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Results for “Persistent Vegetative State”

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PubMed1997

Diminished vasomotor component of systemic arterial pressure signals and baroreflex in brain death.

We compared the cardiovascular autonomic regulatory mechanisms between patients with brain death or under a persistent vegetative state and healthy volunteers, based on auto- and cross-spectral analysis of systolic blood pressure (SBP) and interpulse interval (PPI) signals. Brain-dead patients exhibited a significant reduction in the absolute and relative power of the low-frequency (LF; 0.04-0.15 Hz) component in both SBP and PPI spectra, along with appreciable decrease in the very low frequency (VLF; 0.004-0.04 Hz), LF, and high-frequency (HF; 0.15-0.4 Hz) power of the PPI signals. Patients in a persistent vegetative state exhibited a power of the VLF and LF component in the SBP spectrum that was comparable to that in healthy subjects, although a discernible reduction in the VLF, LF, and HF power of the PPI spectrum was manifested by the former group. Assessments with the magnitude of SBP-PPI transfer function and linear regression analysis of beat-to-beat fluctuations in SBP and PPI revealed a progressive decline in spontaneous baroreflex sensitivity from healthy subjects to patients in a persistent vegetative state or with brain death. We conclude that the vasomotor component of systemic arterial pressure signals and spontaneous baroreflex are highly correlated with the functional integrity of the brain stem.

Adult↗

PubMed2002

Alcohol induced ketoacidosis, severe hypoglycemia and irreversible encephalopathy.

BACKGROUND: Severe hypoglycemia leading to permanent brain damage is rare in non-diabetic population. We present one such case where chronic alcoholism combined with prolonged fasting lead to such a state and patient ended in a persistent vegetative state. CASE REPORT: A 50 year old Asian woman with past history of chronic alcoholism and hepatitis C was found unresponsive in her house after drinking alcohol consecutively for 2 days. Finger-stick glucose done by paramedics was <20 mg/dl. She was given 50 ml of 50% dextrose without any neurological response. On arrival in the emergency department patient was found to be comatose with only withdrawal response to deep painful stimuli and a negative babinski's sign. Computed tomogram of the head revealed mild cerebral atrophy. After an extensive work up a diagnosis of alcoholic ketoacidosis with hypoglycemia related encephalopathy was made. CONCLUSIONS: Alcohol induced ketoacidosis is usually associated with normal blood glucose. The probable etiology of low blood sugar in our patient was alcohol-induced inhibition of gluconeogenesis along with starvation. The prolonged hypoglycemia caused cortical damage simulating ischemic brain damage. Ten months in to follow-up patient is still in persistent vegetative state with no noticeable neurological recovery.

Acidosis↗

PubMed2005

Outcome after cardiac arrest: predictive values and limitations of the neuroproteins neuron-specific enolase and protein S-100 and the Glasgow Coma Scale.

BACKGROUND AND PURPOSE: Patients resuscitated from cardiac arrest are at risk of subsequent death or poor neurological outcome up to a persistent vegetative state. We investigated the prognostic value of several epidemiological and clinical markers and two neuroproteins, neuron-specific enolase (NSE) and S-100 protein (S-100), in 97 patients undergoing cardiopulmonary resuscitation (CPR) after non-traumatic cardiac arrest between 1998 and 2002. RESULTS: 52.6% of the patients died, 28.8% survived with severe, moderate or without neurological disorders, and 18.6% remained in a persistent vegetative state. Unconsciousness>48 h after CPR predicted a 60.6-fold (95% CI 14.3287-257.205, p=0.001) and a Glasgow Coma Scale (GCS)<6 points after 72 h a 11.2-fold (CI 95%, 3.55-36.44, p<0.001) risk of poor neurological outcome. Serum levels>or=65 ng/ml for NSE and >or=1.5 microg/l for S-100 increased the risk of death and persistent vegetative state 16.8 (95% CI 2.146-131.520)- and 12.6 (95% CI 1.1093-99.210)-fold, respectively. By combination of the GCS with elevated serum concentrations of both neuroproteins above the cut off levels on third day after CPR a poor neurological outcome was predicted with a specificity of 100%. CONCLUSION: The combination of GCS with the serum levels of both neuroproteins at 72 h after CPR permit a more reliable prediction of outcome in post arrest coma than the single markers alone, independent of the application of anaesthetic agents.

