SEARCH · PubMed Health

Results for “Persistent Vegetative State”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 901 records · Page 50Linked to original sources

PubMedDate not supplied

[Vegetative states: a syndrome in search of a new name].

OBJECTIVES: 1. To critically analyze the concept of 'vegetative' state and a number of reasons that seem to justify the abandonment of this term. 2. To propose a new conceptual approach to the syndrome and, based on this approach, a new terminology. DEVELOPMENT: The concept of 'vegetative' state became popular in the medical literature, in the context of a 'neocorticalist' theory of consciousness. Its clear-cut simplicity and the prestige of its proponents contributed to this acceptance. However, this concept seems to be neurologically and philosophically inappropriate. In addition, in recent years a number of studies have shown that these states are frequently misdiagnosed, due mainly to their inherent complexity. Thus, the need for a new name for this syndrome has become increasingly evident. A conceptualization of the brain global functioning leads to a redefinition of these states. The 'syndrome of brain dismetafunction' is conceptually defined. This term does not have a pejorative connotation. It respects the inherent uncertainty associated to the subjective dimension of consciousness as well as to the prognosis of these states. It promotes an integrative approach to problems related to the diagnosis, treatment, and rehabilitation of these patients. CONCLUSION: It seems pertinent to propose the abandonment of the term 'vegetative' both as conceptually equivocal and as a term that may become a self-fulfilling prophecy. Moreover, a no less important reason to abandon this qualifier is the possibility of a more coherent conceptualization of this syndrome. As a consequence, this approach leads to a new terminology.

Humans↗

PubMed2004

The withdrawal of nutrition and hydration in the vegetative state patient: societal dimension and issues at stake for the medical profession.

The withdrawal of assisted nutrition and hydration (ANH) is increasingly supported by scientific societies, by hospitals and by some families, once the condition of vegetative state could be considered permanent. In the first part of this article, the authors present the factors used to support the decision to withdraw ANH: a) the prognostic evaluation about outcome transformed into a clinical diagnosis of permanency; b) basic health care transformed into a medical treatment, subject to refusal by the patient; c) the human life (an undisposable good) transformed into a disposable one, open to decisions made by surrogates; d) the evaluations about quality of life transformed into judgments about the indignity of human life to be lived. In the second part, the authors outline the changes that this attitude can provoke in the integrity and the juridical status of the medical and nursing professions, and its potential impact on the society at large.

Attitude to Death↗

PubMed1994

[Prognostic factors of post-traumatic vegetative states: 522 cases].

Long-term prognosis of post-traumatic vegetative state (VS) remains poorly defined. Three kinds of data have been collected for 522 patients in VS 1 month after head injury: pre-traumatic data; early data, collected during the first two weeks after trauma; late data, collected one month or more after trauma. Statistical relationships have been searched for, between these data and outcome one year after trauma, according to the Glasgow Outcome Scale. Some late data appear as essential prognostic factors of VS: threat blink; complications; ventricular dilatation; motor score (Glasgow Coma Score); spontaneous eye movements. Pretraumatic data then take place: age; previous deficiencies. Other data (especially early data) seem to have a weaker influence or outcome.

Adolescent↗

PubMed2005

International differences in end-of-life attitudes in the intensive care unit: results of a survey.

BACKGROUND: Important international differences exist in attitudes toward end-of-life issues in the intensive care unit. METHODS: A simple questionnaire survey was sent by e-mail to participants at an international meeting on intensive care medicine. Respondents were asked to choose 1 of 3 to 5 possible answers for each of 4 questions related to the treatment of a hypothetical patient in a vegetative state due to anoxic encephalopathy after cardiac arrest with no family and no advance directives. RESULTS: From 3494 valid addresses, 1961 complete questionnaires (56%) were received from 21 countries. Sixty-two percent of physicians from Northern and Central Europe said they involved nurses in end-of-life discussions compared with only 32% of physicians in Southern Europe, 38% in Brazil, 39% in Japan, and 29% in the United States (P<.001 for all comparisons). Written do-not-resuscitate orders were preferred in Northern and Central Europe, whereas oral orders took preference in Southern Europe, Turkey, and Brazil. One third of Japanese physicians said that they would not apply do-not-resuscitate orders. Most participants from Japan, Turkey, the United States, Southern Europe, and Brazil chose to treat the hypothetical patient with antibiotics if he/she developed septic shock, whereas in Northern Europe, Central Europe, Canada, and Australia, terminal withdrawal of mechanical ventilation and extubation were the more commonly chosen responses. CONCLUSIONS: In countries where intensive care medicine is relatively well developed, considerable differences remain in physicians' attitudes toward end-of-life care in the intensive care unit. Substantial work remains if an international consensus on these issues is to be reached.

