Teaching NeuroImages: Spindle coma following cerebral herniation and pontine infarction

A 67-year-old woman presented with bilateral subdural hematomas. After hematoma evacuation, she was unresponsive with extensor posturing and preserved brainstem reflexes. MRI (figure 1) revealed extensive posterior circulation infarction including the mid-pons, thought secondary to herniation and vascular compression. EEG (figure 2) revealed an unreactive background resembling normal N2 sleep (including spindles, K-complexes, and vertex waves) for >24 hours, diagnostic of spindle coma.¹ Conditions implicated in spindle coma tend to disrupt the ascending arousal system at the brainstem and hypothalamic level, but spare the thalamus.^1,2 Underlying etiology, extent of injury, and EEG reactivity provide more prognostic insight than spindle coma alone.^1,2

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