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PubMed2003

Separation of health, state. Recent legislation has providers caught in the debate over government involvement in personal medical decisions.

Providers are concerned over three initiatives--a ban on partial-birth abortion, Florida's measure granting Gov. Jeb Bush (left) executive power in a right-to-die case and the Senate vote prohibiting genetic testing. These developments have focused more attention on the debate over when government's intervention becomes intrusion, and when lawmakers should overrule the wishes of patients and providers.

Abortion, Legal↗

PubMed2006

Brain response to one's own name in vegetative state, minimally conscious state, and locked-in syndrome.

BACKGROUND: A major challenge in the management of severely brain-injured patients with altered states of consciousness is to estimate their residual perception of the environment. OBJECTIVE: To investigate the integrity of detection of one's own name in patients in a behaviorally well-documented vegetative state (VS), patients in a minimally conscious state (MCS), and patients with locked-in syndrome. DESIGN: We recorded the auditory evoked potentials to the patient's own name and to 7 other equiprobable first names in 15 brain-damaged patients. RESULTS: A P3 component was observed in response to the patient's name in all patients with locked-in syndrome, in all MCS patients, and in 3 of 5 patients in a VS. P3 latency was significantly (P<.05) delayed for MCS and VS patients compared with healthy volunteers. CONCLUSIONS: These results suggest that partially preserved semantic processing could be observed in noncommunicative brain-damaged patients, notably for the detection of salient stimuli, such as the subject's own name. This function seems delayed in MCS and (if present) in VS patients. More important, a P3 response does not necessarily reflect conscious perception and cannot be used to differentiate VS from MCS patients.

Acoustic Stimulation↗

PubMed2001

Positive outcomes in traumatic brain injury-vegetative state: patients treated with bromocriptine.

OBJECTIVE: To assess the effects of multidisciplinary rehabilitation interventions and use of bromocriptine on outcome in patients with traumatic brain injury-vegetative state (TBI-VS). DESIGN: Retrospective review of clinical cases. SETTING: Free-standing rehabilitation hospital; Acute and extended rehabilitation hospital. PARTICIPANTS: Five consecutive TBI-VS patients, as well as 33 TBI-VS patients and 37 traumatic brain injury-minimally conscious state (TBI-MCS) patients reported in the literature. INTERVENTIONS: Bromocriptine administration, systematic neuropsychologic testing, sensory stimulation, and traditional comprehensive rehabilitation with physical therapy, occupational therapy, and speech therapy. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS) at 1, 3, 6, and 12 months postinjury and FIM instrument scores at 1 month and 12 months postinjury, Coma Recovery Scale, and Barry Rehabilitation Inpatient Screening of Cognition. RESULTS: The 5 TBI-VS patients emerged from a VS into a MCS and regained functional status. Their recovery of physical and cognitive functioning, as rated by the DRS, was greater than previously reported in the literature for patients in a VS or MCS at 3, 6, and 12 months postinjury. CONCLUSION: Bromocriptine administration, systematic neuropsychologic testing, sensory stimulation, a comprehensive rehabilitation program, or a combination of these treatments may enhance functional recovery in this TBI-VS patient group. Further systematic study to quantify the contribution of these variables and to reproduce this data in a larger patient population should be performed.

Activities of Daily Living↗

PubMed1998

Amantadine: a potential treatment for the minimally conscious state.

Pharmacologic strategies have been advocated to enhance the neurorehabilitation of persons with severe traumatic brain injury. Dopaminergic pathways have been felt to play a significant role in arousal. Employing single case design methodology we present the case of a survivor of severe traumatic brain injury who appeared to have a dose dependent response to the pro-dopaminergic medication amantadine. Further research is necessary to clarify the role of pharmacotherapy in the improvement of functional outcome.

Adult↗

PubMedDate not supplied

Neuropathology of the vegetative state after head injury.

