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We used functional magnetic resonance imaging to demonstrate preserved conscious awareness in a patient fulfilling the criteria for a diagnosis of vegetative state. When asked to imagine playing tennis or moving around her home, the patient activated predicted cortical areas in a manner indistinguishable from that of healthy volunteers.
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We proposed neurological diagnostic criteria and new scoring system for the vegetative state (VS). According to these criteria and scoring system, we examined the effects of hyperbaric oxygen (HBO) treatment in 130 cases of VS. As compared with non-HBO treatment, HBO treated patients showed statistically significant recovery from VS.
The aim of this study was to look for the presence of spindling in the different stages of remission of the vegetative state to underline all possible correlations with lesional sites, severity of coma and final outcome. The nocturnal polygraphic recordings from 30 patients were examined: 20 (15M, 5F, mean age 31.7 years, range 16-41) had originally suffered a traumatic brain injury, 10 (4M, 6F, mean age 40.5 years, range 24-48) had hypoxic brain lesions. Evidence of spindling, always reduced in density and duration, was found in 44% of these patients, prevalently in the traumatic patients (53.3% versus 30% of hypoxic patients). No subjects in the full stage 0, 0-1 of the vegetative state (apallic syndrome) presented spindling. No significant correlation was found between spindling and the following parameters: gender, the time between the onset of coma and the polygraphic recording, or the site of the lesion.
The integrative approach to vegetative state remains a challenge. In this article we have presented the evidence for conventional and alternative therapies that can be applied to this condition. Some are intended to support the patient and prevent complications; others enhance the ability of relatives to interact with their loved ones; while others are intended to shorten the vegetative state period. The approaches we reviewed were based on availability of data on MEDLINE and/or their potential to broaden our conceptual approach to vegetative state. Some approaches highlighted within the article including nutritional support, acupuncture, and homeopathy, seem to have a reasonable risk/benefit ratio. Yet, the complexity of vegetative state makes it challenging to recommend an integrative protocol. Rather we recommend an individualized approach, based on patient co-morbidities, caregiver and health professional preferences, and availability of therapists. Other approaches, including herbal medicine, mind-body therapies, intercessory prayer, energy medicine, and shamanism were not included due to the lack of available information and evidence. We acknowledge that a lack of evidence for efficacy is not equivalent to evidence for a lack of efficacy. Further research is critically needed to advance our treatment approach to this challenging state. Vegetative state is a condition that continues to humble the medical world. What we do not know eclipses that which we know. The critical question of what the vegetative state patient experiences continues to mystify us. Our philosophical stance insists that we treat the patient as one who is aware. Simultaneously we struggle with what, if anything, we can successfully do to "reawaken" the patient.
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A detailed neuropathological study was undertaken of the brains of patients who had been assessed clinically as vegetative after blunt head injury. There were 35 cases, (33 male; median age 38 years) with a survival of 6.5-19 months (median 9): 17 were injured in a road traffic accident, 9 after assault and 6 after a fall; 3 were recorded as having had a lucid interval. There was an intracranial hematoma in 9 and the median contusion index was 4; raised intracranial pressure was identified in 25, grades 2 and 3 diffuse traumatic axonal injury was present in 25, ischemic damage in 15 and hydrocephalus in 27. Thalamic and hippocampal damage was present in 28 and stereological studies revealed a differential loss of neurons in three principal nuclei of the thalamus and in different sectors of the hippocampus. Immunohistochemistry provided evidence of an inflammatory reaction and in situ DNA fragmentation, features that are strongly indicative of a continuing neuronal loss in subcortical gray matter. These findings provide evidence for the importance of diffuse brain damage to white matter as the structural basis of the vegetative state after blunt head injury with contributions from neuronal loss in the thalami and the hippocampus. Although amyloid plaques and tau inclusions were identified in some, their contribution did not seem important in the ultimate clinical outcome.
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"Cognitive" auditory event-related potentials (ERPs) were mapped to examine the putative conscious responsiveness of eight patients in a postcoma unawareness (PCU) state and of eight matched normal controls. A "passive P3" paradigm was used to evaluate waves N2, P3, and Slow Waves of the ERPs. Results showed that the signal/noise ratio of the patients' waveshapes was poorer than that of the controls. Yet, on the whole, no between-group significant differences were noted for most of the averaged characteristics of the waves. In general, in the patients, the left hemisphere was dominated by negative potentials relative to the right one, whereas in the controls, the opposite asymmetry was apparent. Thirty-eight percent of the patients had passive N2 and P3 waves, and 67% of the responders regained consciousness (versus none of the non-responders). These findings suggest that the presence of intact "cognitive" waves is compatible with a higher probability for improvement, although nondetection of certain waves at the postcoma unawareness state does not necessarily indicate the worst prognosis.
