# simultaneous decerebrate and decorticate posteuring



## Lifeguards For Life (Sep 29, 2009)

What would cause a patient to display decerebrate posteuring on one side of the body AND decorticate posteuring on the other side of the body?
Is the answer as simple as some combination of upper brainstem injury mixed with bilateral corticospinal tract damage?


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## Lifeguards For Life (Sep 29, 2009)

Lifeguards For Life said:


> What would cause a patient to display decerebrate posteuring on one side of the body AND decorticate posteuring on the other side of the body?
> Is the answer as simple as some combination of upper brainstem injury mixed with bilateral corticospinal tract damage?



And, if a combination of upper brainstem injury mixed with bilateral corticospinal tract damage was the reason, why would the two postures be displayed simultaneously as opposed to alternating between decerebrate and decorticate as the neurologic status fluctuates?
...maybe should of posted this in the ALS or scenario section


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> What would cause a patient to display decerebrate posteuring on one side of the body AND decorticate posteuring on the other side of the body?
> Is the answer as simple as some combination of upper brainstem injury mixed with bilateral corticospinal tract damage?



Wide spread brain damage...


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## Lifeguards For Life (Sep 29, 2009)

rescue99 said:


> Wide spread brain damage...



as opposed to displaying either one or the other? is that to say this is a relatively common finding, for a patient to display one type of posturing on one side and a different posturing contralateraly?


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> as opposed to displaying either one or the other? is that to say this is a relatively common finding, for a patient to display one type of posturing on one side and a different posturing contralateraly?



Lets see if I can get this right. Decerbrate is a midbrain, cerebellum and / or stem injury while decorticate implies a motor neuron disfunction affecting the lateral corticospinal tract. Causes are many. Both can be present at the same time.


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## Lifeguards For Life (Sep 29, 2009)

rescue99 said:


> Lets see if I can get this right. Decerbrate is a midbrain, cerebellum and / or stem injury while decorticate implies a motor neuron disfunction affecting the lateral corticospinal tract. Causes are many. Both can be present at the same time.



i think decerebrate is from injury to the upper brain stem, and decorticate results from trauma to one or both cortico spinal tracts. i was just unclear what would cause the two to happen simultaneuos and contralaterally as opposed to one and then the other alternating as the patients neruo status fluctuates, if that makes sense to you?


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## rhan101277 (Sep 29, 2009)

Both are for sure bad news.  Decorticate is down further, but both should be a vegetative state, on ventilator etc.


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> i think decerebrate is from injury to the upper brain stem, and decorticate results from trauma to one or both cortico spinal tracts. i was just unclear what would cause the two to happen simultaneuos and contralaterally as opposed to one and then the other alternating as the patients neruo status fluctuates, if that makes sense to you?



Oh man..I had tried to rethink my post but went over the time. Let me try this again. 

The dysfunction is to both the corticospinal /rubrospinal tracts and implies brain stem injury (lower specifically I believe). There will always be other significant damage caused by either illness, hypoxia, injury or bleeds..right & left hemisphere, thalamus, mid brain perhaps. Check the pupils and note something unique


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## Lifeguards For Life (Sep 29, 2009)

rescue99 said:


> Check the puplis and note something unique



absence of dolls eye sign?


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> absence of dolls eye sign?



You are partly right. Anyone? Bueller, Bueller...

Man, my multi taksing skills stink tonight...go Tigers!


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## Lifeguards For Life (Sep 29, 2009)

rescue99 said:


> You are partly right. Anyone? Bueller, Bueller...
> 
> Man, my multi taksing skills stink tonight...go Tigers!



accompanied with abnormal pupil size and innapropriate response to light? are we only talking about the eyes? if i have not answered right, i would like to know the correct answer


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## Lifeguards For Life (Sep 29, 2009)

rhan101277 said:


> Both are for sure bad news.  Decorticate is down further, but both should be a vegetative state, on ventilator etc.



decorticate generally offers a better prognosis and may progress into decerebrate if the causative disorder extends lower into the brainstem


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> accompanied with abnormal pupil size and innapropriate response to light? are we only talking about the eyes? if i have not answered right, i would like to know the correct answer



LOL..you just said absence of dolls eyes! The pupils will dilate in and out at random.


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## Lifeguards For Life (Sep 29, 2009)

rescue99 said:


> LOL..you just said absence of dolls eyes! The pupils will dilate in and out at random.



huh i did not know that. does deep coma not result in absence of  doll's eye sign?


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## rescue99 (Sep 29, 2009)

Lifeguards For Life said:


> huh i did not know that. does deep coma not result in absence of  doll's eye sign?



