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Results for “Persistent Vegetative State”

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PubMed2005

Residual cognitive function in comatose, vegetative and minimally conscious states.

PURPOSE OF REVIEW: The clinical evaluation of cognition in non-communicative severely brain-damaged patients is inherently difficult. In addition to novel behavioural 'consciousness-scales', the role of para-clinical markers of consciousness, such as event related potentials and functional neuroimaging is reviewed. RECENT FINDINGS: New behavioural scales for vegetative and minimally conscious patients have been shown to reduce diagnostic error but regrettably remain underused in clinical routine. Electrophysiological studies have confirmed their role in estimating outcome and possibly cognition. Several recent functional neuroimaging studies have shown residual cortical function in undeniably vegetative patients. This cortical activation, however, seems limited to primary 'low-level' areas and does not imply 'higher-order' integration, considered necessary for conscious perception. Minimally conscious patients show large-scale high-order cerebral activation, apparently dependent upon the emotional relevance of the stimulation. SUMMARY: Careful clinical assessment of putative 'conscious behaviour' in vegetative and minimally conscious patients is the first requirement for their proper diagnosis and management. Complementary functional neuroimaging and electrophysiological studies will have a major impact on future clinical decision making and may guide selective therapeutic options. At present, more experimental evidence and the elucidation of methodological and ethical controversies are awaited prior to their routine clinical use.

Cognition↗

PubMed2005

An unusual case of Dantrolene sodium-induced urinary retention in post-traumatic minimally responsive state.

INTRODUCTION: An unusual case of urinary retention is reported occurring during the inpatient rehabilitation of minimally responsive state (MRS) following severe traumatic brain injury (TBI). CLINICAL PICTURE: Urodynamic evaluation showed detrusor acontractility and subsequent management involved intermittent bladder catheterization and treatment of a single urinary tract infection. TREATMENT: Factors contributing to her bladder paralysis included severe immobility, tetraplegia and treatment of diffuse spasticity with oral Dantrolene sodium 250 mg per day. Constipation, diabetes and spinal cord injury were absent. In addition, she received unilateral partial sciatic neurolysis with 50% alcohol for severe knee flexor spasticity and intra-muscular Botulinum toxin A to both spastic upper limbs. OUTCOME: Bladder acontractility resolved completely when Dantrolene was reduced with subsequent achievement of a catheter-free status and small post-void residual volumes. Repeat urodynamics showed spontaneous detrusor contractions. CONCLUSION: A discussion of possible aetiologic factors for detrusor acontracility following TBI is presented including a brief review of the literature.

Adult↗

PubMed2006

The portrayal of coma in contemporary motion pictures.

BACKGROUND: Coma has been a theme of screenplays in motion pictures, but there is no information about its accuracy. METHODS: The authors reviewed 30 movies from 1970 to 2004 with actors depicting prolonged coma. Accurate depiction of comatose patients was defined by appearance, the complexity of care, accurate cause of coma and probability of awakening, and appropriate compassionate discussion between the physician and family members. Twenty-two key scenes from 17 movies were rated for accuracy by a panel of neurointensivists and neuroscience nurses and then were shown to 72 nonmedical viewers. Accuracy of the scenes was assessed using a Likert Scale. RESULTS: Coma was most often caused by motor vehicle accidents or violence (63%). The time in a comatose state varied from days to 10 years. Awakening occurred in 18 of 30 motion pictures (60%). Awakening was sudden with cognition intact, even after prolonged time in a coma. Actors personified "Sleeping Beauty" (eyes closed, beautifully groomed). Physicians appeared as caricatures. Only two movies had a reasonable accurate representation (Dream Life of Angels and Reversal of Fortune). The majority of the surveyed viewers identified inaccuracy of representation of coma, awakenings, and conversations on the experience of being in a coma, except in 8 of the 22 scenes (36%). Twenty-eight of the 72 viewers (39%) could potentially allow these scenes to influence decisions in real life. CONCLUSIONS: Misrepresentation of coma and awakening was common in motion pictures and impacted on the public perception of coma. Neurologic advice regarding prolonged coma is needed.

Adolescent↗

PubMed2000

[Approach to the patient in vegetative state. Part II: differential diagnosis].