Adolescent↗

PubMed2005

Death of John Paul II and the basic human care for the sick and the dying.

The death of Terri Schiavo by starvation and its sanction by some United States Courts indicates the alarming revival of the eugenics and euthanasia movement. From the legal sanction of physician-assisted suicide, the euthanasia movement now tries to advance the legal protection for "mercy killing." Terri was diagnosed with persistent vegetative state, a term that is outdated, vague and imprecise and that likens a human being to a vegetable. Medical literature indicates that patient with so-called "persistent vegetative state" can recover, and that they do experience pain. The euthanasia movement, linked to eugenics in its origin and present day influence in bioethics espouses the Nazi notion of "lives not worth living," unlimited patient autonomy, and philosophical utilitarianism. John Paul II countered the eugenic philosophy with the classical Western concept of man as the image and likeness of God, responsible for the care of himself and society as a whole. He taught in writing and by example that food and water are basic human care that every person should receive. In the last days of his life he showed a judicious use of proportionate or ordinary means to maintain life. He chose to forego disproportionate medical treatment when there was no reasonable hope of recovery. At that point he continued to receive ordinary medical care, together with basic human and spiritual care.

Catholicism↗

PubMedDate not supplied

Outcome of children with prolonged unconsciousness and vegetative states.

The outcomes of 60 children unconscious for 90 days or longer following acquired brain injury are reported. Eight children who died had remained in persistent vegetative states. As expected, most neurologic improvement occurred within the first year after injury, although some delayed improvements were observed. Outcomes were strongly correlated with causes of brain injury. Better cognitive and motor function was observed with nonanoxic injuries. No child in this report with anoxic brain injury regained functional cognitive or motor skills, although 3 became socially responsive. The remarkable contrast with adults following acquired brain injury is the significantly longer survival of children. The only children who died had remained in persistent vegetative states.

Adolescent↗

PubMedDate not supplied

Ethics and the vegetative state.

Before discussing ethical issues to do with patients in permanent (or persistent) vegetative state (PVS) it is necessary to address the foundational issue of whether PVS as a concept is able to provide a robust link to situations in the real world. The high reported rates of misdiagnosis and recovery in patients diagnosed as being in PVS casts doubt upon the applicability of ethicists' thought experiments on Platonic forms to actual decision making in clinical situations. We should abandon the illusion that we can have access to logical certainty through diagnostic definition, and should instead frame our opinions and our procedures in ways that can accommodate a high element of uncertainty, and should in the light of recent studies give considerable weight to the possibility that patients, at present unable to express opinions on their care, will later become able to do so, if given proper treatment and adequate evaluation.

Humans↗

PubMed1988

Prognosis of intraventricular hemorrhage due to hypertensive hemorrhagic cerebrovascular disease.

The prognosis of intraventricular hemorrhage (IVH) due to hemorrhagic cerebrovascular disease has been regarded as unfavorable. The authors studied factors affecting the prognosis in 55 patients with IVH due to hypertensive thalamic and putaminal hemorrhages. The mortality rate in this study was 38%, a poorer rate than that in patients without IVH (18%). As for morbidity, 50% of the survivors (31% of all patients) with IVH had nor or moderate disability, but the other 50% had severe disability or were in a persistent vegetative state. On the other hand, there was no or moderate disability in 55%, and severe disability or a persistent vegetative state in 27% of the patients without IVH. Patients with intracerebral or intraventricular hematoma volumes greater than 25 ml, Glasgow Coma Scales of less than nine, intracranial pressures above 30 mm Hg, and ventriculocranial ratios over 0.22 had poor prognoses. These results suggest that greater volumes of intracerebral or intraventricular hematoma and the presence of acute hydrocephalus are of great significance when considering the outcomes of IVH cases.

