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PubMed2006

Functional neuroimaging applications for assessment and rehabilitation planning in patients with disorders of consciousness.

OBJECTIVE: To describe the theoretic framework, design, and potential clinical applications of functional neuroimaging protocols in patients with disorders of consciousness. DATA SOURCES: Recent published literature and authors' own work. STUDY SELECTION: Studies using functional neuroimaging techniques to investigate cognitive processing in patients diagnosed with vegetative and minimally conscious state. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Positron-emission tomography activation studies suggest that the vegetative state represents a global disconnection syndrome in which higher order association cortices are functionally disconnected from primary cortical areas. In contrast, patterns of activation in functional magnetic resonance imaging studies of patients in the minimally conscious state show preservation of large-scale cortical networks associated with language and visual processing. CONCLUSIONS: Novel applications of functional neuroimaging in patients with disorders of consciousness may aid in differential diagnosis, prognostic assessment and identification of pathophysiologic mechanisms. Improvements in patient characterization may, in turn, provide new opportunities for restoration of function through interventional neuromodulation.

Auditory Perception↗
PubMed2002

[Intervened death: from brain death to withholding or withdrawal of life-sustaining treatment].

The concept of intervened death accounts for all those situations in which the withholding or withdrawal of life-sustaining treatment constitutes a limit to therapeutic action associated to the occurrence of the traditional cardio-respiratory death. The 1968 Harvard Report advanced a new definition of death through the concept of complete cessation of global brain functions and, more than thirty years later, this process of intervention in its diagnosis may be seen as a continuum link to the need to procure organs for transplant purposes and the need to avoid long agonies in unrecoverable patients. During the last decade, the ethical admissibility of withdrawing ordinary and advanced life-sustaining therapy in cases that do not amount to brain death diagnosis--such as vegetative states and other irreversible clinical situations--and even the advances made for purposes of obtaining organs for transplant purposes in these situations (with the explicit authorization of the donor or his/her representative) allows a joint interpretation of these situations through the acceptance that limits may be established in medical assistance. Reflection on intervened death as an emerging phenomenon of our culture is mandatory so that society may get involved in an issue of its absolute and exclusive interest.

Brain Death↗
PubMed2006

[Evaluation of the functional brain state in comatose children].

This article reviews scientific literature data of the last decade and analyses the possibilities to evaluate functional brain state in comatose children. Observations after the development of coma, its short-term and long-term outcomes show that when duration of coma is over 30 days, the chances to regain consciousness and autonomy are decreased. Coma of hypoxic origin has more complicated course, and its prognosis is worse compared to the one of a traumatic origin. Vegetative condition is observed more frequently as a consequence of hypoxic brain damage. Survival in vegetative condition without recovery of consciousness raises medical, psychological, social, and patient care problems. The article reviews different methodical approaches for the evaluation of functional brain state. Various methods of brain bioelectric evaluation are analyzed, including routine and qualitative methods of electroencephalography, possibilities of its spectral analysis and evoked potentials of various types. The results of the observation that evaluate the changes of brain structure and neurophysiological parameters are reviewed. The analysis of 48 articles draws a conclusion that the most objective criteria for evaluation the prognosis of coma can be achieved while following the clinical condition of the patient in parallel with the brain neuroimaging studies and evaluation of neurophysiological parameters, such as electroencephalography spectral analysis and evoked potentials of brainstem and cortex. The best evaluation of the functional brain state and prognosis of coma can be achieved with repeatable investigations during coma development and comparison of the results of several parameters.

Age Factors↗
PubMed2004

The papal allocution on caring for persons in a "vegetative state".

On March 20, 2004, Pope John Paul II issued a statement to the International Conference on "Life Sustaining Treatments and Vegetative State: Scientific and Ethical Dilemmas" on the provision of food and water to patients in a "vegetative state." The purpose of this allocution was to promote and protect the dignity of patients, even when they are in a seriously ill and disabled state. To promote the dignity of these patients, the Pope explicitly stated that "quality of life judgments" were not to be applied to the administration of nutrition and fluids. The Holy Father made it clear that he was avoiding any position that could be construed as tolerating, permitting, or promoting euthanasia by omission. His statement sought to prevent Catholics and Catholic health care facilities from becoming involved in euthanasia by omission that has become a fast-growing threat.

Catholicism↗
PubMed1996

Post-traumatic apallic syndrome following head injury. Part 2: Treatment.

There is no doubt that vegetative patients need the appropriate medical and nursing procedures as well as family involvement, education and counselling. Additional structured stimulation programmes are used for the treatment of coma and vegetative state. The theoretical foundation is derived from animal studies. The relevance of the results for the rehabilitation of head-injured human patients remains questionable, because all animal studies involve the use of cerebral lesions different from those found in human head-injured patients. The studies of human sensory stimulation give more an orientation than a definitive statement. Very recently, hypotheses concerning sensory regulation have begun to be evaluated. Further investigations are required to provide a more definite conclusion.

Animals↗
PubMed2005

Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes.

