In cases of sudden onset brain ischemia, few signs of neurologic compromise may precede loss of consciousness. Convulsions and pupillary dilation may occur with loss of muscular tone. With shock, symptoms may be insidious. Confusion and lethargy may appear.
Agitation alternating with lethargy is common.
Failure to recognize parents is an early, ominous sign of cortical hypoperfusion. Hypotonia and intermittent flexor or extensor posturing may occur with prolonged cerebral hypoperfusion or extreme hypoxemia. Always check electrolytes and a dextrostix on any neurologically impaired patient. It also serves as a baseline for comparison later in the hospital course. The exam needs to be tailored to the situation.