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PubMedDate not supplied

Levodopa treatment for patients in persistent vegetative or minimally conscious states.

The persistent vegetative state (PVS) and the minimally conscious state (MCS) are conditions of altered consciousness after severe brain damage due to a variety of pathologies. However, the specific pathophysiological mechanisms and a therapeutic strategy for intervention have not as yet been established. We review previous reports of levodopa treatment for patients in PVS, MCS, or other mental disorders, and have focused on five representative cases: four of PVS and one of MCS after severe brain injury. In summary, our review suggests the effectiveness of levodopa treatment is probably dependent upon the following criteria: (1) Diagnosis of PVS or MCS as distinct from other related conditions, (2) Concomitant symptoms of parkinsonism, and (3) Concomitant neuroradiological findings of high intensity lesions in the dopaminergic pathway on T2 weighted MRI. The apparent success of levodopa in the five cases described may reflect a specific subgroup of PVS and MCS patients, where the administration of levodopa is effective. However, we should not regard PVS or MCS as a single entity, since levodopa is unlikely to be effective in all cases. Therapeutic strategies should aim to identify the key pathophysiological mechanism for each patient and target interventions accordingly.

Adolescent↗
PubMed1997

Disorders of consciousness: differential diagnosis and neuropathologic features.

Disorders of consciousness present intriguing challenges to the neurologist and neurorehabilitation specialist. Assessment is constrained by the lack of reliable methods of assessing consciousness, and there are no treatment interventions known to influence the course of recovery from these conditions. In addition, the relationship between the clinical features associated with these disorders and their corresponding pathophysiologic substrate is also unclear. Our understanding of disorders of consciousness has not kept pace with the advances in neurosurgical management that have decreased mortality following severe injury. There is still considerable confusion regarding differential diagnosis and prognostication concerning states of severely altered consciousness. The purpose of this article is to discuss the content and neural basis of consciousness and to review the terminology most often used to describe altered states of consciousness. The neurobehavioral criteria for differentiating among specific syndromes associated with severe alterations in consciousness are presented. Representative case studies are utilized to illustrate the characteristic clinical profiles of coma, vegetative state, persistent and permanent vegetative state, minimally conscious state, akinetic mutism, and locked-in syndrome. Areas of ambiguity and controversy are emphasized and future directions for research are suggested.

Akinetic Mutism↗
PubMed2004

Catholic moral teaching, medically assisted nutrition and hydration and the vegetative state.

A wide range of medical, legal and ethical opinion regarding withholding or withdrawing medically assisted nutrition and hydration (ANH) from vegetative state (VS) and persistent vegetative state patients (PVS) has been presented in professional journals over the past twenty years. This article concerns the moral aspects of this debate as it has developed within the Catholic Church, especially in the United States. It presents traditional Catholic teaching about the extent and limits of the moral obligation to employ medical means in the preservation of human life, and examines how this teaching applies to the specific question of supplying ANH to PVS patients. It provides a critique of two contradictory views on the morality of discontinuing ANH for PVS patients presented by Catholic theologians. It examines the teaching of Pope John Paul II, who identifies ANH as a natural means of preserving life that must be maintained as long as it preserves the patient's life or alleviates his suffering. Finally, it discusses the practical implications this papal teaching has for the treatment of PVS patients in all Catholic health care facilities.

Catholicism↗
PubMed1990

Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children.

We conducted a retrospective review of 55 near-drowning victims (mean age 4.75 years) admitted to the intensive care unit during a 5-year period, to determine the factors that may influence survival both before and after hospital admission. All patients who remained comatose after resuscitation received ventilation for an initial 24 hour period, after which an assessment of central nervous system injury was made. Intracranial pressure was not monitored, and barbiturate therapy was used only for seizure control. Thirty-seven children survived and 18 died; five survivors had profound neurologic damage resulting in a persistent vegetative state: the remaining 32 (58%) survived intact. The major factors that separated intact survivors from those who died and from survivors in a persistent vegetative state were the presence of a detectable heartbeat and hypothermia (less than 33 degrees C) on examination in the emergency department. Thirteen patients with absent vital signs and a temperature of greater than 33 degrees C either died or survived in a persistent vegetative state. Fourteen patients had a combination of absent vital signs and hypothermia and were resuscitated; eight died, two survived in a persistent vegetative state, and four survived intact. All intact survivors had been submerged in cold water for prolonged periods, and all underwent prolonged cardiopulmonary resuscitation. All patients with a detectable pulse, regardless of temperature, survived without neurologic sequelae. The 58% intact survival rate in this series compares favorably with the 50% we reported previously when high-dose barbiturate therapy and hypothermia were used to control intracranial pressure; at the same time, the number of survivors with a persistent vegetative state has been reduced by 50%. We conclude that prolonged in-hospital resuscitation and aggressive treatment of near-drowning victims who initially have absence of vital signs and are not hypothermic either results in eventual death or increases the number of survivors with a persistent vegetative state.