A detailed neuropathological study of patients identified clinically after head injury as either severely disabled (SD, n = 30) or vegetative (VS, n = 35) has been carried out to determine the nature and frequency of the various pathologies that form the basis of these clinical states. Patients who were SD were older (SD median 49.5 yrs vs. VS median 38 yrs, p = .04), more likely to have a lucid interval (SD 31% vs. VS 9%, p = .03), and to have had an acute intracranial haematoma (SD 70% vs. VS 26%, p < .001). SD patients less often had severe, Grades (2 or 3) of traumatic diffuse axonal injury (SD 30% vs. VS 71%, p = .001) and less often had thalamic damage (SD 37% vs. VS 80%, p < .001). Similar features of both focal and diffuse damage were present in some SD and VS cases with both groups having considerable damage to white matter and to the thalamus. It is concluded that the principal structural basis of both SD and VS is diffuse traumatic axonal injury (DAI) with widespread damage to white matter and changes in the thalami. However, both ischaemic brain damage and the vascular complications of raised intracranial pressure contributed to the clinical signs and symptoms.

Adolescent↗

PubMed1998

Outcome after external decompression for massive cerebral infarction.

Acute ischemic stroke involving the entire vascular distribution of a carotid or middle cerebral artery can cause massive cerebral edema. This study evaluated external decompression for the treatment of massive stroke and analyzed possible prognostic factors. Twenty-four patients with acute massive cerebral infarction, which had progressed to tentorial herniation and impending death, underwent external decompression after medical therapy failed to achieve an effective response. The neurological outcome 2 months after surgery using the Glasgow Outcome Scale was severe disability in 14 patients, vegetative state in two, and death in eight. The overall mortality was 33%. Various characteristics (age, sex, etiology, side of hemispheric infarction, pupillary asymmetry, Japan Coma Scale, distribution of infarction, hemorrhagic infarction, midline shift, tentorial herniation) were evaluated to determine the factors associated with high mortality after surgical intervention. There was no statistically significant relationship between any variable and mortality. Mortality was especially high in the patients with preoperative consciousness level of 200, anterior, middle, and posterior cerebral artery territory infarction, and stage III of tentorial herniation. Postoperatively, all patients with severe disability returned to a clear level of consciousness. Six patients with dominant hemisphere stroke had some measure of communicative skills in spite of aphasia. External decompression is a life-saving treatment for patients with massive cerebral infarction and can provide a reasonable quality of life even for those with dominant hemisphere strokes. Decompressive surgery should be considered and performed as soon as possible if computed tomography demonstrates signs of descending tentorial herniation.

Acute Disease↗

PubMedDate not supplied

Apallic syndrome is not apallic: is vegetative state vegetative?

Initial conceptualisation about the nature of vegetative state (VS) assumed at least temporary loss of the entire cortical functioning. Since a broad range of stimulus-related cortical activations was demonstrated in VS patients, this simplified idea is not tenable any longer, but no alternative concept emerges instead. Two recent hypotheses, empirically testable and well grounded, could fill this vacuum: (1) In VS, isolated cortical areas may work, but their integration into a distributed network is lacking. (2) In VS, complex stimulus processing is limited to primary sensory and motor areas; the co-ordination between them and the secondary and tertiary areas is lacking. To test these hypotheses, we estimated the frequency of occurrence of late event-related potential components P3 and N400, presumably indicating activity of complex distributed networks including high-level sensory and associative areas. Both components occurred in VS with above-chance frequencies, but less frequently than in two control groups. Besides these frequent normal brain activations, some VS patients exhibit highly significant but abnormal activations, whose functional meaning remains unclear. A methodological analysis leads to the conclusion that any neurophysiological assessment of VS patients is biased toward under-, rather than over-estimation, of their remaining information processing abilities.

Brain↗

PubMed1999

Life expectancy and median survival time in the permanent vegetative state.