Could I suppose. There are lots of folks alert with the type of brain damage you describe. Some have doll looking eyes, some not.


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## Smash (Sep 29, 2009)

rescue99 said:


> Could I suppose. There are lots of folks alert with the type of brain damage you describe. Some have doll looking eyes, some not.




Dolls eyes (lack of oculovestibular reflex) indicates bilateral pontine injury. It is seen when there is an absence of brainstem activity. Not something you'll see while the patient is chatting to you post head injury.


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## Smash (Sep 30, 2009)

Having just read the whole post instead of the the last reply all I can say is: what? 

Can someone please post the question lucidly, and be careful that you use the right terminology eg dolls eyes represents an _absence_ of the oculovestibular reflex which would normally keep the eyes fixed at one point while the head moves. Therefore the dolls eye sign is fixed gaze even when the head is moved and is a very grave sign (see above). It is also very creepy. 

However it is not correct to call it a reflex.

Inappropriate miosis/midriasis can result from a number of causes, such as seizures. Of course even in a paralysed (with medication) patient there will still be some fluctuation of pupil size due to fluctuations in intraocular pressure. 

Anyway, what was the question again?


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## mycrofft (Sep 30, 2009)

*Let's see...*

Thread is "posturing".
First cause: pt happened to assume that position. Rearrange them then see what they assume.
Second cause: misinterpretation.
Third cause: pt rapidly on the way out, cut the hairsplittnig and didimau.

Never heard of brainstem signs being unilateral. Hmmmmm.

Oh, consider likely cause of this, be it toxic, mechanical open, mechanical closed, mechanical delayed/closed, or vascular. or neoplastic. Or infectious. The zebras draw nearer, but etiology is good info for the ER your pt needs to get to.


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## Smash (Sep 30, 2009)

Ok, got it. Got distracted by the errors concerning dolls eye sign. Alternating posturing on either side is not something I have heard of or seen. What was the scenario?


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## Ridryder911 (Sep 30, 2009)

Smash said:


> Ok, got it. Got distracted by the errors concerning dolls eye sign. Alternating posturing on either side is not something I have heard of or seen. What was the scenario?



I agree, erroneous information on the doll's eyes, as well I really doubt the posturing was alternating unless they went to progressive posturing as in ICP causing more damage. In regards to doll's eyes many perform the easy caloric test to detect brain stem function test. 

R/r 911


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## Lifeguards For Life (Sep 30, 2009)

Ridryder911 said:


> I agree, erroneous information on the doll's eyes, as well I really doubt the posturing was alternating unless they went to progressive posturing as in ICP causing more damage. In regards to doll's eyes many perform the easy caloric test to detect brain stem function test.
> 
> R/r 911



I'm getting confused about the  absence of the doll's eye sign(An indicator of brain stem dysfunction, the absence of the doll's eye sign is detected by rapid, gentle turning of the patient's head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned. I was reading a book that said the absence of this sign or reflex is generally found in decerebrate patients. After reading some of the posts here i re cheked on a few websites and got the same information.

Is the absence of the doll's eye sign derived more from the ICP than being decerebrately posteuring? I was hoping someone could clear me up on any misinformation i received or interpreted, and if i am completely wrong, what would be the signifigance of the absence of the doll's eye sign?
thanks


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## rescue99 (Sep 30, 2009)

rescue99 said:


> Could I suppose. There are lots of folks alert with the type of brain damage you describe. Some have doll looking eyes, some not.



Guess I should  have clarified reactive and non-reactive person.


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## Smash (Sep 30, 2009)

Lifeguards For Life said:


> I'm getting confused about the  absence of the doll's eye sign(An indicator of brain stem dysfunction, the absence of the doll's eye sign is detected by rapid, gentle turning of the patient's head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned. I was reading a book that said the absence of this sign or reflex is generally found in decerebrate patients. After reading some of the posts here i re cheked on a few websites and got the same information.
> 
> Is the absence of the doll's eye sign derived more from the ICP than being decerebrately posteuring? I was hoping someone could clear me up on any misinformation i received or interpreted, and if i am completely wrong, what would be the signifigance of the absence of the doll's eye sign?
> thanks



Whoops, sorry I said oculovestibular when I meant oculocephalic. 

You describe the oculocephalic reflex correctly. It allows the gaze to remain on a fixed point. Reading would be nigh on impossible without this reflex allowing for the small involuntary movements of the head. 