Child, Preschool↗
PubMed1989

Effects of dorsal column spinal cord stimulation (DCS) on reversibility of neuronal function--experience of treatment for vegetative states.

We have reported that DCS (dorsal column stimulation) improves the clinical symptoms of cases in persistent vegetative states. Since then, we have accumulated 23 cases who have been treated by DCS. We describe the clinical EEG, rCBF, and biochemical changes in cerebrospinal fluid (CSF) caused by DCS in patients in persistent vegetative states: (1) eight of these cases showed good clinical improvement; (2) most patients were young and the CT scan did not show large, diffuse, definite or bilateral low density areas in cortex, brainstem of thalmus; (3) neurostimulation increased rCBF (cerebral blood flow) in many parts of the brain in cases with vegetative states; blood flow increased in the cerebrum, cerebellum and brainstem; (4) neurostimulation enhanced the metabolism of catecholamines in CSF, NE, DA, DOPAC, HVA, and 5HIAA increased, but 3MT and 5HT decreased in CSF. DCS increased rCBF, enhanced the metabolism of catecholamines in CSF, and improved the EEG in patients in persistent vegetative states.

Cerebrovascular Circulation↗
PubMed1996

[Acute subdural hematoma caused by professional boxing].

Knockout in boxing entails deliberate production of the state of unconsciousness. Acute subdural hematoma which is the most common acute brain injury in boxing, accounts for 75% of all acute brain injuries and is the leading cause of boxing fatalities. The aim of this study is to evaluate acute subdural hematoma caused by professional boxing by analyzing the content of bouts, the level of consciousness on admission, CT scan, therapy and outcome 3 months after admission. Fifteen boxers who had suffered from acute subdural hematoma were classified into three groups according to the pattern of loss of consciousness. Transient unconsciousness type (Transient type): boxers who had returned to alertness within an hour from the time of injury. Lucid interval type: neurological deterioration appeared with a lucid interval from ten minutes to an hour after knockout. Deterioration of consciousness type (Deterioration type): A state of unconsciousness appeared and worsened from a few minutes after knockout. Analyzing the number of rounds in bouts indicated that the hematoma occurred most frequently in bouts of 10 rounds. All of our subjects presented subdural hematomas without cerebral contusions on CT scan. With regard to the location of the hematomas, 9 hematomas involved the left side, 3 the right, 2 the suboccipit and 1 the interhemisphere. Transient type was found in 7 patients who had GCS scores of 14, 15 on admission. Since CT scan revealed thin subdural hematoma with or without mild midline shift, conservative therapy was carried out in all patients. All patients had a good recovery. Five patients of lucid interval type with an admission GCS score of 4, 6 and 7 demonstrated thicker hematoma compared to that presented by the transient type with significant midline shift on CT scan. All patients required surgery. Outcome of this type was good recovery (n = 2), moderate disability (n = 1), persistent vegetative state (n = 1), death (n = 1). Three patients of deterioration type had GCS scores of 5, 6. Because of subdural hematoma with remarkable midline shift on CT scan, all patients underwent surgery. Outcome was good recovery (n = 1), moderate disability (n = 1), persistent vegetative state (n = 1). Overall outcome was good recovery 66.7%, moderate disability 13.3%, persistent vegetative state 13.3%, death 6.7%. Furthermore, 8 patients who underwent surgery with a GCS score of less than 8 exhibited good recovery 37.5%, moderate disability 25%, persistent vegetative state 25%, death 12.5%. CT scan of lucid interval and deterioration type showed a tendency to show thick subdural hematoma and remarkable midline shift compared to transient type. Outcomes of lucid interval and deterioration type were worse than those of transient type. This result suggests that the influence of repeated head injury and diffuse brain injury might make a difference between these groups. Repeated head injury means that further impacts repeatedly damaged the injured brain after bleeding in the bouts. Overall outcome was better than that published in previous reports and also than that observed in other head injuries, for example, traffic accident and fall. The reasons for this could be that the patients were younger, that there was immediate surgical treatment, and that brain injury without cerebral contusion had contributed to better outcome. Finally, the best medical management intervention seems to be to diagnose and treat the lesions as early as possible after occurrence of subdural hematoma.

