Apallic syndrome

Everyone probably knows what a coma or comatose state is. But not many are familiar with the term "apallic syndrome". Apallic syndrome is a type of coma - a vegetative state in which there is a profound disorder of the cerebral cortex function.

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Epidemiology

The term "apallic syndrome" as a nosological variant of nervous system pathology is still insufficiently used by domestic doctors. At present, diagnostic formulations such as "decortication state", "decerebration state", "decortication rigidity state" are widely used when making a diagnosis. All of the above terms only vaguely define the degree of nervous system damage that is present in apallic syndrome.

Due to the archaic attitude of most medical specialists towards the pathological condition called apallic syndrome, it is impossible to talk about any epidemiological facts about the disease.

According to foreign sources, apallic syndrome occurs in 2-15% of patients who are in a state of prolonged traumatic coma, as well as in 11% of patients who are diagnosed with a non-traumatic coma. Moreover, the longer the coma, the more likely the apallic syndrome is to occur.

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

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Causes apallic syndrome

Apallic syndrome may be a consequence of:

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

Most patients with apallic syndrome are admitted to medical institutions after severe traumatic brain injuries – and the syndrome is one of the stages of regeneration of consciousness after a comatose state.

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Risk factors

Risk factors are not the causes of the syndrome, but they can trigger its development. Among such factors, the greatest threat to the development of apallic syndrome is:

• old age and pre-old age;
• head injuries;
• severe poisoning;
• severe infections;
• conditions of severe hypoxia and disruption of trophic processes in the brain.

Apallic syndrome in a child most often develops after infections with brain damage (for example, after meningitis), after complex resuscitation measures or traumatic brain injuries.

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Pathogenesis

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

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

Disturbances in the organic and functional cortex lead to loss of consciousness and can be a consequence of:

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

In order for a comatose state to develop into an apallic syndrome, the function of the reticular formation of the midbrain must be preserved.

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Symptoms apallic syndrome

A patient with apallic syndrome is in visible consciousness: his eyes are open, but his gaze is not fixed on objects in the surrounding environment. There is no reaction to the name, voice, tactile touch and other irritants. The patient shows no signs of attention, does not show emotions, does not speak and does not perform any actions.

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

There is a reaction to pain, and often it is even a hyperreaction, which manifests itself in convulsive muscle contractions or uncoordinated movements.

The swallowing reflex is preserved.

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

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

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Stages

In some patients, whose apallic syndrome was provoked by a head injury, positive dynamics of the condition are possible. In such a situation, apallic syndrome passes into the stage of akinetic mutism, in which the cycle of "sleep-wakefulness" occurs more clearly, the patient begins to react to loud speech, can fix his gaze, tries to concentrate on something. However, the patient does not make contact.

The stage of akinetic mutism gradually passes into the next stage, which is characterized by the restoration of contact with the patient. Even with a complete absence of movements in the limbs, the patient makes attempts to communicate: nods his head, pronounces individual simple words, recognizes relatives.

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

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Forms

Apallic syndrome is usually divided into two types:

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

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Complications and consequences

In elderly or pre-elderly patients, increasing atrophy processes can cause the development of decerebrate rigidity, a condition accompanied by seizures.

In case of serious damage to the brain with a decrease in its functionality, the patient may die or remain disabled.

The consequences may not always be negative, as there are known cases of recovery of patients who have experienced coma and apallic syndrome. The outcome of the syndrome is determined by several factors:

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

With prolonged stay in a comatose state, secondary complications may arise:

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

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Diagnostics apallic syndrome

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

Tests:

• general blood test;
• general urine analysis;
• biochemical blood test.

Instrumental diagnostics:

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

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

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Differential diagnosis

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

The syndrome is also differentiated from dementia, in which there is no shutdown of the cortex's functionality, but a slow deterioration of mental activity or the cessation of certain mental functions occurs.

Treatment apallic syndrome

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

Additionally, parenteral nutrition is provided.

Medicines used for apallic syndrome usually belong to the following groups:

• nootropic drugs (nootropil, aminalon, piracetam, pantogam);
• amino acids (prephysone, cerebrolysin);
• B vitamins;
• drugs that improve cerebral circulation (trental, cavinton).

	Method of administration and dosage	Side effects	Special instructions
Nootropil	Prescribed dose is from 30 to 160 mg per kilogram of patient weight.	Hyperkinesis, drowsiness, asthenia, dyspepsia, weight gain.	Use with caution if you have problems with blood clotting.

	Method of administration and dosage	Side effects	Special instructions
Pantogam	Prescribed from 250 mg to 1 g 3-4 times a day.	Allergies, neurological disorders.	Taking the drug at night should be avoided.

	Method of administration and dosage	Side effects	Special instructions
Cerebrolysin	Prescribed at 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 monitoring of renal and hepatic function.

	Method of administration and dosage	Side effects	Special instructions
Cavinton	Prescribed at 15-30 mg per day in three doses.	Changes in ECG (extrasystole, increased heart rate), skin redness, sleep disorders, allergies, sweating.	Cavinton tablets contain lactose, which must be taken into account when treating patients with lactose intolerance.