The minimally conscious state (MCS) defines a functional level of recovery following severe brain injuries. Patients in MCS demonstrate unequivocal evidence of response to their environment yet fail to recover the ability to communicate. Drawing on recent functional brain-imaging studies, pathological data, and neurophysiological investigations, models of brain function in MCS are proposed. MCS models are compared and contrasted with models of the vegetative state (VS), a condition characterized by wakeful appearance and unconsciousness. VS reflects a total loss of cognitive function and failure to recover basic aspects of the normal physiologic brain state associated with wakefulness. MCS may represent a recovery of the minimal dynamic architecture required to organize behavioral sets and respond to sensory stimuli. Several pathophysiological mechanisms that might limit further recovery in MCS patients are considered. Implications for future research directions and possible therapeutic strategies are reviewed.
The neuropathology of the vegetative (VS) and minimally conscious (MCS) states and the pathophysiology of spasticity are reviewed. Current treatment options available in the physical management of children in a low-level state and factors influencing the physiotherapy treatment of children in a low-level state will be discussed. The complex neuropathology of VS and MCS helps to explain the varied clinical presentations of children in VS and MCS. Spasticity and muscle contracture are common motor sequelae of VS and MCS. Loss of inhibition by descending motor pathways is thought to result in increased muscle tone or spasticity. However, secondary changes in muscle fibre structure and periarticular connective tissue may be an additional component to increased muscle tone. A multimodal approach combining physical, pharmacological and surgical interventions is likely to be the most effective. Knowledge of the likelihood of recovery from VS and MCS can be helpful in determining the frequency and intensity of physiotherapy. Ethical issues in the management of children in a low-level state include a consideration of the benefits to the child and the child's family and the costs to the health care team and the medical institution.
H(2)(15)O-PET was used to investigate changes in regional cerebral blood flow in response to auditory stimulation in patients in the vegetative state. Five patients in a vegetative state of hypoxic origin were compared with 18 age-matched controls. In addition, the cerebral metabolism of these patients and 53 age-matched controls was studied using [(18)F]fluorodeoxyglucose. In control subjects, auditory click stimuli activated bilateral auditory cortices [Brodmann areas (BA) 41 and 42] and the contralateral auditory association cortices (BA 22). In the patients, although resting metabolism was decreased to 61% of normal values, bilateral auditory areas 41 and 42 showed activation as seen in the controls, but the temporoparietal junction cortex (BA 22) failed to be activated. Moreover, the auditory association cortex was functionally disconnected from the posterior parietal association area (BA 40), the anterior cingulate cortex (BA 24) and the hippocampus, as revealed by psychophysiological interaction analysis. Thus, despite altered resting metabolism, the auditory primary cortices were still activated during external stimulation, whereas hierarchically higher-order multi- modal association areas were not. Such a cascade of functional disconnections along the auditory cortical pathways, from the primary auditory areas to multimodal and limbic areas, suggests that the residual cortical processing observed in the vegetative state cannot lead to the integrative processes that are thought to be necessary for the attainment of the normal level of awareness.
Fat embolism syndrome is a dire complication of long bone trauma. It is usually associated with neurological, hematological and respiratory involvement, the latter being the major cause of death. We present a case of severe fat embolism syndrome occurring 3 hours after a long bone injury, leading to permanent vegetative state and death without any respiratory signs. The diagnosis was confirmed by cytology of the bronchoalveolar lavage fluid. Clinical presentation of the puzzling fat embolism syndrome and diagnostic tests in suspected fat embolism syndrome are reviewed.
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The tragic circumstances surrounding the death of Theresa Marie Schiavo have reignited discussion regarding end-of-life decisionmaking. In this Article, the author examines the current legal and ethical environment surrounding the decision to end life-sustaining treatment. Starting with the New Jersey Supreme Court's decision in In re Quinlan, the author discusses how such important issues as who should be the surrogate decisionmaker, attitudes towards artificial nutrition and dehydration, and difficulties in defining medical futility. Looking through a post-Schiavo lens, the Article examines state law addressing these issues and how these choices may be reexamined in the coming years.