OBJECTIVES: To establish the prevalence of vegetative state in Dutch nursing homes, describe the patient characteristics, and highlight the possible influence of medical decisions at the end of life. DESIGN: A cross-sectional survey. The vegetative state was defined according to the Multi Society Task Force on PVS. All Dutch nursing homes were approached to provide data on patients in a vegetative state. In cases of doubt, the researcher discussed the diagnosis with the patient's physician and, if necessary, examined the patient. Information on patients in a vegetative state in care between 2000 and September 2003 and end of life decisions for them were also recorded. RESULTS: All nursing homes and physicians participated. After assessment of 12 doubtful patients, 32 met the criteria of vegetative state lasting longer than one month, a prevalence of 2/1,000,000. Of these, 30 patients' data were analysed: age 9-90 years; 73% female; duration of vegetative state 2 months-20 years (26 surviving >1 year, 13 >5 years). Stroke was the commonest cause. Between 2000 and September 2003, there were 76 patients in a vegetative state in care of whom 34 died of complications and nine after withdrawal of artificial nutrition and hydration. CONCLUSIONS: The prevalence of vegetative state in Dutch nursing homes has been established for the first time. The figures are lower than suggested in the literature. The study included a heterogeneous group of patients, of which a substantial number survived for many years. The results cannot be explained by a policy of systematically withdrawing artificial nutrition and hydration.

Adolescent↗
PubMedDate not supplied

Sleep in the last remission stages of vegetative state of traumatic nature.

Polygraphic studies were carried out on 20 patients (13 male, 7 female, average age 25.3 years) in the last remission stages of a traumatically caused vegetative state (apallic syndrome: stages V-VIII according to Gerstenbrand's classification). The presence of all the stages of NREM and REM sleep was observed in all patients, as was typical spindling activity. With respect to patients in the first remission stages of vegetative state, the total sleep time (TST) was seen to increase as a percentage of the total time in bed (95%) and with respect to TST, the periods of waking after a period of sleep diminished (wake after sleep onset: 9.73%). Stage I decreased (10.39%), while stages II-III-IV increased (32.36%, 4.29% and 6.04% respectively). There was a clear increase in the REM percentage (37.19%); spindling rate and index both increased (4.9/min and 12.1 respectively).

Action Potentials↗
PubMed2003

Outcome of prolonged coma following severe traumatic brain injury.

PRIMARY OBJECTIVE: To assess the outcome of severe traumatic brain injury 1 year after trauma. RESEARCH DESIGN: Prospective study conducted at the neurosurgical department of a university hospital. METHODS AND PROCEDURES: A total of 24 patients were included. Outcome was assessed by means of Glasgow outcome scale, Barthel index, Functional independence measure (FIM) and Disability rating scale (DRS). Need of care and job ability were also evaluated. EXPERIMENTAL INTERVENTIONS: Patients received multimodal early-onset stimulation and continuous inpatient and outpatient rehabilitation therapy. MAIN OUTCOMES AND RESULTS: Six patients died, three remained in a vegetative state, six were severely disabled, six were moderately disabled and three achieved a good recovery 1 year after injury. Mean Barthel index was 68.9, mean FIM was 88.3 and mean DRS 27.7. The majority of patients still were at least intermittently dependent on care. Most of the trauma survivors were unable to work. CONCLUSIONS: Despite intensive rehabilitation treatment, severe traumatic brain injury is still burdened with significant mortality and morbidity.

Adolescent↗
PubMed1996

Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit.

OBJECTIVE: To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics. DESIGN: Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments. SETTING: 20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state. SUBJECTS: 40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state. OUTCOME MEASURES: Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer. RESULTS: Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues-some to a high level. CONCLUSIONS: The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding.

Awareness↗
PubMedDate not supplied

Incidence and prevalence of the vegetative and minimally conscious states.

The methodological difficulties of obtaining accurate epidemiological data for vegetative state (VS) and minimally conscious state (MCS) are considered, and prompt the conclusion that published data are of uncertain validity, partly due to variation in the criteria for diagnosis. On the basis of these data, incidence of VS continuing for at least six months arises at a rate of between 5 and 25 per million population (PMP). The prevalence of VS in adults in the US is between 40 and 168 PMP, and may be lower in the UK, but precise figures are not available. The incidence and prevalence of MCS have yet to be established.

Humans↗
PubMed2006

Theresa Marie Schiavo's long road to peace.

The death of Theresa Marie Schiavo came about only after almost 7 years of argument among her family members. Her husband, Michael Schiavo, was convinced that she would have refused the medically supplied nutrition and hydration maintaining her life. Her parents, Robert and Mary Schindler, and her siblings were equally convinced that her condition was not so hopeless that she would have chosen to refuse treatment. The result was a bitter battle reaching through state and federal court systems, legislatures, and chief executives' offices. This article provides introductory factual background for the articles that discuss the Schiavo case in this special issue of Death Studies.

