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PubMedDate not supplied

Neurophysiological patterns of vegetative and minimally conscious states.

This paper reviews the possible usefulness of electroencephalogram (EEG) and evoked potential (EP) recording in vegetative and poorly-responsive patients. There is a marked inter-individual EEG and EP variability, which reflects the state heterogeneity. Four clinical applications are described: (1) the identification of primary midbrain dysfunction--and, therefore, a possible reversibility--in post-traumatic states; (2) the identification of the permeability of sensory channels; (3) quantitative follow-up; and (4) individual assessment of cognitive functions and/or consciousness. Regarding this last issue, the loss of primary cortical EPs, although rarely observed, constitutes one major argument against consciousness. Conversely, cognitive EPs definitely proved the persistence of cognitive functions in several vegetative patients. Whether these cognitive functions are conscious or not remains a matter of debate.

Acute Disease↗
PubMed1995

The ultimate curse.

This paper tells the story of a doctor in a vegetative state. The approach towards him is quite different from that towards a common patient. The other physicians cannot deal with this situation with the necessary open mind.

Curare↗
PubMed2005

[Ethical and legal points concerning minimally conscious state and permanent vegetative state].

The ethical and legal problems posed by severe outcome of coma are complex and their analysis requires a multi-disciplinary approach. Three aspects have been particularly studied in this paper. The first is a reminder of the medical definitions of the concepts of vegetative state and minimally conscious state. The second focuses on the analysis of the ethical and legal debate of these conditions at an international level. Finally, the third concerns the wealth prospects, proposed, in France, by the circular letter dated May 3, 2002.

Coma↗
PubMed1997

Localised proton MR spectroscopy of brain metabolism changes in vegetative patients.

We examined 14 vegetative brain-injured patients with proton magnetic resonance single-volume spectroscopy (1H MRS) at 1.5 T to establish whether there were changes in relative concentrations of N-acetyl aspartate (NAA), choline (Cho) and creatine (CR) metabolites from those found in healthy brains. Spectra were obtained from two different (2 x 2 x 2 cm) volumes of interest in the left and in the right frontal cortex, normal on MRI. All spectra revealed abnormalities compared with normal spectra obtained from age-matched control subjects. Values outside the normal range for at least one of the metabolite ratios were observed in all patients. Cho/Cr was markedly higher and NAA/Cho and NAA/Cr were markedly lower than in the control subjects. At different times six patients regained awareness and the ability to obey commands, and four were re-examined; changes in metabolite ratios were observed, which were different in individual patients. The NAA/Cho ratio reaches statistical significance in discriminating between the patients with a poor outcome (death or prolonged vegetative state) and those who regained awareness; the dividing line appears to be at a value of about 1.6.

Adolescent↗
PubMedDate not supplied

Recovery of consciousness and life expectancy of children in a vegetative state.

The vegetative state does occur in children and is most commonly due to acquired traumatic and non-traumatic injuries. However, neurometabolic and degenerative diseases, as well as certain developmental brain malformations such as anencephaly, can also cause this condition. There are limited data available in children concerning recovery of consciousness and function from the vegetative state as well as life expectancy. This review concentrates on these issues and is based primarily on the data published in the Multi-Society Task Force Report on PVS which was published in 1994 as well as other epidemiological studies. Children in a vegetative state do have a poor prognosis for recovery of consciousness and function and do have a shortened life expectancy. Further research is needed to better understand what variables might contribute to recovery and what therapies might be of benefit.

Adolescent↗
PubMed2005

The neural correlate of (un)awareness: lessons from the vegetative state.

Consciousness has two main components: wakefulness and awareness. The vegetative state is characterized by wakefulness without awareness. Recent functional neuroimaging results have shown that some parts of the cortex are still functioning in 'vegetative' patients. External stimulation, such as a painful stimulus, still activates 'primary' sensory cortices in these patients but these areas are functionally disconnected from 'higher order' associative areas needed for awareness. Such studies are disentangling the neural correlates of the vegetative state from the minimally conscious state, and have major clinical consequences in addition to empirical importance for the understanding of consciousness.

Agnosia↗
PubMed2005

Filamentary keratopathy as a chronic problem in the long-term care of patients in a vegetative state.

