be corrected gradually.
O Mental status changes
O Autonomic hyperactivity
O Neuromuscular abnormalities (tremor,
rigidity, myoclonus, hyper-reflexia,
clonus, and babinski)
O Onset within 6-24 hours
O Hunter criteria
O We have to perform the work up!!!
O Mental status change
O Single dose or many years
O Usually within first two weeks of therapy
TAKE HOME MESSAGE
O Metabolic disorders
O Post-operative state
O Drugs – always!! Always!!
O Withdrawal state
O Thiamine – high dose IV!!!!
O Is the CNS involved itself??
O Always Imaging (CT v/s MRI) before LP.
O Correction of underlying factors.
O Remove Foley, IV lines etc.
O Sleep wake cycle.
O GABAergic agents!!!
O Hyper-active or Hypo-active delirium – Anti-
O Others: Ondansetron, Rivastigmine, and