Attitude to Death↗

PubMed2006

Tracking the recovery of consciousness from coma.

Predicting the chances of recovery of consciousness and communication in patients who survive their coma but transit in a vegetative state or minimally conscious state (MCS) remains a major challenge for their medical caregivers. Very few studies have examined the slow neuronal changes underlying functional recovery of consciousness from severe chronic brain damage. A case study in this issue of the JCI reports an extraordinary recovery of functional verbal communication and motor function in a patient who remained in MCS for 19 years (see the related article beginning on page 2005). Diffusion tensor MRI showed increased fractional anisotropy (assumed to reflect myelinated fiber density) in posteromedial cortices, encompassing cuneus and precuneus. These same areas showed increased glucose metabolism as studied by PET scanning, likely reflecting the neuronal regrowth paralleling the patient's clinical recovery. This case shows that old dogmas need to be oppugned, as recovery with meaningful reduction in disability continued in this case for nearly 2 decades after extremely severe traumatic brain injury.

Coma↗

PubMed2006

Affirming the right to care, preserving the right to die: disorders of consciousness and neuroethics after Schiavo.

In this article, I attempt to untangle some of the cultural, philosophical, and ethical currents that informed the Schiavo case. My objective is to better apprehend what the Schiavo case means for end-of-life care in general and to assert that our discourse about the ethical issues attendant to brain injury will be impoverished if we limit our discussions about disorders of consciousness solely to the vegetative state. If we ignore emerging developments in neuroscience that are helping to elucidate the nature of these disorders and fail to broaden the conversation about brain injury, beyond the unmitigated futility of the permanent vegetative state, we will imperil others who might improve and be helped. Through such efforts we can help mitigate the tragedy of the Schiavo case and overcome the rhetoric that marked the national discourse in March 2005. Once the complexity of disorders of consciousness is appreciated, rhetorical statements about a right to die or a right to life are exposed as being incompatible with the challenge of providing care to such patients. This is especially true as neuroscience brings greater diagnostic refinement to their assessment and management, a topic addressed in this article, which specifically focuses on the clinical and ethical implications of the recently described minimally conscious state. Instead of staking out ideological positions that do not meet the needs of patients or families, we should strive to both preserve the right to die for those who are beyond hope while affirming the right to care to those who might benefit from coming advances in neuroscience. If we can achieve that delicate balance, we will be able to transcend the partisan debate that shrouded the life and death of Theresa Marie Schiavo and begin to articulate a palliative neuroethics of care for those touched by severe brain injury and disorders of consciousness.

Brain Damage, Chronic↗

PubMed1993

Is coma morally equivalent to anencephalia?

In this article I contend that the tendency to equate coma with anencephalia is a mistake. A key idea here is that there is a type of "mental-state" predicate that is applicable to the comatose but not to anencephalics. One of the moral implications of this is that the concept of "brain death," its alleged popularity notwithstanding, is badly confused. Also, because anencephalics have no mental life, there are few moral grounds for hesitating to use anencephalics as organ donors.

Anencephaly↗

PubMed1999

Assessment of command-following in minimally conscious brain injured patients.

OBJECTIVE: To develop a method for establishing the presence of command-following in individuals with traumatic brain injury, based on the principles of single-subject experimental design. DESIGN: A series of single-subject experiments, individualized to the particular command-following question about a particular patient. SETTING: An inpatient rehabilitation hospital with a specialized program for vegetative and minimally conscious brain injured patients. PATIENTS: Eight individuals with serious brain injury of traumatic or nontraumatic origin, presenting in vegetative or minimally conscious states. INTERVENTIONS: The frequency of performance of the behavior in question was assessed in response to commands and in relation to appropriate control conditions. Data were analyzed with chi2 or Fisher's exact test, as well as measures derived from signal detection theory. MAIN OUTCOME MEASURES: The frequency of performance of a specific behavior in the presence of a command and in relevant contrasting conditions. RESULTS: This method identified whether a specific behavior was being performed in response to command and whether the reliability of this behavior was changing over time either spontaneously or in response to treatment. CONCLUSIONS: Quantitative assessment of command-following based on principles of single-subject experimental design can determine whether patients are capable of following commands and whether this ability changes over time or in response to treatment.