PURPOSE: To emphasize that filamentary keratopathy may occur in the long-term care of patients in a vegetative state. METHODS: Clinical observation of 2 young patients who had survived 16 and 8(1/2) years, respectively, in a vegetative state after an acute traumatic brain accident. Interventions were analyzed against the background of the different speculations about the relationship between filamentary keratopathy and the vegetative state. RESULTS: Both patients' medical records registered 36 and 24 episodes of "a red eye," respectively, which in most cases were due to filamentary keratopathy. The episodes lasted 1-5(1/2) months, despite lubrication, removal of filaments, and regular application of corticoid ointment. The longest remission occurred when the eyes were frequently opened, and no topical medications were applied. This experience supports the hypothesis that prolonged eyelid closure is more likely related to filamentary keratopathy in these patients, more so than a moistening disturbance. CONCLUSIONS: Filamentary keratopathy can be a chronic problem in the long-term course of a patient in a vegetative state with remissions and exacerbations. These cases substantiate a relationship, although the precise mechanism is speculative. The incidence and effective treatment await further reports.

Adult↗
PubMedDate not supplied

Bispectral analysis of electroencephalogram signals during recovery from coma: preliminary findings.

The aim of this study was to investigate the accuracy of bispectral index (BIS), spectral edge frequency (SEF 95%), total power (TOTPOW) and frontal spontaneous electromyography (F-EMG) in monitoring consciousness in severely brain damaged patients. In 29 patients a total of 106 sedation-free and good quality EEG epochs were correlated with the level of consciousness as assessed by means of the Glasgow Liège Scale (GLS) and the Wessex Head Injury Matrix (WHIM). The strongest correlation with behavioural measures of consciousness was observed with BIS recordings. An empirically defined BIS cut-off value of 50 differentiated unconscious patients (coma or vegetative state) from conscious patients (minimally conscious state or emergence from minimally conscious state) with a sensitivity of 75% and specificity of 75%. These preliminary findings are encouraging in the search for electrophysiological correlates of consciousness in severe acute brain damage.

Acute Disease↗
PubMed2002

Agitation assessment in severe traumatic brain injury: methodological and clinical issues.

The aim of this single case study was to evaluate the applicability of a graphic and statistical time-series analyses in the observation of an agitation disturbance in a 16-year-old patient who had sustained a severe traumatic brain injury. The agitation was measured using the Agitated Behaviour Scale. The experimental model was of the A-B type: phase A corresponded to the period of vegetative state, and phase B to the period following the reawakening from coma. The data were submitted to visual and statistical analysis by the split-middle trend line method, function of autocorrelation, and C statistic. The results show the different nature and frequency of the agitated behaviour during the vegetative state and after reawakening from coma. The application of a statistical analysis to establish whether the behavioural disturbance is random or a response to the environment allows the adoption of specific and potentially more efficacious treatments.

Adolescent↗
PubMed2004

Diffusion-weighted MRI during early global cerebral hypoxia: a predictor for clinical outcome?

OBJECTIVES: As prognostic assessment of prolonged cerebral hypoxia is often difficult on clinical grounds, a tool for an early prognosis of clinical outcome is desirable. PATIENTS AND METHODS: In a prospective study, we investigated the prognostic value of diffusion-weighted MRI (DWI) in 12 patients within 36 h after global cerebral hypoxia. Results of DWI including apparent diffusion coefficient maps (ADC) were analyzed and related to the clinical outcome after 6 months, in comparison with conventional magnetic resonance imaging (cMRI). RESULTS: Three patients with a short resuscitation time showed normal findings in cMRI and DWI and a good recovery. In seven patients, DWI revealed multiple large hyperintense areas although cMRI was normal. In two patients, large diffuse lesions were observed in DWI which were also found in cMRI. All of these nine patients developed a vegetative state in the follow-up examination. CONCLUSION: Pathological DWI during the early phase after cerebral hypoxia might be superior to cMRI as a predictor of a worse clinical outcome.

Adult↗
PubMed2000

Ethical issues in gestational surrogacy.

The introduction of contraceptive technologies has resulted in the separation of sex and procreation. The introduction of new reproductive technologies (mainly IVF and embryo transfer) has led not only to the separation of procreation and sex, but also to the redefinition of the terms mother and family. For the purpose of this essay, I will distinguish between: 1. the genetic mother--the donor of the egg; 2. the gestational mother--she who bears and gives birth to the baby; 3. the social mother--the woman who raises the child. This essay will deal only with the form of gestational surrogacy in which the genetic parents intend to be the social parents, and the surrogate mother has no genetic relationship to the child she bears and delivers. I will raise questions regarding medical ethical aspects of surrogacy and the obligation(s) of the physician(s) to the parties involved. I will argue that the gestational surrogate is "a womb to rent," that there is great similarity between gestational commercial surrogacy and organ transplant marketing. Furthermore, despite claims to freedom of choice and free marketing, I will claim that gestational surrogacy is a form of prostitution and slavery, exploitation of the poor and needy by those who are better off. The right to be a parent, although not constitutional, is intuitive and deeply rooted. However, the issue remains whether this right overrules all other rights, and at what price to the parties involved. I will finally raise the following provocative question to society: In the interim period between today's limited technology and tomorrow's extra-corporeal gestation technology (ectogenesis), should utilizing females in PVS (persistent vehetative state) for gestational surrogacy be socially acceptable/permissible--provided they have left permission in writing?