Adult↗

PubMed2003

Paediatric near-drowning: mortality and outcome in a temperate climate.

The decision whether to continue to resuscitate the paediatric victim of near-drowning is influenced by potential poor neurological outcome. A low core body temperature at presentation is frequently cited as a reason to continue resuscitation. We report the case of an 11 month old infant admitted to the intensive care unit following near-drowning and a prolonged resuscitation. The infant's core body temperature was 29 degrees C. Cardiac output was restored, but the child remains in a persistent vegetative state. We present the results of a ten year review of near-drowning in a tertiary referral institution, to evaluate the mortality and outcome in a temperate climate. Thirteen patients were identified in the review. The mortality was 23%. The incidence of a persistent vegetative state was 15%. Asystole, immersion time greater than 15 minutes, resuscitation time longer than 30 minutes, the administration of epinephrine, and a low core body temperature were associated with a poor outcome.

Body Temperature↗

PubMed1989

Prognosis of intraventricular hemorrhage due to rupture of intracranial aneurysm.

The prognosis of intraventricular hemorrhage (IVH) from rupture of intracranial aneurysms was studied in 43 patients admitted to our institution and to Kaga Central Hospital between April 1984 and December 1987. The total number of aneurysmal subarachnoid hemorrhage (SAH) patients admitted during this period was 156, so that 28% of SAH patients had IVH. In this study, the patients were analyzed with respect to IVH grading, volumes of intraventricular and intracerebral hematoma, consciousness level, intracranial pressure (ICP), ventricular dilatation and age. The IVH resulted from aneurysmal rupture of the anterior communicating artery (48%), anterior cerebral artery (distal portion of the anterior communicating artery) (11%), internal carotid artery (21%), middle cerebral artery (25%), and vertebro-basilar artery (14%). The mortality rate in patients with IVH was 33%, a poorer rate than that in patients without IVH (25%). As for morbidity, 44% of the patients with IVH had no or moderate disability, whereas the other 23% had severe disability or were in a persistent vegetative state. On the other hand, there was no or only moderate disability in 63%, and severe disability or a persistent vegetative state in 12% of the patients without IVH.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1998

MR of hypoxic encephalopathy in children after near drowning: correlation with quantitative proton MR spectroscopy and clinical outcome.

BACKGROUND AND PURPOSE: Quantitative MR spectroscopy has a proved role in the investigation of hypoxia caused by near drowning. To date, no studies have addressed the MR imaging changes that may also accompany this condition. The purpose of this study was to describe the MR imaging findings in children with hypoxic encephalopathy caused by near drowning and to compare these findings with the results of qualitative and quantitative proton MR spectroscopy and clinical outcome. METHODS: Twenty-two children (6 months to 11 years old) admitted to the pediatric intensive care unit after near drowning incidents underwent cerebral MR imaging and quantitative proton MR spectroscopy. Clinical and imaging studies were reviewed retrospectively, and subjects were grouped according to outcome: good result, persistent vegetative state, and death. Images were scored for edema, basal ganglia changes, and cortical changes, and were compared with MR spectra and outcome at days 1 to 2, 3 to 4, and 5 or more. RESULTS: Six patients had a good outcome, four remained in a persistent vegetative state, and 12 died. Generalized/occipital edema correlated with poor outcome. Indistinct lentiform nuclei margins on T1-weighted images were a frequent finding (78%). Basal ganglia T2 hyperintensity correlated with poor outcome, progressing from a patchy/peripheral distribution to diffuse high intensity. Patchy high T2 signal in the cortex or subcortical lines were specific but insensitive for poor outcome, as were brain stem infarcts. CONCLUSION: MR images in children with hypoxic encephalopathy after near drowning show a spectrum of changes. The most sensitive prognostic result may be achieved by combining MR imaging with qualitative and quantitative MR spectroscopic data.