A prerequisite to the diagnosis of vegetative state is the exclusion of apparently similar syndromes, in which the patient retains the consciousness partially or even completely. Some syndromes are not separate nosological entities and should be abandoned: the apallic state, the neocortical death, the decerebrate and decorticate state, the alpha-coma, the vigil or prolonged or irreversible coma are among them. Three conditions deserve special consideration. The term locked-in syndrome describes a patient completely paralysed and mute, but fully conscious, and is usually caused by ischemic lesions of the pons. Several variants do exist, either in the causes and site of lesion. Some patients may become paralysed and mute, but conscious because of polyneuropathies, that is in the absence of any lesions of the central nervous system. The akinetic mutism is a rare condition characterised by loss of speech and nearly absent bodily movements. Painful stimulation may cause appropriate withdrawing, and wakefulness and self-awareness may be preserved, but cognitive impairment is usually present. It must be emphasised that this condition can be due to potentially treatable lesions, such as hydrocephalus and craniopharyngioma. The term "minimally responsive" or "minimally conscious" describes severely disabled patients in whom meaningful responses can be demonstrated, although inconstantly. This condition, the true diagnostic challenge, often represents a transition phase of vegetative patients recovering consciousness. Physicians, physiotherapists and patient's relatives should work all together to reach a correct diagnosis, by using current available methods to monitorize the recovery of consciousness.

Diagnosis, Differential↗

PubMed1995

Psychovegetative syndrome diagnosis: an automated psychophysiological investigation and mathematical modeling approach.

1. INTRODUCTION. The main purpose of our work was to create the informational expert system of psychovegetative syndrome diagnosis by applying clinical data and estimating the functioning of the central and peripheral part of regulatory apparatus of the human organism, taking into consideration parallel and consecutive sensory, motor, associative, emotional drive systems, and internal body state. We used automatized psychophysiological investigation and mathematical models. For this purpose the following principal tasks have been prepared: the creation of database of quantifiable estimation patient state; the definition and automation of psychophysiological investigation; mathematical modeling of vegetative functions using a non-invasive sample and its connection with real psychophysiological experiment; mathematical modeling of organisms inner medium homeostasis; and the creation of an informational-expert system of psychovegetative syndrome diagnosis. 2. DATABASE OF ESTIMATION OF PATIENTS STATE. The medical records of the DB "PATIENT" contain data on patient psychic and somatoneurological status. 3. AUTOMATED PSYCHOPHYSIOLOGICAL INVESTIGATION. Psychophysiological investigation enables estimation of the functioning of several subsystems of the human organism and establishes an interrelationship between them by means of electrophysiological data and performance parameters. The study of psychophysiological provision of behavior by psychophysiological investigation enables us to get information about adaptational mechanisms of the patient under certain environmental loads. By means of special mathematical provision, the mathematical elaboration of biosignals as performance parameters has been realized; also realized were the formation of received parameters in the database, the estimation of separated parameters in the view of informativity, and the establishment of diagnostic patterns. 4. MATHEMATICAL MODELS FOR ESTIMATION INTERNAL BODY STATE. The proposed mathematical models allow investigation of homeostatic regulation in various intensities of the metabolic processes and external load. This approach in mathematical models allows us to characterize the relations between the central and peripheral parts of the regulatory mechanisms, using non-invasive samples under psychophysiological investigation and the simulation of different surroundings for brain cells functioning. 5. INFORMATION-EXPERT SYSTEM. Proceeding from the principle of psychoneural unity, we characterized the functioning mechanisms of CNS by means of automatized EEG analysis, visually evoked potential analysis, estimated psychic status, and the characteristics of neural system biochemical processes received by mathematical modeling. By using the indices of the viscero-vegetative and somatolocomotor system (as well as parameters received by automatized analysis of ECG), the EEG respiratory signal--from mathematical models of vegetative functions decision support system applied in estimation of a peripheral block of the regulatory system--is reflected in diagnosis of certain syndromes. The informational expert system, proceeding from the functioning of the human organism's regulatory apparatus, diagnosed psychovegetative syndrome and described the mechanisms of its development. 6. CONCLUSION. The informational expert system enables estimation of the functioning of a human organism as a whole and can be introduced in the sphere of practical medicine and professional orientation as well as in laboratories of experimental psychology and neurosciences.

Brain↗

PubMed2000

Physician-assisted suicide in the United States: confronting legal and medical reasoning--Part two.

In the United States, judicial rulings that unrealistically addressed the complexity of cases and demonstrated limited understanding of principles, helped to create a legal quagmire which legislatures had to confront. Moreover, the legislative response was often slow and inadequate in terms of both the scope and clarity of the laws. However, since the 1970s, progress has been made on many fronts, particularly in regard to advance directives dealing with end-of-life decisions. The debate over physician-assisted suicide has spawned a repetition of moral and legal arguments. Those against legalization have failed to make a realistic appraisal of the dilemmas facing patients and their families in an age of technological medicine delivered in the context of the marketplace. The underlying problem is a system in dire need of reform that will no longer treat health care as a commodity of the marketplace and provide universal health care. Terminal care as an integral part of health care will substantially benefit from such reforms because a major obstacle to comprehensive palliative care is the condition of the present system.

Adult↗

PubMed2006

Perceptions of patients on the utility or futility of end-of-life treatment.