The authors studied life expectancy and risk factors for mortality of persons in the vegetative state (VS). The study participants were 1,021 California patients in the VS during 1981-1996. Because of the large sample size, the authors were able to use multivariate methods to assess the effect of several risk factors on mortality. The authors found a strong secular trend in infant mortality, with rates in the mid-1990s being only one third of those in the early 1980s (P < 0.01). A smaller secular trend was observed for children aged 2-10 years and none for older patients. The mortality risk for older patients fell by approximately 8% for each year since the onset of the VS. The need for gastrostomy feeding was associated with a substantially higher risk, especially for infants and older patients (P < 0.01). Ventilator dependence also appeared to be a risk factor. On the basis of recent mortality rates, life expectancy in the VS is frequently higher than has generally been thought. For example, it is 10.5 additional years (+/- 2 years) for a 15-year-old patient who has been in the VS for 1 year, and 12.2 years for a 15-year-old patient who has been in the VS for 4 years.

Adolescent↗

PubMed2002

Loewenstein communication scale for the minimally responsive patient.

PRIMARY OBJECTIVE: Any sign of communicative ability in patients in vegetative state can provide information about regain of consciousness and conservation of cognitive abilities. The aim of this study was to test the reliability and validity of an instrument designed to measure the degree of communication in minimally responsive patients. MATERIALS: The Loewenstein Communication Scale (LCS) measures five hierarchical functions - mobility, respiration, visual responsiveness, auditory comprehension and linguistic skills (verbal or alternative) - which are divided into five parameters and rated in developmental order on a 5-point scale by level of difficulty. Scores for each function are summed to obtain a quantitative communication profile. METHODS: Forty-two adult patients in vegetative state, as a result of acquired brain injury, were examined with the proposed LCS for the minimally responsive patients by two speech and language clinicians at admission to the Intensive Care Unit (ICU) for brain injured patients and, thereafter, at least once weekly. At the end of the ICU stay, 27 patients who showed signs of recovery and were referred for continued rehabilitation were compared to a group of 15 patients who were not referred for continued rehabilitation, for functional and general LCS scores. The predictive power of the LCS in differentiating between these groups was tested. RESULTS: The LCS was found to have very good reliability with good inter-rater agreement. Patients who eventually continued rehabilitation had significantly higher total scores as well as in the motor, visual and auditory sub-scales. Logistic regression results indicated that these parameters successfully differentiated between the two groups of patients, even after adjusting for age and for scores on the Glasgow Coma Scale. CONCLUSION: The LCS for the minimally responsive patients proved to be reliable and predictive of rehabilitation progress of minimally responsive patients. It may be useful for the interdisciplinary rehabilitation team in planning early individually targeted therapeutic programmes.

Adolescent↗

PubMedDate not supplied

Forensic assessment issues in low level neurological states.

Forensic assessment of persons in low-level neurological state (LLNS) is fraught with limitations and caveats. Examiners must be aware of the nuances of forensic evaluation in the context of the conditions of examination, ethics and responsibilities that they have been charged with as an independent evaluator and fact seeker in the context of litigation-oriented dispute resolution. This article provides an overview of the independent medical evaluation (IME) of persons in LLNS including ethics, contextual limitations, history gathering, corroboratory interviews and suggested examination, as well as report format, among other important issues.

Brain↗

PubMed2005

Schiavo's lessons for health attorneys when good law is all you have: reflections of the special guardian ad litem to Theresa Marie Schiavo.

Rarely have all the branches of federal and state government converged upon a single issue, a single person as they did in the tragic and acrimonious case of Theresa Maria Schiavo. In late 2003, the Florida Legislature passed what become known as "Terri's Law" and in Spring of 2005, Congress and the President of the United States sought to directly intervene in the care of the severely brain damaged woman. During that period, the state and federal court systems, through the highest courts in both venues, ruled on Ms. Schiavo's life, resulting in the removal of an artificial feeding tube and her death during Easter week. The legal and medical issues in this complex, politically and emotionally charged case continue to raise important questions for health attorneys. In this Article, Professor Wolfson, who served as the legislatively mandated, court appointed special guardian ad litem for Theresa Schiavo in late 2003, provides a distinctive first-person overview of the Schiavo case.