Brain Diseases↗

PubMedDate not supplied

[Resistant vegetative state: considerations regarding bioethics of contemporary medicine].

INTRODUCTION: The diagnosis and conduct toward persistent vegetative state (PVS) is one of the emergent themes in bioethic in our contemporary society. This clinical condition is defined. DEVELOPMENT: To homologate PVS with brain death (BD) is one of the most discussed present controversies at the bioethic international area. If we keep in mind the present concepts of BD, it's not correct to homologate both terms. There is an increasing practice in admitting the end of medical treatment in PVS. In fact, with the introduction of cost-effectiveness concept in intensive medicine, the right to treatment of these patients is discussed at Intensive Care Units. Some present criteria about this are presented, taking age into consideration, diagnostic certainty and the establishment of function recovery prognosis. CONCLUSIONS: The introduction of recently developed models for the rehabilitation of patients with severe brain injuries and PVS may lead to substantial improvements in outcome and may also be cost efficient. It is not ethical to make an arbitrary decision to withdraw a medical treatment of a patient, when we know there is the structural possibility of recovering some functions.

Brain Death↗

PubMed1986

Hyponatremia, convulsions, respiratory arrest, and permanent brain damage after elective surgery in healthy women.

Severe hyponatremia developed after elective surgery in 15 previously healthy women who subsequently either died or had permanent brain damage. The mean age was 41 years (range, 22 to 66), and the preoperative serum sodium level was 138 mmol per liter. All the patients recovered from anesthesia, but about 49 hours after surgery, when the average plasma sodium level was 108 mmol per liter, grand mal seizures, followed by respiratory arrest requiring intubation, developed in all 15. At that time, the urinary sodium level and the osmolality averaged 68 mmol per liter and 501 mOsm per kilogram, suggesting inappropriate secretion of antidiuretic hormone. In 10 of 15 patients, an acute cerebral vascular disorder was suspected, leading to a delay in treatment and multiple diagnostic studies, including CT scanning, cerebral angiography, and open-brain biopsies. The net postoperative fluid retention was 7.5 liters, and when correction of the serum sodium level was initiated, the rate of correction was less than 0.7 mmol per liter per hour. Histologic studies of the brain in five patients were not diagnostic, and no patient had any evidence of central pontine myelinolysis on the basis of autopsy, brain biopsy, or CT scanning. Seven patients recovered from coma after the serum sodium level was increased to 131 mmol per liter, but coma recurred two to six days later and ended in either death or a persistent vegetative state. Overall, 27 percent of the patients died, 13 percent had limb paralysis, and 60 percent were left in a persistent vegetative state.

Adult↗

PubMed2000

Heterotopic ossification in childhood and adolescence.

Heterotopic ossification, or myositis ossificans, denotes true bone in an abnormal place. The pathogenic mechanism is still unclear. A total of 643 patients (mean age, 9.1 years) admitted for neuropediatric rehabilitation were analyzed retrospectively with respect to the existence of neurogenic heterotopic ossification. The purpose of this study was to obtain information about incidence, etiology, clinical aspect, and consequences for diagnosis and therapy of this condition in childhood and adolescence. Heterotopic ossification was diagnosed in 32 patients (mean age, 14.8 years) with average time of onset of 4 months after traumatic brain injury, near drowning, strangulation, cerebral hemorrhage, hydrocephalus, or spinal cord injury. The sex ratio was not significant. In contrast to what has been found in adult studies, serum alkaline phosphatase was not elevated during heterotopic ossification formation. A persistent vegetative state for longer than 30 days proved to be a significant risk factor for heterotopic ossification. The incidence of neurogenic heterotopic ossification in children seems to be lower than in adults. A genetic predisposition to heterotopic ossification is suspected but not proven. As a prophylactic regimen against heterotopic ossification we use salicylates for those patients in a coma or persistent vegetative state with warm and painful swelling of a joint and consider continuous intrathecal baclofen infusion and botulinum toxin injection for those patients with severe spasticity. We prefer to wait at least 1 year after trauma before excision of heterotopic ossification.