Absence of the oculocephalic reflex is known as Dolls Eyes where the position of the orbit remains fixed instead of moving when the head is moved. 

It is a sign of absent brain stem activity, or bilateral pontine lesions. Bad stuff. I've only seen it a couple of times and it is creepy, not least because it essentially means the patient is braindead. 

Oculovestibular sign is elicited by putting cold water in one ear (cold caloric test).  A normal reflex is shown by slow movement of the eyes to the same side, followed by fast movement back (nystagmus). An absence of this demonstrates that the reticular activating system is broken (the sleep/wake switch). An unconscious patient will demonstrate a normal oculovestibular reflex but a comatose patient won't. 

Clear as mud?

As the the posturing, can you describe exactly what was happening?  I struggle to think of a good explanation for such a phenomon. The only thing that keeps coming to mind is pseudoseizures where unequal clonic activity is essentially diagnostic.


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## rescue99 (Sep 30, 2009)

Smash said:


> Whoops, sorry I said oculovestibular when I meant oculocephalic.
> 
> You describe the oculocephalic reflex correctly. It allows the gaze to remain on a fixed point. Reading would be nigh on impossible without this reflex allowing for the small involuntary movements of the head.
> 
> ...



I can think of one explanation....lantern skull. I'm sure there are others.


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## mycrofft (Sep 30, 2009)

*Smash, as always yor last paragraph occurred to me.*

If you shoot in cold water and the pt screams, barfs and opens his eyes, or gets up and runs away....it's a MIRACLE!

Look at the whole picture,other signs and symptoms may indicate what's wrong while one obsesses over a particular one.

I am considering getting a "signature" that says "Cut to the chase".


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## Lifeguards For Life (Sep 30, 2009)

Smash said:


> Whoops, sorry I said oculovestibular when I meant oculocephalic.
> 
> You describe the oculocephalic reflex correctly. It allows the gaze to remain on a fixed point. Reading would be nigh on impossible without this reflex allowing for the small involuntary movements of the head.
> 
> ...



Yeah, clear as mud, thank you for the clarification. I talked to my Anatomy teacher, who said that an absence of the doll's eye sign or reflex is more indicative of the increased ICP, not necessarily either of the earlier mentioned postures. Neither alternating(periods of displaying decerebrate posturing interrupted by periods of decoritate posturing) nor simultaneously displaying decerebrate and decorticate posturing(for instance being decerebrate on the left side of your body, at the same time being decorticate on the right side) offers a better prognosis, the are supposedly equally bad.
Put as simply as i can, if the patient is alternating between the two, it may be as simple as fluctuations in neuro status, i do not remember her full explanation exactly, nor do i remember the reason that the patient would display both as opposed to alternating between the two. Does that clear up my original question?
I believe it was a confusing question, probably poorly worded on my part, though she was able to provide an in depth explanation,


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## mycrofft (Sep 30, 2009)

*Intracranial swelling is non-discriminatory...I meant indiscriminate.*

I guess in theory various structures in the brain are affected in some sort of sequence by progressive increases in ICP and demonstrated by a sequenced series of changing signs, but basically they are all being squished in the same closed vessel (your head, unless it has been opened) and can progress rapidly enough that they are, for field/stream/street EMS, mostly academic.
In-house and fer emergency admit, probably much more important and apparent.


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## Smash (Sep 30, 2009)

Lantern skull?  Aside from the ones I carve out of pumpkins every year, I've not heard of that.


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## Lifeguards For Life (Sep 30, 2009)

Smash said:


> Lantern skull?  Aside from the ones I carve out of pumpkins every year, I've not heard of that.



yes, and several google search's have only shown halloween pumpkins. Could you explain rescue?
thought theese pumpkins were humerous though...
http://www.shipmentoffail.com/wp-content/uploads/2009/09/puking-pumpkins-win.jpg


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## rescue99 (Oct 1, 2009)

Lifeguards For Life said:


> yes, and several google search's have only shown halloween pumpkins. Could you explain rescue?
> thought theese pumpkins were humerous though...
> http://www.shipmentoffail.com/wp-content/uploads/2009/09/puking-pumpkins-win.jpg



Transillumination of the skull. A notable finding when significant hydranencephaly is present in neonates to maybe 12ish years old, when the skull is thinner. A light or direct light held to the skull shows a glow where fluid is present. Similar looking to what happens when you hold a light to your hand. I've seen it and hope to never see it again.


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## mycrofft (Oct 1, 2009)

*An example was pointed out to me yesterday*

Mulitple small but potent insults such as bleeds can cause exhibition of both decerebrate and decorticate signs.


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