Resumen Coma Ritmico

Clasificación del Coma

Fisiologicamente, la perdida de la conciencia implica que el paciente sufre de una disfunción extensa
de los hemisferios cerebrales, del tallo cerebral o de ambos.
Rítmico o no Rítmico
Coma Rítmico
Pramote 473
Suele observarse como consecuencia de lesiones a nivel del área pontino mesencefalica, durante
eventos de hipoxia y anoxia o lesiones estructurales que causen disrupción de la vía
reticulotalamocortical
Se llama así a los subtipos de coma que presentan un ritmo invariable, no reactivo, con actividad
eléctrica de distribución difusa en frecuencias beta, alfa, theta y de husos del sueño
El patrón puede evolucionar de un patrón rítmico a otro cuando se hacen estudios seriados, la
interrupción de la via reticulotalamocortical, la deaferentación y la disfunción metabolica determinan
dicha evolución.
El pronóstico depende de la causa subyacente

Rhythmic coma pattern (alpha, theta, beta, delta coma, spindle) (Figures 5-53 to 5-56, 6-25 to
6-37)

• Etiology and outcome of alpha coma (AC) patterns and other rhythmic coma patterns were
similar.
• One type of rhythmic pattern changed to another._ Reactive rhythmic coma is associated
with favorable outcome in 67%.
• Sixty percent with nonreactive pattern were associated with unfavorable outcome.
• Rhythmic coma patterns in comatose children are not uncommon. The etiology, reactivity,
and outcome of individual patterns are similar and thus make the rhythmic coma patterns
distinct EEG signatures in comatose children. There was a clinically signifi cant better
outcome with reactive rhythmic coma patterns.
• Comatose children with reactive electroencephalographic patterns have better clinical
outcome in terms of morbidity and mortality.
 Relación de los Tipos del coma y las lesiones subyacentes
Los patrones de los tipos de coma se pueden correlacionar con las lesiones subyacentes.
518
Factores que Modifican el pronóstico
• Variabilidad
• Reactividad
• Actividad Epiléptica
515
Pronóstico
509
El riesgo de severo déficit neurológico o muerte es muy alto en el coma alfa, theta y alfa-theta tras
un evento postanoxia. El Coma de Husos es de buen pronóstico mientras sea simétrico y continuo y
de mal pronóstico en caso opuesto. El coma delta tiene un pronóstico mucho más variable, siendo
mejor cuando es de causa metabólica y peor cuando la causa es estructural o traumática.

COMA NO RITMICO

Neidermeyer 412,413
Coma Delta
Neidermeyer 413,414
Indica la lesión o disfunción de estructuras diencefálicas, particularmente a nivel del tálamo, aunque
también puede verse inicialmente actividad delta rítmica intermitente cuando hay lesión de la
sustancia blanca telencefálica, en resumen, corresponde a la función anormal del haz talamocortical,
particularmente en el núcleo dorsal medial del tálamo (comisura gris intertalámica)

Pramote 471
Se suele observar un patrón de actividad delta polimórfica, Además a medida que progresa la lesión
o la disfunción se observa la reducción e incluso ausencia de los grafoelementos del sueño.
Característicamente cuando se observa una combinación de FIRDA o OIRDA sobre una base de
Actividad Delta Polimórfica es un signo electroencefalográfico de herniación cerebral inminente, no
obstante, el mismo patrón puede observarse en pacientes con lesiones estructurales focales y por
disfunción toxico metabólica, por lo cual la correlación clínica es indispensable.
PramotePg 476,478
Delta Frequency Pattern
• Delta pattern comas may show polymorphic morphology or more rhythmic or stereotyped
blunted TWs.
 • These patterns are usually seen with more advanced states of encephalopathy, either
predominating over the anterior head regions or appearing diffusely with progression to
deeper stages of coma.
• In early stages of coma, delta activity may attenuate with external stimuli, but for the most
part, it is usually unreactive. Many polymorphic delta comas are due to structural
abnormalities involving subcortical White matter, but some profound metabolic comas can
produce a similar pattern.

• AC of diverse etiologies, with mortalities exceeding 65%. However, the overall mortality in
SC is only 23%.
• In both SC and AC, there is a strong association between coma etiology and outcome. The
marked difference in prognosis between AC and SC may be due to the differences in the
etiologies producing the two EEG patterns. Whereas in AC, CRA accounts for most of the
cases, carrying with it a correspondingly poor prognosis (83% mortality). CRA accounts for
only 3/227 patients with SC. This suggests that the more “benign” nature of SC compared to
AC is largely related to the lesser severity or extent of cerebral damage occurring with SC.