Adult↗

PubMed1994

Death on neurological grounds.

During centuries, the loss of spontaneous cardio-pulmonary function was found to predict permanent non-functioning of the "organism as a whole", therefore serving adequately as a criterion of death, but during the era of Intensive Care, there was a shift to brain-oriented definitions of death, ie, the irreversible cessation of brain functions, started to be considered as the main reason for cessation of functioning of the "organism as a whole". A concept or definition of death is related to the question: What is it "about human life, which is irreplaceable by any artifice, and that its loss is so essential, that the individual who loses it ought to be called dead?" Further work has been centered on how much of the brain needs to be dead, before a person can be declared dead on neurological grounds: "whole brain", "brainstem death" ("brain as a whole") and "higher brain" formulations of death. These brain-oriented formulations of death are discussed and criticized, with the conclusion that although there is only one function, irreplaceable, which characterizes the human being: the "content" of consciousness, society is not yet prepared to define, diagnose and accept a "content" of consciousness-based standard of death, when this function is lost in isolation in PVS, advanced forms of dementia and anencephalics. I propose a concept of death that excludes those states taking in consideration the basic mechanisms of consciousness generation in human beings: "The irreversible loss of consciousness, considering both its capacity and its content". This definition of human death takes consideration as hallmarks, both components of consciousness which are essentially significant to the nature of man, to provide the functioning of the "organism as a whole".

Brain Death↗

PubMed2002

Critical review of passive muscle stretch: implications for the treatment of children in vegetative and minimally conscious states.

The efficacy of passive muscle stretch in the treatment of children in vegetative (VS) and minimally conscious (MCS) states is reviewed. Seventeen studies are critically reviewed. Study quality was evaluated using a quality filter adapted from Guyatt. Levels of evidence were assigned to each study using criteria based on Sackett's guidelines and a recent adaptation of those guidelines. Based on these levels of evidence, specific recommendations were made. These recommendations were classified as grade A, B, C or D depending on the levels of evidence used to generate them. There is limited evidence to support the efficacy of passive muscle stretch to improve range of motion and reduce spasticity in children in VS and MCS. Caution must be used when interpreting these recommendations because of the limited number of studies available and the extrapolation of study results from a different population. Further research is needed to strengthen these recommendations and establish the efficacy of passive muscle stretch in the treatment of children in VS and MCS.

Child↗

PubMed1996

Relationship between ischemic damage and concentrations of phenytoin and phenobarbital in the brain cortex of epileptic patients in vegetative state at death.

Post-mortem concentrations of phenytoin (PHT) and phenobarbital (PB) were determined by high-performance liquid chromatography in the cortical matter of specified brain regions and in the serum (total and free) from 3 epileptic males in vegetative state and compared to the data of 45 deceased epileptic control patients. The duration of the vegetative state was 12 days, 15 days or about 4 months until death and was associated with corresponding stages of generalized ischemic brain damage. The histological examination was completed by immunohistochemical and morphometric methods. According to other investigators nerve cells are the major binding sites for PHT and PB in the cerebral cortex of rodents. But, in the 3 comatose patients the PHT and PB concentrations of the isocortex and neocerebellum were not significantly decreased in comparison with the control patients despite necrosis and loss of neurons as well as other distinct tissue alterations. The results strongly favor the non-specific binding of PHT and PB to cells and subcellular structures of the brain-mainly based on simple physico-chemical principles.

Adult↗

PubMed2004

Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment.

