LESIONS

A Guide to Localisation in Neurology

Case 14 - coma and dilated pupil

Case

A 69 year old woman was brought to hospital by ambulance after being found unconscious.

She had been in her usual state of health the previous day and had not reported any concerning symptoms. The morning of admission she had been found unresponsive by her daughter who lived nearby. Her daughter rang an ambulance.

She had a background of hypertension, taking two agents, and atrial fibrillation, treated with oral anticoagulant therapy. She also had respiratory issues due to smoking and had been physically declining in the last 3 years, with reduced exertional tolerance.

On examination:

• She was lying on a trolley with eyes closed, did not speak or follow commands, and made no response to vocal or painful stimuli
• Her right eye was turned partially outwards , with a dilated pupil which did not constrict to light
• She was not making any spontaneous movements with the left arm or leg but would occasionally move the right limbs
• The left arm and leg had reduced tone compared to the right
• The left plantar was upgoing

She was hypertensive (180/100mmHg), slightly tachycardic, with normal oxygen saturations, respiratory rate 18 breaths per minute, and was apyrexial.

The rest of the examination was unremarkable, including no meningism.