	Method of administration and dosage	Side effects	Special instructions
Cyanocobalamin (vitamin B¹²)	Prescribed in the amount of 200-500 mcg per day.	General state of excitement, heart pain, allergies.	Use with caution in cases of angina pectoris.

	Method of administration and dosage	Side effects	Special instructions
Pyridoxine (vitamin B6)	Prescribed at 50-150 mg up to 4 times a day.	Allergy, increased secretion of hydrochloric acid in the stomach.	Pyridoxine should be used with caution in cases of gastric ulcer, duodenal ulcer, and ischemic heart disease.

Physiotherapy treatment

Physiotherapy may be appropriate only at the stage of restoring contact with the patient, when his chances of recovery become obvious. The following are usually used:

• general UV exposure in combination with oxygen baths, iodine-bromine baths, carbon dioxide and salt baths;
• calcium electrophoresis with impact on the collar zone;
• manual therapy and massage.

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

Folk remedies

Apallic syndrome is a resuscitation condition in which medical specialists take all possible measures to ensure the patient's life. Of course, in this period, there can be no talk of any folk treatment. Some folk recipes can be useful only at the stage of recovery and establishing contact with the patient.

Thus, rosehip tea will help the patient recover faster and replenish the lack of vitamins in the body.

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

Cranberry drinks will help in cases where the development of apallic syndrome is associated with severe intoxication of the body. Berries can be ground with honey - this will improve the functional capacity of the liver and urinary system.

Apple juice also contains a lot of vitamins, pectin and microelements. Apples will help to cope with anemia, accelerate the removal of toxic substances and tissue regeneration.

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Herbal treatment

Treatment of apallic syndrome with herbal infusions is carried out only after the patient begins to communicate and shows clear signs of improvement. He can already independently take food and drinks - parenteral nutrition is canceled. You should not begin herbal treatment without consulting a doctor.

• Strawberry leaf – 10 g, nettle leaf – 10 g, birch leaf – 20 g, flax seed – 50 g. Pour 250 ml of boiling water over two tablespoons of the mixture and leave for 60 minutes. Take several times a day, half an hour before meals.
• Chamomile and lily of the valley flowers – 10 g each, fennel fruits – 20 g, mint leaves – 30 g and valerian root – 40 g. Infuse one tablespoon of the mixture in 1 liter of boiling water, take 50 ml 5 times a day.
• Motherwort herb – 15 g, immortelle herb – 10 g, hawthorn flowers – 10 g, mint leaves – 5 g, birch leaves – 5 g, oregano – 5 g, sweet clover – 5 g. Every night, brew 3 tbsp of the mixture with 500 ml of boiling water. In the morning, filter and take 180 ml three times a day, half an hour before meals.

Ginkgo biloba-based preparations in combination with red clover will also help improve recovery. You can buy a ready-made preparation at a pharmacy, or prepare a tincture yourself: dry grass is tightly packed into a clean 0.5 l jar and filled with vodka, kept for 4 weeks in the refrigerator, filtered. Take 1 teaspoon before meals three times a day.

Homeopathy

The benefits of homeopathic treatment for apallic syndrome are questioned by many, because the syndrome is a complex condition that requires constant medical monitoring and drug support. Sometimes, at the recovery stage, the use of homeopathic drugs is allowed, but only against the background of the main traditional treatment.

The following drugs can be used:

• Cerebrum compositum - this drug is prescribed 1 ampoule intramuscularly 1-3 times a week. Allergy to Cerebrum compositum is rare, and no other side effects have been observed after using the drug.
• Gotu kola – take 2 capsules twice daily with food. The drug may cause allergies, so it should be used with great caution.
• Nervoheel is a sedative homeopathic remedy that is prescribed 1 tablet three times a day under the tongue, half an hour before meals. The drug is practically safe, since the only possible side effect from taking it - allergy - is very rare.
• Vertigohel - take 10 drops three times a day for dizziness and disturbances of consciousness. The drug can rarely cause an allergic reaction, so it should only be taken under the supervision of a doctor.

Surgical treatment

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

• in case of head and neck injuries that provoked the development of the syndrome;
• for hematomas of the meninges.

The surgery is performed by a surgeon or neurosurgeon, depending on the problem detected.

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

Prevention

Prevention of apallic syndrome consists of avoiding, if possible, the initial provoking factors that can cause its occurrence. For this purpose, it is recommended to undergo periodic preventive examinations by medical specialists, which will allow early detection and elimination of the causes of the syndrome.

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Forecast

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

If the syndrome is accompanied by atrophic processes, then the prognosis can be considered unfavorable: a state of decerebrate weakness (rigidity) occurs with a transition to a state of agony.

In post-traumatic apallic syndrome, the patient may experience positive dynamics on an increasing schedule, over several months, until a complete transition to a psychoorganic syndrome with a chronic course. In rare cases, a relative recovery is observed.

Apallic syndrome can be called one of the options for a patient to emerge from a comatose state, therefore its outcome largely depends on the completeness and quality of resuscitation measures.

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