OBJECTIVE: The goal of the study was to look for the response of treatment with increasing doses of dopaminergic medication on the recovery of vegetative state patients post-TBI. DESIGN: A prospective study of eight patients aged 25-50 years in vegetative state (VS) of mean duration of 104 days following traumatic brain injury (TBI) was performed by investigating changes of their state of consciousness while they were treated with levodopa/carbidopa. RESULTS: Initial improvement was observed in all patients within a mean of 13 days after onset of treatment. Seven patients recovered consciousness after a mean time of 31 days of treatment. The remaining patient showed only slight improvement to minimally conscious state. The sequence of symptoms leading to recovery was the same in all patients; the first to appear was moving a limb on a request, which appeared at a mean time of 13 days. Gradual increase of dose leads to the appearance of better-organized responses like reacting to more than one command, than opening the mouth and appearance of a reciprocal contact. The only side effect was visual hallucinations in one patient, which disappeared after decreasing the dosage. CONCLUSIONS: Clinical awareness to the structured order of responses and to the effect of dosage can help clinicians in early assessment of response to dopaminergic treatment in VS patients.

Adult↗

PubMed2000

'Near PVS': a new medico-legal syndrome?

This paper addresses the current medico-legal issues surrounding PVS (Permanent Vegetative State), including: the lack of a unified definition of the acronym PVS, the varying criteria for diagnosis of PVS, and the issue of patients who maintain a minimal degree of consciousness and cannot be categorized as PVS patients. First, we analyse the differing medical definitions and criteria for diagnosis in vegetative conditions. We also ask what part 'consciousness' plays in treatment decisions made by the family, the healthcare team, and the courts, by analysing a unique Irish case of a patient in a state deemed by the courts as 'near PVS'. The paper demonstrates that there is now a legal dichotomy in vegetative patients. However, the manner in which the court treated these patients is the same. Underlying this discussion we hope to demonstrate how medical practice is subject to legal decisions and thus the importance of establishing uniform medical guidelines to assist the non-medical professional.

Adult↗

PubMed1999

[Disorders of consciousness: the basis for ethical assessment].

During the past few years there is an ethical debate about neurological disease entities that are characterised by a) prolongation of life owing to medical treatment, b) limited chances of cure, and c) impaired to unbearable life quality: akinetic mutism, vegetative state ("Wachkoma", apallic syndrome), and locked-in syndrome. These are compared to typical coma and brain death. According to Gerstenbrand (1967) [34] the vegetative state is differentiated into the transitional state following typical coma, the variations of typical and incomplete vegetative state, the remission state and the "Durchgangssyndrom" (characterized by preserved wakefulness with affective lability, disorientation, and amnesia). With regard to pathogenesis we differentiate posttraumatic and posthypoxic origin and variable lesions in cerebral cortex, thalamus or mesencephalic reticular formation. Uncertainty of prognosis is stressed. In respect of brain death we compare a) neocortical death, b) brain stem death, and c) whole brain death, and discuss problems of difficult delimitation and uncertainty of diagnosis. These syndromes are compared to anencephaly and hydranencephaly. Regarding the locked-in syndrome, typical, incomplete and complete (total) forms are distinguished. The differential diagnosis between the complete locked-in syndrome and brain stem death seems problematic. Difficulties in decisions limiting therapeutic effort stem from a) essentially intuitive judgement about observations, b) variability of syndromes and courses, c) uncertainty of prognosis, and d) differences in understanding and valuation throughout society. Emphasis is on a trustful and open colloquy among the persons concerned.

Brain Death↗

PubMedDate not supplied

Assessing level of consciousness and cognitive changes from vegetative state to full recovery.

Although investigations addressing cognitive recovery from the vegetative state have been reported, to date there have been no detailed studies of these patients combining both neuropsychology and functional imaging to monitor and record the recovery of consciousness. This paper describes the recovery of a specific vegetative state (VS) case. The patient (OG) remained in the vegetative state for approximately two months, increasing her level of awareness to a minimally conscious state, where she continued for approximately 70 days. In the course of the ensuing 18 months, she was able to reach an acceptable level of cognitive functioning, with partial levels of independence. Throughout this two year period, she received continuous cognitive evaluation, for which several different tools were applied including coma and low functioning scales, full cognitive batteries, and structural and functional magnetic resonance imaging (MRI). We present here preliminary data on fMRI using a word presentation paradigm before and after recovery; we also discuss the difficulty of how to determine level of consciousness using the tools currently available, and the subsequent improvement in different cognitive domains. We confirm that accurate diagnosis and proper cognitive assessment are critical for the rehabilitation of patients with disorders of consciousness.

