01Approach to the Critical Patient/attcp68

Immediate priorities

›Establish preserved consciousness vs true coma

›Spontaneous eye opening present

›Distinguishes from coma

›Eyes open but no goal-directed behavior

›Visual tracking when present

›Distinguishes from vegetative state

›Inconsistent tracking favors minimally conscious state

›Withdrawal to noxious stimulus

›Sensorimotor pathways intact

›Indifference to pain despite reaction

›Airway and aspiration threat

›No volitional initiation of swallowing

›Pooled oropharyngeal secretions

›High aspiration pneumonia risk

›Depressed protective reflexes

›Cough and gag assessment

›If unable to protect airway, definitive airway control

›NPO until formal swallow safety established

›Bedside aspiration screen first

›Early enteral access planning

›Identify reversible structural emergency

›Acute bilateral ACA territory infarction

›Classic vascular cause of akinetic mutism

›If acute stroke window, emergent stroke pathway activation

›Obstructive hydrocephalus

›Headache, vomiting, upgaze palsy

›If acute hydrocephalus, urgent neurosurgery for EVD

02History/hx81

Onset and tempo

›Temporal pattern

›Acute onset

›Ischemic or hemorrhagic stroke

›Bilateral ACA territory event

›Subacute onset

›Hydrocephalus

›Tumor or infection

›Post-procedural onset

›After AComA aneurysm clipping or coiling

›After neurosurgery or shunt

›Course since onset

›Initial coma with later behavioral non-recovery

›Consciousness returned but volition did not

›Gradual reduction in spontaneity

›Fluctuation of arousal

›Reactive but disorganized states

›Non-convulsive status consideration

Preceding events and exposures

›Neurologic precipitants

›Recent neurosurgery

›AComA aneurysm repair

›Tumor resection

›Head trauma

›Bifrontal contusion

›Diffuse axonal injury

›Hypoxic-ischemic event

›Cardiac arrest

03Physical Exam/exam62

Vital signs and general

›Stability snapshot

›Temperature

›Fever as infection or NMS marker

›Hyperthermia with rigidity escalates concern

›Blood pressure

›Hypertension with acute stroke

›Autonomic instability marker

›Respiratory pattern

›Hypoventilation from immobility

›Aspiration-related desaturation

Neurologic exam

›Arousal and awareness

›Eyes open spontaneously

›Distinguishes from coma

›Sleep-wake cycles preserved

›Visual tracking

›Distinguishes from vegetative state

›Reproducible following of examiner

›Response to noxious stimulus

›Withdrawal present

›Indifference to pain despite reaction

›Motor and tone

›Absence of spontaneous movement

›No initiation despite intact strength

›Normal tone in pure akinetic mutism

›Tone abnormalities suggesting mimics

›Rigidity in NMS or parkinsonism

04Differential Diagnosis/ddx53

Disorders of diminished motivation spectrum

›Motivation spectrum

›Apathy

›Reduced goal-directed behavior

›Mildest end of spectrum

›Abulia

›Markedly reduced initiation

›Intermediate severity

›Akinetic mutism

›Near-complete absence of movement and speech

›Severe end of spectrum

Life threats and structural causes

›Vascular emergencies

›Bilateral ACA infarction

›ICD-10 I63.9 cerebral infarction

›Classic akinetic mutism cause

›Thalamic or mesencephalic infarction

›Paramedian territory

›Mixed transcortical aphasia overlap

›Intracranial hemorrhage

›ICD-10 I61.9

›Mass effect on frontal circuits

›Structural non-vascular

›Obstructive hydrocephalus

›ICD-10 G91.1

›Third ventricular or aqueductal obstruction

›Frontal or third ventricular tumor

›Bifrontal compression

05Laboratory Tests/lt45

Core metabolic and infectious

›Metabolic and endocrine screen

›Complete blood count and metabolic panel

›Electrolyte derangement

›Renal and hepatic function

›TSH

›Myxedema coma mimic

›Severe hypothyroidism

›Ammonia

›Hepatic encephalopathy

›Reversible cause

›Infectious and inflammatory markers

›ESR and CRP and procalcitonin

›Infectious or inflammatory etiology

›Trend with treatment

›Blood cultures

›If fever or sepsis concern

›Prior to antibiotics when feasible

Toxic and NMS workup

›Toxicologic studies

›Toxicology screen

›Drug-induced states

›Sedative or serotonergic agents

›Carboxyhemoglobin

›If CO exposure suspected

›Delayed leukoencephalopathy link

›NMS markers

›Creatine kinase

06Diagnostic Tests/dt77

Scoring Systems

›Bush-Francis Catatonia Rating Scale

›Standardized catatonia assessment

›Scores mutism and stupor items

›Lacks catalepsy and echophenomena in akinetic mutism

›Interpretation

›High score with classic signs favors catatonia

›Differentiates from akinetic mutism

›Coma Recovery Scale-Revised

›Disorder of consciousness assessment

›Arousal subscale may be full in akinetic mutism

›Differentiates from vegetative state

›Serial scoring

›Tracks recovery trajectory

›Rehabilitation benchmarking

›Glasgow Coma Scale limitation

›Underestimates awareness

›Verbal and motor scores low despite consciousness

›Not diagnostic for akinetic mutism

MRI

›MRI brain with DWI

›Gold standard for etiology

›Identifies acute infarction

›Bilateral ACA, thalamic, mesencephalic territories

›Key regions to evaluate

›Anterior cingulate cortex and medial prefrontal cortex

›Caudate, thalamus, mesencephalon

›Additional sequences

07Disposition/dispo37

Level of care selection

›Admission indications