Adult↗

PubMed2006

Closing the Schiavo case: an analysis of legal reasoning.

The conflict surrounding Terri Schiavo, whom Florida's courts had determined wished not to be kept alive in a persistent vegetative state, played out on a national stage. The dispute between Schiavo's husband and parents engulfed America's legislative, executive, and judicial systems, raising profound questions about the laws and policies that govern advance directives. In this paper, we offer an analysis of the legal reasoning in Schiavo and offer predictions about the case's likely impact on law and policy in the future. We reviewed an extensive collection of case materials that included consensus definitions of persistent vegetative state, media reports, court decisions and briefs, legal chronologies, guardian reports, and Schiavo's autopsy report. We also reviewed cases cited as sources for legal reasoning used in Schiavo, including Quinlan, Cruzan, and Browning. We also examined the political, cultural, and media factors that affected the conflict. Based upon these reviews, we identified the legal reasoning that decided the Schiavo conflict. We found that Florida's constitutional right to privacy, a principle that shaped the Florida statutory and case law, guided the courts' consistent rulings. The conflict that characterized the case reflected profound differences in American politics rather than a failure of the medical and/or legal systems. The outcome of the Schiavo case remained consistent with established Florida statutory and case law, and honored Terri Schiavo's state constitutional right to privacy. Although Schiavo may not affect advance directive law and policy in palliative medicine immediately, evidence suggests it has already increased interest in creating living wills.

Advance Directives↗

PubMedDate not supplied

The vegetative state: promoting greater clarity and improved treatment.

The condition commonly referred to as the persistent vegetative state (PVS) or vegetative state (VS) generates tremendous confusion among health care professionals. Muddled and nihilistic views of very severe brain injury have hampered efforts to improve the diagnosis and treatment of patients thought to be in the VS. Significant obstacles to diagnostic clarity arise from multiple sources including imprecise terminology and conflation of the concepts of "behaviour" and "awareness". Failure to employ effective, uniform protocols of assessment and rehabilitation contributes to inadequate treatment of these extremely vulnerable patients. Despite diagnostic and prognostic difficulties, courts across the globe have accepted medical opinion as persuasive evidence for life-support withdrawal. A new outlook on severe brain injury is needed, with greater clarity and standardisation of assessment and care. Best practices in assessment and rehabilitation must be incorporated along with new developments in cognitive neuroscience and neuroimaging. Such a rehabilitative view will encourage intellectual curiosity towards improved quality of care for patients with severe brain injury. Attaining high levels of accuracy depends upon reaching a clearer understanding of the nature of human consciousness itself, of the condition, and of the patient's potential for full or partial recovery.

Attitude of Health Personnel↗

PubMed2004

Cerebral fat embolism diagnosed by magnetic resonance imaging at one, eight, and 50 days after hip arthroplasty: a case report.

PURPOSE: To describe cardiovascular collapse during a cemented hip hemiarthroplasty in a patient who, despite a successful cardiopulmonary resuscitation, remained in a persistent vegetative state due to cerebral fat embolism diagnosed by magnetic resonance imaging (MRI). CLINICAL FEATURES: A 75-yr-old woman with no medical history underwent cemented hip hemiarthroplasty under spinal anesthesia for a right femoral neck fracture. Shortly after insertion of the prosthesis, a sudden oxygen desaturation, hypotension, bradycardia, and cardiac arrest occurred. The patient was successfully resuscitated, but did not regain consciousness. The patient developed high-grade fever, thrombocytopenia, anemia, and oliguria. MRI scans of the brain revealed multiple high intensity signals throughout the white matter, the basal ganglia, the cerebellum, and the brain stem. The diagnosis of fat embolism was made on the basis of clinical findings and MRI images. Although her cardiorespiratory status improved over the next week, the patient remained in a persistent vegetative state. CONCLUSION: When fat embolism is suspected, serial MRI scans of the brain should be performed to diagnose the etiology of cerebral embolism as well as to evaluate the severity of brain damage.