Adult↗

PubMed2004

Functional neuroimaging in the vegetative state.

The interest of functional imaging in patients in a vegetative state is twofold. First, the vegetative state continues to represent a major clinical and ethical problem, in terms of diagnosis, prognosis, treatment, everyday management and end-of-life decisions. Second, it offers a lesional approach to the study of human consciousness and adds to the international research effort on identifying the neural correlate of consciousness. Cerebral metabolism has been shown to be massively reduced in the vegetative state. However, recovery of consciousness from vegetative state seems not always associated with substantial changes in global metabolism. Recent PET data indicate that some vegetative patients are unconscious not just because of a global loss of neuronal function, but due to an altered activity in a critical fronto-parietal cortical network and to abolished functional connections within this network and with non-specific thalamic nuclei. Recovery of consciousness was shown to be paralleled by a restoration of this cortico-thalamo-cortical interaction. Despite the metabolic impairment, external stimulation still induces neuronal activation as shown by both auditory and noxious stimuli. However, this activation is limited to primary cortices and dissociated from higher-order associative cortices, thought to be necessary for conscious perception.

Humans↗

PubMed1997

Long-term ventilation in children with severe central nervous system impairment.

Absent from the list of indications for long-term ventilation (LTV) is its use for children with severe central nervous system impairment, including those with severe mental retardation or in a permanent vegetative state. Over a two year period, we evaluated eight children with severe CNS dysfunction for whom long-term ventilation was being contemplated. Of these eight patients, three were in a permanent vegetative state and the remainder were severely neurologically impaired, with minimal cognition. The following recommendations were developed: (1) LTV for patients in a permanent vegetative state is inappropriate. (2) In a patient with severe neurologic disease, the process of informed consent must be viewed as dynamic; once the patient's condition is diagnosed, discussion should begin about the likely course of the disease (upper airway obstruction, respiratory failure, or both) and available treatment options. (3) Continued efforts must be made to resolve conflicts between healthcare professionals and surrogates concerning aggressive support of children with severe CNS dysfunction. Discussions should continue even after a decision to provide long-term ventilation is made. (4) Currently, requests by surrogates for LTV in patients with severe neurologic impairment are usually honored because of respect for family values. (5) Physicians and other healthcare professionals should develop an open and fair process for determining inappropriate care. (6) Once LTV is initiated, efforts to transfer the child to home or a long-term care facility should be made. Further life-saving support should be discouraged. (7) Irremediable patient suffering is reason to refuse a surrogate request for LTV. A patient's preservable existence might be so torturous, painful, or filled with suffering that continued medical intervention would be inhumane or abusive.

Adolescent↗

PubMed2002

The minimally conscious state: definition and diagnostic criteria.

OBJECTIVE: To establish consensus recommendations among health care specialties for defining and establishing diagnostic criteria for the minimally conscious state (MCS). BACKGROUND: There is a subgroup of patients with severe alteration in consciousness who do not meet diagnostic criteria for coma or the vegetative state (VS). These patients demonstrate inconsistent but discernible evidence of consciousness. It is important to distinguish patients in MCS from those in coma and VS because preliminary findings suggest that there are meaningful differences in outcome. METHODS: An evidence-based literature review of disorders of consciousness was completed to define MCS, develop diagnostic criteria for entry into MCS, and identify markers for emergence to higher levels of cognitive function. RESULTS: There were insufficient data to establish evidence-based guidelines for diagnosis, prognosis, and management of MCS. Therefore, a consensus-based case definition with behaviorally referenced diagnostic criteria was formulated to facilitate future empirical investigation. CONCLUSIONS: MCS is characterized by inconsistent but clearly discernible behavioral evidence of consciousness and can be distinguished from coma and VS by documenting the presence of specific behavioral features not found in either of these conditions. Patients may evolve to MCS from coma or VS after acute brain injury. MCS may also result from degenerative or congenital nervous system disorders. This condition is often transient but may also exist as a permanent outcome. Defining MCS should promote further research on its epidemiology, neuropathology, natural history, and management.