›All new-onset akinetic mutism

›Inpatient etiologic workup

›Neurology involvement

›ICU criteria

›Acute stroke with monitoring needs

›Elevated ICP or hemodynamic instability

›Step-down or ward

›Stable established etiology

›Complication management

›Specialist consultation triggers

›Neurology for all cases

›Localization and etiology

›Treatment guidance

›Neurosurgery for structural cause

›Hydrocephalus or mass

›Aneurysm

›Psychiatry for catatonia question

›Lorazepam challenge interpretation

›Bush-Francis scoring

Discharge and transfer criteria

›Discharge readiness

›Underlying etiology treated or stabilized

›Reversible cause addressed

›Stable neuro-observation

›Pharmacologic trial initiated

›Dopaminergic agent started

08Treatment/t82

Initial stabilization and etiologic treatment

›Resuscitation and supportive measures

›Airway protection

›Suctioning of pooled secretions

›If unable to protect airway, intubation

›Aspiration prevention

›Head of bed elevation

›NPO until swallow safety confirmed

›Complication prophylaxis

›DVT prophylaxis

›Skin care and pressure injury prevention

›Etiology-directed therapy

›Hydrocephalus

›If acute, external ventricular drain

›Shunt revision when contributing

›Embolic stroke

›Anticoagulation for cardioembolic source when indicated

›Secondary prevention

›CNS infection

›Empiric antibiotics or antivirals

›Targeted therapy on results

Dopaminergic pharmacotherapy

›First-line dopaminergic agents

›Carbidopa-levodopa

›Start 25/100 mg PO three times daily

›Titrate as tolerated to response

›Evidence from case reports and series

›Bromocriptine

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Etiology evaluation

›Eclampsia and PRES in differential

›Cerebral venous sinus thrombosis risk

›Imaging approach

›MRI without gadolinium preferred

›CT with abdominal shielding when essential

›Medication safety

›Limited safety data for dopaminergic agents

›Maternal-fetal risk-benefit discussion

›Monitoring

›Fetal monitoring when viable gestation

›Multidisciplinary obstetric input

Geriatric

›Older adult features

›Higher vascular burden

›Bilateral ACA infarction more common

›Atrial fibrillation prevalence

›Mimics more frequent

›Depression with psychomotor retardation

›Normal pressure hydrocephalus

›Medication sensitivity

›Start low and titrate slowly

›Renal dosing for amantadine

›Disposition bias

›Frailty and limited supports

›Rehabilitation placement need

10Background/b55

Epidemiology

›Frequency and associations

›Rare neurological syndrome

›Extreme end of diminished motivation spectrum

›Apathy to abulia to akinetic mutism

›Classic vascular association

›AComA aneurysm rupture or repair

›Bilateral ACA territory infarction

›Other recognized causes

›Obstructive hydrocephalus

›Hypoxic-ischemic and CO poisoning

›Emerging associations

›COVID-19 related cases

›Severe respiratory illness or meningoencephalitis

›Often resolves over 1 to 2 weeks

›Delayed post-hypoxic leukoencephalopathy

›Interval deterioration after recovery

›White matter injury

Pathophysiology

›Frontal-subcortical circuit disruption

›Medial prefrontal and anterior cingulate cortex

›Drive for goal-directed behavior

›Initiation of movement and speech

›Subcortical nodes

›Caudate nucleus

›Thalamus and mesencephalon

›Tract-level injury

›Prefronto-caudate tract

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Akinetic mutism caregiver guidance

›The patient is aware but cannot easily start movement or speech

›Give all prescribed medications exactly as directed

›Keep the head of the bed raised during and after feeds

›Follow the swallowing and feeding plan to prevent choking

›Warning signs to return to ER

›New weakness, facial droop, or trouble moving one side

›Choking, coughing with feeds, or trouble breathing

›Fever, neck stiffness, or worsening sleepiness

›Shaking, twitching, or possible seizure

›Sudden worsening of alertness or responsiveness

›Daily care and prevention

›Reposition regularly to protect the skin

›Daily oral hygiene to reduce aspiration risk

›Gentle range-of-motion to prevent stiffness

›Encourage engagement and structured stimulation

›Follow up

›Neurology appointment within 1 to 2 weeks

›Continue rehabilitation therapies as scheduled

›Repeat brain imaging if your team recommends

›Bring an updated medication list to every visit

12References/r15

Guidelines and key sources

›Pathophysiology and treatment reviews

›Arnts et al on pathophysiology and treatment of akinetic mutism

›Fusunyan et al narrative review on akinetic mutism and COVID-19

›Diagnostic and differentiation sources

›Jang and Byun on diffusion tensor tractography of the fronto-subcortical circuit

›Byun and Jang on differentiating akinetic mutism from disorders of consciousness

›American Psychiatric Association resource document on catatonia

›Treatment evidence

›Alexander on chronic akinetic mutism remediated with dopaminergic medications

›Rozen on IV magnesium sulfate in delayed post-hypoxic leukoencephalopathy

›Kim et al on atomoxetine treatment of chronic akinetic mutism

›Coding standards

›ICD-10 I63.9 cerebral infarction unspecified

›ICD-10 R41.89 other symptoms involving cognitive functions and awareness

›SNOMED CT akinetic mutism disorder concept

Evidence & Review

Evidence & Review