Toe Tremors in Comatose Patients: What You Need to Know

Toe twitching

Hello Doctor, my mother previously underwent a tracheostomy due to tracheal stenosis.
On October 27, she was hospitalized for emergency treatment due to tracheal spasms, but due to a delay in the ambulance, it took over an hour for her to arrive at the hospital, by which time she had already stopped breathing and had a heart rate of 29.
Although she was resuscitated, she fell into a severe coma with a Glasgow Coma Scale score of 3.
The EEG showed slow waves, and she has not regained consciousness up to today.
Previously, my mother's hands would clench tightly and curl inward; the nursing staff indicated this was a sign of brain injury.
In the past few days (about 30 days into her coma), my mother's toes have been twitching involuntarily, and sometimes her legs even curl up.
I would like to ask the doctor what this means for my mother; is this a sign of improvement or deterioration? Thank you.

Māomī, 40~49 year old female. Ask Date: 2008/11/30

Dr. Gao Chunde reply Neurology

The patient has been in a coma for a month, and the chances of regaining consciousness are likely lower, but not entirely absent.
There may be spontaneous twitching in the toes and legs, which could be related to muscle spasms and abnormal electrical discharges in the brain.
If this is the case, treatment is necessary to prevent excessive excitation that could lead to further damage.
It is also possible that these movements are simple reflexes, which may originate from the spinal cord level.
While it cannot be guaranteed that the situation will improve, continued observation is warranted.
Currently, medical evidence regarding the treatment of hypoxic brain injury is limited.
Family members can provide sensory stimulation to the patient, as this may help activate the remaining brain cell functions.

Reply Date: 2008/11/30

More Info

I'm sorry to hear about your mother's condition. It sounds like a very challenging and distressing situation for both you and your family. Understanding the nuances of toe tremors in comatose patients can be complex, but I will do my best to provide you with some insights based on medical knowledge.

Toe tremors or involuntary movements in patients who are in a comatose state can be indicative of several underlying factors. In your mother's case, given her history of severe brain injury and the current state of her consciousness (with a Glasgow Coma Scale score of 3), these movements could be a result of several physiological processes.

1. Neurological Response: In patients with significant brain injury, the brain may still exhibit some level of activity even when the patient is unresponsive. These involuntary movements can be a sign of residual brain activity. The brain's motor pathways might still be functioning to some extent, leading to movements in the limbs, including the toes.

2. Spasticity and Hypertonia: After a brain injury, patients can develop spasticity, which is characterized by increased muscle tone and involuntary muscle contractions. This could explain why your mother's toes are twitching or curling inward. Spasticity can occur due to damage to the brain areas that control voluntary movement, leading to abnormal reflexes and muscle tightness.

3. Decerebrate or Decorticate Posturing: The movements you describe, such as the curling of the toes and legs, may also be related to decerebrate or decorticate posturing. These are abnormal postures that can occur in response to severe brain injury. Decerebrate posturing involves extension of the arms and legs, while decorticate posturing involves flexion of the arms and extension of the legs. These postures indicate different levels of brain dysfunction and can provide insight into the extent of neurological damage.

4. Seizure Activity: In some cases, involuntary movements can be a sign of seizure activity, particularly in patients with significant brain injuries. If the movements are rhythmic and repetitive, it may be worth discussing with the medical team whether further evaluation for seizures is warranted.

5. Reflex Activity: Sometimes, movements in comatose patients can be purely reflexive, not indicative of conscious awareness or improvement. The spinal cord can still respond to stimuli even when the brain is not functioning normally.

Regarding whether these movements indicate improvement or deterioration, it is difficult to determine without a comprehensive neurological evaluation. The presence of movements could suggest some level of neurological activity, but it does not necessarily mean that your mother is regaining consciousness or improving overall. It is essential to have ongoing discussions with her medical team, as they can provide more specific insights based on her condition and any diagnostic tests they may perform.

In summary, toe tremors in a comatose patient can arise from various neurological mechanisms, including residual brain activity, spasticity, abnormal posturing, or even seizure activity. It is crucial to maintain open communication with the healthcare providers caring for your mother to understand her condition better and to receive appropriate care and support during this challenging time. Your mother's situation is complex, and the medical team will be best equipped to provide guidance tailored to her specific needs.

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