Adult↗
PubMed2003

Adult survivors of severe cerebral hypoxia--case series survey and comparative analysis.

Over 16 years, Wilson [31] saw and assessed 567 patients, 18 (3.2%) had a primary diagnosis of cerebral hypoxia. The present patient survey includes all referrals for assessment, management/advice and neuropsychological rehabilitation to a part-time clinical neuropsychology service, who were seen by the first author over a five year period (October 1995-2000). Of the total patient sample (n = 168), 13 (7.7%) had incurred hypoxic damage from a variety of causes; [3] carbon monoxide poisoning (smoke inhalation), [3] cardiac arrest, [1] accidental alcohol and drug overdose, [1] near (partial) drowning, [1] near hanging (suffocation), [2] respiratory arrest following prolonged status epilepticus, [1] respiratory arrest following severe pneumonia and [1] following Addisonian crisis. The survey includes a sub-group of patients in vegetative and minimally responsive states on referral. Wilson [31] highlighted that considerable variation in cognitive functioning is likely to be observed depending on (a) nature or cause of the hypoxic insult and (b) the degree of anoxia/hypoxia experienced itself. The results of the present survey when compared with Wilson's earlier work provide a larger total data-set from which to draw conclusions and has implications for practitioners who see such patients and are involved in their multidisciplinary management and rehabilitation.

Adult↗
PubMed2000

Subacute central nervous system degeneration in a child: an unusual manifestation of ifosfamide intoxication.

A 5-year-old child with desmoplastic small round-cell tumor was treated with a protocol of very-high-dose, short-term chemotherapy, containing HD-CAV (cyclophosphamide, doxorubicin, vincristine, and mesna), ifosfamide, and etoposide. Two days after the initiation of ifosfamide, he exhibited new-onset lethal encephalopathy manifested by subacutely progressive cerebellar and then temporal and frontocortical degeneration leading to a vegetative state and eventually to death. A full work-up, including brain biopsy, was negative, excluding infections and metabolic or vascular causes. Ifosfamide is known to be capable of causing acute encephalopathy that can be severe but is generally reversible. This child showed a very atypical progressive, lethal course of ifosfamide toxicity. The possibility of this complication should be considered when high-dose ifosfamide treatment is planned for children.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

[The P300 component of the auditory evoked potential in the posttraumatic vegetative state].

The dynamic studies of P300 component of the acoustic evoked potential were conducted in 12 patients in posttraumatic state of the autonomic system. The amplitude and time parameters of P300 were analyzed, its spatial distribution over the cortex, and features of generation. The obtained results were compared with the normative data. Significant changes in P300 in comparison with the normal characteristics were revealed in patients with the absence of conscious mental activity. These changes were maximally expressed when the state of patients was irreversible. In case of patients' outcome from the studied state the amplitude-temporal and topographic response characteristics tended to normalization but did not reach it completely. The obtained results allow us to consider the P300 component as one of the most informative indices in consciousness recovery after severe brain injury.

Adolescent↗
PubMed2006

How should functional imaging of patients with disorders of consciousness contribute to their clinical rehabilitation needs?

PURPOSE OF REVIEW: We discuss the problems of evidence-based neurorehabilitation in disorders of consciousness, and recent functional neuroimaging data obtained in the vegetative state and minimally conscious state. RECENT FINDINGS: Published data are insufficient to make recommendations for or against any of the neurorehabilitative treatments in vegetative state and minimally conscious state patients. Electrophysiological and functional imaging studies have been shown to be useful in measuring residual brain function in noncommunicative brain-damaged patients. Despite the fact that such studies could in principle allow an objective quantification of the putative cerebral effect of rehabilitative treatment in the vegetative state and minimally conscious state, they have so far not been used in this context. SUMMARY: Without controlled studies and careful patient selection criteria it will not be possible to evaluate the potential of therapeutic interventions in disorders of consciousness. There also is a need to elucidate the neurophysiological effects of such treatments. Integration of multimodal neuroimaging techniques should eventually improve our ability to disentangle differences in outcome on the basis of underlying mechanisms and better guide our therapeutic options in the challenging patient populations encountered following severe acute brain damage.

Brain↗
PubMedDate not supplied

The vegetative and minimally conscious states: current knowledge and remaining questions.

In the last 2 decades, the minimally conscious state has been distinguished conceptually from the vegetative state and operational criteria for these diagnoses have been published. Standardized and individualized assessment tools have been developed to assist with the diagnosis of severe disorders of consciousness and the measurement of clinical improvement. The natural course of recovery and the importance of key prognostic predictors have been elucidated. Important advances have also been made in defining the similarities and differences in the pathophysiology of these two states, and functional imaging modalities have begun to explicate the neural substrate underlying the behavioral features of these disorders. Research on the efficacy of treatments for severe disorders of consciousness lags behind, due to the practical and ethical difficulties in executing large rigorously controlled clinical trials. The past and future scientific developments in this area provide an important background for continuing discussions of the ethical controversies surrounding end-of-life decision making and resource allocation.

Brain↗