Adult↗

PubMedDate not supplied

Vegetative and minimally conscious states: serial assessment approaches in diagnosis and management.

Assessment of vegetative (VS) and minimally conscious state (MCS) patients presents clinicians with inherent difficulties (Royal College of Physicians, 2003) in terms of the reliable detection of potential signs of awareness given that all current assessment tools rely on observed behaviour. Recently developed measures such as SMART (Gill-Thwaites & Munday, 1999) and WHIM (Shiel et al., 2000), employing structured operational defined behavioural observations can facilitate the serial assessment of patient awareness, progress and appropriate goal setting particularly as one-off bedside assessments are more likely to be inaccurate. The use of sensitive tailored approaches involving experienced multidisciplinary teams is strongly advocated (Royal College of Physicians and British Society of Rehabilitation Medicine, 2003), notwithstanding clinicians should carefully consider potential confounding clinical factors, which may deleteriously influence patient arousal or ability to respond. Finally, areas for future development and recommendations regarding multidisciplinary assessment approaches with VS and MCS patients are outlined.

Awareness↗

PubMed2001

[The therapy of non-traumatic vegetative state syndrome in children].

Twenty nine non-traumatic appalic syndrome (AS) cases of various etiology were observed in children aged from 3 to 14 years. The clinical picture study was carried out, along with brain structure visualization in vivo (CT and MRT), EEG and cerebral blood flow detection with transcranial ultrasonic dopplerography. All the cases were studied in dynamics in relation to influence of complex course therapy developed by the authors, including vasoactive drugs, nootropics, craniopuncture, acupuncture and electrostimulation of craniopuncture zones. Five patients (17.2%) had a distinct positive dynamics with complete consciousness rehabilitation on the background of moderate neurological deficit regress. In general, CT-data and changes of EEG and cerebral blood flow in AS were not found to have any prognostic value and to be etiologically specific. But changes of EEG and cerebral blood flow in response to the treatment appear to be positive prognostic sign. The prognosis for AS due to meningoencephalitis is worse than one for AS due to hypoxic-ischemic encephalopathy. The non-traumatic AS duration for more than 2 months corresponds to unfavorable outcome.

Adolescent↗

PubMed2001

Prognostic value of evoked potentials and sleep recordings in the prolonged comatose state of children. Preliminary data.

OBJECTIVES: Sleep recordings and evoked potentials (EPs) were used in five comatose children to evaluate their predictive value for outcome following a severe comatose state. METHODS AND SUBJECTS: The protocol included EEG, Brainstem Evoked Responses (BERs), Somatosensory Evoked Potentials (SEPs) and polysomnography. From 10 to 15 days post-coma (D10 to D15), EEG and clinical examinations were carried out every second day, then one day in four from 15 to 30 days post-coma (D15 to D30), and one day in seven from D30 to six months (M6). Evoked potentials and Polysomnography were recorded on D10-D15 or D30 in the second month (M2) and in M6. Of the five children, three were in anoxic coma and two in traumatic coma. All had extensive lesions and a Glasgow Coma Scale (GCS) score of less than five. The results of the EEG, polysomnographic and EP recordings were compared to the clinical outcome. RESULTS AND CONCLUSION: In the three anoxic comas we observed BER abnormalities and the absence of SEP N20 associated with wide cortical lesions with brainstem extension. Sleep recordings showed major alterations of the wake-sleep cycle without any improvement in M6. Abnormalities included loss of the normal REM-sleep pattern associated with alteration of NREM sleep and periods of increase in motor activity without EEG arousal. This sleep pattern appeared to be associated with involvement of the brainstem. In the two traumatic comas, alterations of the early cortical SEP responses were less severe and the BERs were normal. Some sleep spindles were observed as well as the persistence of sleep cycles in the first weeks post-coma. The combined use of EEG, EPs and polysomnography improved the outcome prediction in comparison with the use of just one modality. EPs and sleep recordings were far superior to clinical evaluation and to GCS in the appreciation of the functional status of comatose children. The reappearance of sleep patterns is considered to be of favorable prognosis for outcome of the coma state, as is the presence of sleep spindles in post-trauma coma. This study showed that EPs and sleep recordings help to further distinguish between patients with good or bad outcomes.

Brain Damage, Chronic↗