Pramote 507 508

COMA RITMICO
Coma Beta
Pramote 473
El coma beta es causado generalmente por la intoxicación farmacológica, y como tal suele ser
reversible, no obstante en raros casos puede ser la manifestación de lesiones agudas del tallo
cerebral
Beta Frequency Pattern
• Predominance of high-voltage beta activity.
• Drug overdoses or even sedative withdrawal, especially benzodiazepines and barbiturates,
result in more diffuse and higher voltage EEG beta activity,
• occasionally with sleeplike spindle activity, and diffuse high-voltage delta slowing.
• In lesser degrees of encephalopathy, the EEG patterns are usually reactive to external
stimuli. Coma is largely reversible and has a good prognosis.
 Coma Alfa
Pramote 473
Generalmente es un patrón predictor de muerte, excepto en niños donde su pronóstico no suele ser
tan malo.
Se presenta con una distribución generalizada, en una frecuencia de 8 a 13Hz y se distingue del
ritmo alfa fisiológico por presentar una morfología monofásica, monótona, simétrica y de predominio
en regiones anteriores, exceptuando el caso donde hay una lesión localizada en el tallo en cuyo
caso presenta un predominio en regiones posteriores, persistente y no reactivo a estímulos
Pramote 501, 502
Alpha Frequency Pattern (Alpha Coma)
• Seen diffusely in comatose patients.
• When coma arises from a brainstem lesion, the Alpha activity is seen more posteriorly and
varies often with external painful stimuli; the prognosis is poor.
• When alpha frequency patterns are seen with anoxia after CRA, alpha frequencies appear
more diffusely on EEG and are usually less reactive to external stimuli. Such patients also
have a poor prognosis with mortality exceeding 90%.
• Outcome of AC pattern depends on the underlying cause of coma. Reactive AC usually
occurs after drug overdoses and lead to recovery in 90% of patients. At the opposite end of
the spectrum, survival after CRA is 12% or less.

Coma de Husos
Neidermeyer 415
La presencia de grafoelementos del sueño en un paciente comatoso representa la integridad del
telencéfalo y diéncefalo, ubicando la lesión por debajo del sistema talamocortical, mientras más
caudal sea la lesión menos frecuentes y más asimétricos se vuelve la presencia de dichos
grafoelementos y peor es su pronóstico
Spindle Coma (SC)
• Predominantly over the fronto-central regions, often with vertex sharp waves, and remitting
only briefly with stimuli.
• EEG pattern of “sleeplike” activity characterized by spindles in the 9- to 14-Hz range, often
with vertex sharp waves and K-complexes occurring in patients with unconsciousness or
coma.
• Metabolic, infectious, and hypoxic encephalopathies are the most common etiologies; there
was no case of CNS trauma. It is assumed that SC represents a coexistence of true sleep
and coma, the latter accounting for the failure of arousal that is attributed to impairment of
the activating ascending reticular formation at the midbrain level. The presence of spindles,
vertex waves, and K-complexes indicates relative integrity of the cerebral hemispheres.
• The specific frequency of the EEG pattern such as alpha, beta, spindle, or theta did not
influence the outcome. The clinical outcome appeared to depend on the primary disease
process rather than the electroencephalographic finding.
 • The prognosis of rhythmic coma, in general, was better in children than in adults. The
pathophysiology in children may be similar (interruption of reticulothalamocortical pathways
by metabolic or structural abnormalities, but the expression of this deafferentation may be
more varied in the developing brain).93
• Often with multiple concurrent pathologies, including head injury; cerebral, thalamic,
midbrain, and brainstem infarctions and hemorrhages; encephalopathy; hypoxia; drug
intoxication; eclampsia; and seizures.
• There is controversy surrounding the prognostic significance of SC.
• Prognosis is usually poor in other EEG patterns associated with coma such as diffuse
suppression, B-S after CRA, generalized periodic pattern, intermittent attenuating, and AC of
diverse etiologies, with mortalities exceeding 65%. However, the overall mortality in SC is
only 23%.
• In both SC and AC, there is a strong association between coma etiology and outcome. The
marked difference in prognosis between AC and SC may be due to the differences in the
etiologies producing the two EEG patterns. Whereas in AC, CRA accounts for most of the
cases, carrying with it a correspondingly poor prognosis (83% mortality). CRA accounts for
only 3/227 patients with SC. This suggests that the more “benign” nature of SC compared to
AC is largely related to the lesser severity or extent of cerebral damage occurring with SC.

512
Coma Theta
Pramote 473
Este aparece como consecuencia de una disfunción metabólica o una lesión hipóxica que afecta en
forma difusa a la corteza cerebral, es considerado una variante del Coma Alfa, y aunque ambos son
de mal pronóstico, el coma theta es relativamente menos severo. Tambien puede ser reversible en
caso de intoxicación farmacológica.
Theta Frequency Pattern
• Diffuse theta patterns may occur on their own or may be mixed with other frequencies such
as alpha or delta in coma. This mixed pattern in coma may occur after CRA where theta
activity (although diffuse) is more prominent anteriorly, is usually unreactive to external
stimuli, and usually carries a poor prognosis similar to AC.