Aged↗

PubMed1994

Pediatric resident attitudes about technologic support of vegetative patients and the effects of parental input--a longitudinal study.

OBJECTIVE: To evaluate the change over time of attitudes about withdrawal of care from hopelessly ill children among a cohort of pediatric residents. DESIGN: Prospective data collection via surveys. SETTING: A pediatric residency program in a children's hospital. SUBJECTS: Pediatric residents beginning training in 1987 and 1988; 29 residents completed the study. INTERVENTIONS: Study participants completed a structured case-oriented questionnaire yearly from June 1988 through the completion of their residency training. The withholding of vasoactive agents or cardiopulmonary resuscitation, and the withdrawal of intravenous fluids, nutrition, or mechanical ventilation were the specific therapeutic options presented for a patient in a persistent vegetative state. The effects of time (further training) and parental wishes on resident decisions were assessed. MEASUREMENTS AND MAIN RESULTS: No resident wanted to provide intensive care to a child in a persistent vegetative state who was in respiratory failure; all residents would withhold vasoactive agents and CPR from such a child. At the conclusion of training, most (97%) would withdraw mechanical ventilation. A minority would withdraw intravenous (IV) fluids (41%) or nutrition (35%). Residents became more willing to withdraw IV fluids from these patients (0/16 vs 6/16; P = .03) and to withhold or withdraw therapies in general (P = .03) over the course of their training. All of this change occurred over the first year of training. Parental wishes altered treatment plans for these patients significantly, both when parents desired additional treatment (P < .0001), and when parents wanted treatment stopped (P = .04). The residents' level of training had no effect on responses to parents' therapeutic requests. CONCLUSION: Although exposure to level of care issues occurs throughout pediatric residency training, almost all changes in trainees' attitudes occur during the first year. Efforts to promote effective learning and coping should be concentrated in this period.

Adult↗

PubMed2003

Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O-H2O PET study.

Survivors of prolonged cerebral anoxia often remain in the persistent vegetative state (PVS). In this study, long-term PVS patients were investigated by 15O-H(2)O PET to analyze their central processing of pain. The study was approved by the local Ethics Committee, the experiments were performed in accordance with the Helsinki Declaration of 2000. Seven patients remaining in PVS of anoxic origin for a mean of 1.6 years (range 0.25-4 years) were investigated. We performed functional PET of the brain using 15O-labelled water during electrical nociceptive stimulation. Additionally, a brain metabolism study using 18F-fluorodeoxyglucose (FDG) PET and multi-sequence MRI (including a 3-D data set) were acquired in all patients. PET data were analyzed by means of Statistical Parametric Mapping (SPM99) and coregistered to a study-specific brain template. MRI and FDG PET showed severe cortical impairment at the structural and the functional level, that is, general atrophy of various degrees and a widespread significant hypometabolism, respectively. Pain-induced activation (hyperperfusion) was found in the posterior insula/secondary somatosensory cortex (SII), postcentral gyrus/primary somatosensory cortex (SI), and the cingulate cortex contralateral to the stimulus and in the posterior insula ipsilateral to the stimulus (P<0.05, small-volume-corrected). No additional areas of the complex pain-processing matrix were significantly activated. In conclusion, the regional activity found at the cortical level indicates that a residual pain-related cerebral network remains active in long-term PVS patients.

Adult↗