Depersonalization↗
PubMed2002

A critique of Callahan's utilitarian approach to resource allocation in health care.

The rationale of this article is grounded in the liberal tradition. It places the individual at the center of concern, and attempts to fortify the individual's basic right to health care. Attention is focused on the writings of Daniel Callahan, arguing that his approach is too cold and detached, and that age should not serve as the decisive criterion. The criticism of his views on older patients and on patients in post-coma unawareness (PCU) stems from two different lines of reasoning: the medical and the moral-contractual. From the medical perspective, while age is an important variable in determining a patient's medical condition, there are other--no less important--factors that influence one's health. From the moral-contractual line of reasoning, liberal society should not desert its citizens at the time they need its help most. The age criterion is too simple, too general, too sweeping. It provides too convenient an answer to a tough and troubling question. Similarly, the argument with regard to PCU patients should be qualified, taking into account the age of the patient, the cause of the condition, and the length of time in state of unawareness.

Age Factors↗
PubMed2003

Intrathecal baclofen withdrawal mimicking sepsis.

Baclofen (Lioresal) is a drug of choice to treat spasticity and is increasingly being administered intrathecally via an implantable pump in cases refractory to oral therapy. Emergency physicians will likely treat patients with baclofen withdrawal or overdose as this treatment becomes more widespread. The syndrome of baclofen withdrawal presents with altered mental status, fever, tachycardia, hypertension or hypotension, seizures, and rebound spasticity, and may be fatal if not treated appropriately. Baclofen withdrawal may mimic other diseases including sepsis, meningitis, autonomic dysreflexia, malignant hyperthermia, or neuroleptic malignant syndrome. Treatment consists of supportive care, reinstitution of baclofen, benzodiazepines, and diagnosis and eventual repair of intrathecal pump and catheter malfunction.

Baclofen↗
PubMed2001

Pearls and pitfalls of ethical issues in neurology.

The growth of bioethics as a practical, meaningful player in the arena of health care has paralleled that of clinical neurology not only in time but also in interaction between the two disciplines. Almost every advance in neurology has spawned an ethical dilemma, the unraveling of which has brought new insights to both fields of endeavor. The myriad ways in which this parallel growth has touched one clinical neurologist, the persons with whom he has been privileged to work, and those for whom they have cared is offered in reflection on the meaning of ethics, the essence of concepts such as "brain death," the pain of truth telling, the complexity of informed consent, the societal dimension of the "vegetative state," and finally, even the business of medicine. Should readers not find any pearls of wisdom in this offering, the author can at least hope it will prevent them from falling into the same pits.

Anecdotes as Topic↗
PubMed2005

DBS therapy for the vegetative state and minimally conscious state.

Twenty-one cases of a vegetative state (VS) and 5 cases of a minimally conscious state (MCS) caused by various kinds of brain damage were evaluated neurologically and electrophysiologically at 3 months after brain injury. These cases were treated by deep brain stimulation (DBS) therapy, and followed up for over 10 years. The mesencephalic reticular formation was selected as a target in 2 cases of VS, and the CM-pf complex was selected as a target in the other 19 cases of VS and 5 cases of MCS. Eight of the 21 patients emerged from the VS, and became able to obey verbal commands. However, they remained in a bedridden state except for 1 case. Four of the 5 MCS patients emerged from the bedridden state, and were able to enjoy their life in their own home. DBS therapy may be useful for allowing patients to emerge from the VS, if the candidates are selected according to appropriate neurophysiological criteria. Also, a special neurorehabilitation system may be necessary for emergence from the bedridden state in the treatment of VS patients. Further, DBS therapy is useful in MCS patients to achieve consistent discernible behavioral evidence of consciousness, and emergence from the bedridden state.

Adolescent↗
PubMedDate not supplied

[Pontine myelinolysis after a hypoglycemic episode].

A case of central pontine myelinolysis following hypoglycemia is reported. The case was a 26- year-old female. Diabetes mellitus was found when she was 8 years old and she has hypertension and renal failure. She suffered a severe hypoglycemia at an unknown time. After the episode she developed a vegetative state. A magnetic resonance scan showed features consistent with the presence of central pontine myelinolysis.

Adult↗