Acute Disease↗
PubMed2005

The Terri Schiavo case: legal, ethical, and medical perspectives.

Although tragic, the plight of Terri Schiavo provides a valuable case study. The conflicts and misunderstandings surrounding her situation offer important lessons in medicine, law, and ethics. Despite media saturation and intense public interest, widespread confusion lingers regarding the diagnosis of persistent vegetative state, the judicial processes involved, and the appropriateness of the ethical framework used by those entrusted with Terri Schiavo's care. First, the authors review the current medical understanding of persistent vegetative state, including the requirements for patient examination, the differential diagnosis, and the practice guidelines of the American Academy of Neurology regarding artificial nutrition and hydration for patients with this diagnosis. Second, they examine the legal history, including the 2000 trial, the 2002 evidentiary hearing, and the subsequent appeals. The authors argue that the law did not fail Terri Schiavo, but produced the highest-quality evidence and provided the most judicial review of any end-of-life guardianship case in U.S. history. Third, they review alternative ethical frameworks for understanding the Terri Schiavo case and contend that the principle of respect for autonomy is paramount in this case and in similar cases. Far from being unusual, the manner in which Terri Schiavo's case was reviewed and the basis for the decision reflect a broad medical, legal, and ethical consensus. Greater clarity regarding the persistent vegetative state, less apprehension of the presumed mysteries of legal proceedings, and greater appreciation of the ethical principles at work are the chief benefits obtained from studying this provocative case.

Adult↗
PubMed2003

Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury.

OBJECTIVES: To determine whether proton magnetic resonance spectroscopy (MRS), a newer radiographic technology, would be useful in the evaluation of the thalamus of patients in vegetative states resulting from traumatic brain injury. METHODS: 14 victims of severe traumatic brain injury who were in the vegetative state and whose magnetic resonance images of the thalamus were normal underwent bilateral thalamic proton (MRS) studies. The N-acetyl aspartate to creatine (NAA:Cr) and choline to creatine (Cho:Cr) ratios were obtained for each patient. The proton thalamic MRS findings of patients who were in a persistent vegetative state (n = 8) and in patients who had regained awareness after being in the vegetative state (n = 6) were compared with proton thalamic MRS findings in five healthy volunteers. RESULTS: While conventional magnetic resonance imaging suggested that each patient had a normal thalamus, proton MRS indicated that the thalamus of each patient in the series was damaged. The NAA:Cr ratio was significantly lower in the thalami of both the patients who remained in a persistent vegetative state for the duration of the study and in those who regained awareness after being in the vegetative state (p < 0.001). In addition, NAA:Cr ratios were lower in the group of patients who remained in a persistent vegetative state than in the group of patients who regained awareness after being in the vegetative state (p < 0.001). CONCLUSIONS: Results suggest that the NAA:Cr ratio within the thalamus is significant and that thalamic MRS may be helpful when attempting to determine the degree of severity of neuronal and axonal injury in patients in the vegetative state.

Adolescent↗
PubMed1994

[The "Apallic Syndrome"--the necessity and consequences of a conceptual clarification].

Starting from the increasing clinical requirement to make grave decisions (e.g. discontinuation of treatment) during hospitalisation of patients in an apallic syndrome, problems of defining the "apallic syndrome"--compared with the Anglo-American term "persistent vegetative state"--are reviewed. Besides conceptual criticism based on pathogenetic considerations and neuropathological findings the author especially demonstrates the varying inclusion criteria of the clinical syndrome concerning the apallic syndrome as well as the persistent vegetative state. Furthermore attempts to introduce more precisely defined subgroups (e.g. complete apallic syndrome) and new competing terms are shown. Referring to clinical diagnosis the low value of technical studies resulting from a great range of--sometimes controversial--findings contrasts with the high importance of identifying clinically related syndromes. Recent prognostic data that apply to judging the permanence of an apallic syndrome or persistent vegetative state are discussed. From this follows that they are of limited validity for the single patient. Finally it is attempted to work out some implications for clinical proceedings that should enable to meet a situation afflicted with diagnostic and prognostic uncertainties according to the present medical knowledge.

Coma↗