Humans↗

PubMed2004

Cerebral processing in the minimally conscious state.

We studied a patient in a minimally conscious state using PET and cognitive evoked potentials. Cerebral metabolism was below half of normal values. Auditory stimuli with emotional valence (infant cries and the patient's own name) induced a much more widespread activation than did meaningless noise; the activation pattern was comparable with that previously obtained in controls. Cognitive potentials showed preserved P300 responses to the patient's own name.

Adult↗

PubMed1997

The Sensory Modality Assessment Rehabilitation Technique--a tool for assessment and treatment of patients with severe brain injury in a vegetative state.

An analysis of data from 30 subjects diagnosed as being in vegetative state (VS) on admission to a specialized Brain Injury Unit was carried out. Rancho Level ratings given by the referring physician were compared with those of the units occupational therapists (OT). Scores were obtained from the Sensory Modality Assessment Technique (SMART) and the Western Neuro Sensory Stimulation Profile (WNSSP) on admission and at 2 monthly intervals and converted to Rancho Level ratings to allow comparison. The comparison of the assessments within one week of admission showed agreement between Rancho Level scores derived from the WNSSP and those from the referring physicians. The Rancho scores derived from the SMART were significantly different from the physicians' and the WNSSP (P < 0.01), with the SMART rating the patient at a higher level of cognitive functioning. Although all 30 subjects were diagnosed as VS on admission, the SMART assessed six subjects not to be in VS within 2 to 4 months from admission and this was established at least 6 weeks earlier than the comparable conclusion from the WNSSP in four subjects. This initial validation study shows that the SMART is a useful tool in discriminating awareness and more sensitive at detecting the higher cognitive functions than both the WNSPP and referring physician, thus indicating the need to conduct a specifically designed prospective study to validate and further evaluate the SMART.

Adolescent↗

PubMed1998

[New research and considerations in managing minimally conscious coma patients].

The "Wachkoma", minimally conscious state (synonyms in use: "apallic syndrome", "vegetative state"), is a severe, complex condition arising from brain damage of diverse etiologies, for which definitional consensus does not exist internationally; it gives rise to frequent misdiagnosis and carries substantial insecurities concerning treatment outcomes. In the framework of expanding early rehabilitation, however, recent years have seen a distinct shift away from a defect-oriented, reductionist view towards a relational-medicine based understanding of patients with severe brain damage, seeking to gain a comprehensive perception of the patient's altered physical existence and taking a multidisciplinary--nursing, medical, therapeutic and neuropsychological--perspective which includes the patient's relatives and family. Historically, a transition is under way away from the classical brain-pathology focus toward a neuropsychologically grounded, differentiated perspective. Along with in-depth differential diagnostics and assessment of rehab potentials (early intervention diagnostics), comprehensive intervention measures are initiated as early as possible by an interdisciplinary team. These include "coma stimulation" measures, body language forms of interaction ("dialogue management"), and technical communication devices. By building long-term care assistance in ambulatory and residential service delivery systems ("small social network"), social reintegration of these very severely affected patients is attempted, involving the familial and social resources available. Recurrently raised within the bioethical discourse, demands to consider doctor-assisted dying or food withdrawal are to be rejected from a clinical, medical and social-ethical perspective.

Brain Damage, Chronic↗

PubMed2006

Approach to the comatose patient.

BACKGROUND: Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist. OBJECTIVE: To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient. DATA SOURCE: Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs. DATA SYNTHESIS AND CONCLUSIONS: Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.

Brain Death↗