BACKGROUND AND OBJECTIVES: Definitions of medical futility, offered by healthcare professionals, bioethicists and other experts, have been rigorously debated by many investigators, but the perceptions of patients of futility have been explored only by a few. Patients were allowed to discuss their concerns about end-of-life care, so that their ideas about treatment futility or utility could be extrapolated by us. METHODS: In this cross-sectional study, in-depth, semistructured interviews were conducted with 30 elderly people who were receiving outpatient care in a large, urban Veterans Affairs medical centre in the US. Each of their healthcare providers was also interviewed. Participants were asked to consider four terms commonly used in advance directive forms (ie, life-sustaining treatment, terminal condition, state of permanent unconsciousness and decision-making capacity) and to discuss what these terms meant to them. Audiotapes of the open-ended interviews were transcribed and responses were coded and categorised by constant comparison, a commonly used qualitative method. RESULTS: The following four factors were taken into account by the participants when discussing end-of-life interventions and outcomes: (1) expected quality of life; (2) emotional and financial costs of treatment; (3) likelihood of treatment success; and (4) expected effect on longevity. CONCLUSIONS: Although the terms "utility" or "futility" were not generally used by the participants, segments of speech indicating their perceptions of these terms were identified. Treatment was not always discussed in the same way by patients and providers, but seemed to reflect the same four concerns. Therefore, it may be fruitful for providers to focus on these concerns when discussing end-of-life treatment options with their patients.

Advance Directives↗

PubMed2000

The neuropathology of the vegetative state after an acute brain insult.

The vegetative state is often described clinically as loss of function of the cortex while the function of the brainstem is preserved. In an attempt to define the structural basis of the vegetative state we have undertaken a detailed neuropathological study of the brains of 49 patients who remained vegetative until death, 1 month to 8 years after an acute brain insult. Of these, 35 had sustained a blunt head injury and 14 some type of acute non-traumatic brain damage. In the traumatic cases the commonest structural abnormalities identified were grades 2 and 3 diffuse axonal injury (25 cases, 71%). The thalamus was abnormal in 28 cases (80%), and in 96% of the cases who survived for more than 3 months. Other abnormalities included ischaemic damage in the neocortex (13 cases, 37%) and intracranial haematoma (nine cases, 26%). In the non-traumatic cases there was diffuse ischaemic damage in the neocortex in nine cases (64%) and focal damage in four (29%); the thalamus was abnormal in every case. There were cases in both groups where the cerebral cortex, the cerebellum and the brainstem were of structurally normal appearance. In every case, however, there was profound damage to the subcortical white matter or to the major relay nuclei of the thalamus, or both. These lesions render any structurally intact cortex unable to function because connections between different cortical areas via the thalamic nuclei are no longer functional, and there is also extensive damage to afferent and efferent cerebral connections.

Adolescent↗

PubMed1997

Postcomatose unawareness/vegetative state following severe brain injury: a content methodology.

Postcomatose unawareness/vegetative state (PCU/VS) is an altered state of consciousness that may follow coma. It is characterized by wakefulness without awareness of self or the environment. While most frequently associated with trauma, it is also associated with anoxia, vascular injury or encephalitis. In this article, the clinical phenomenon of PCU/VS is explored using the content methodology process (CMP) in order to explicate content for nursing practice. There are five steps in the process: literature review, identification of the characteristic features and patient behaviors associated with PCU/VS, description of the specific abilities that are affected, formulation of nursing assessment and intervention approaches, and evaluation of these approaches in clinical practice and research. In this article, there is an extensive review and analysis of the literature related to PCU/VS. Substantive nursing knowledge was developed using the CMP. It was determined that the Freeman Questionnaire and the Sensory Stimulation Assessment Measure are appropriate tools to assess the interpretative abilities of patients with PCU/VS during the acute care period. Sensory regulation techniques that are appropriate for use during patient care to promote the recovery of cognitive abilities were identified. Both the recommended tools and the intervention approaches require further validation in empirical research.

Brain Injuries↗

PubMed1999

Assessment of minimally responsive patients: clinical difficulties of single-case design.

Improved management of very severely central nervous system (CNS) injured individuals has given rise to an increasing number of patients in a minimally responsive state. There is a growing literature stressing the importance of accurately determining these patients' level of cognitive functioning and its role in appropriate rehabilitation and long term management. The single case design model appears to be the intervention of choice, with its great flexibility and tailored approach to each individual case. The recent literature has focused on the technical aspects of the assessment, offering clear procedural guidelines. Unfortunately, there is a dearth of information about clinical factors such as clinical setting and family involvement, which may interfere with or prevent a planned intervention. The case of MT is presented, who was the subject of a single case intervention 9 months following an extremely severe traumatic brain injury. The planned intervention was to examine the effects of a psychostimulant on MT's level of arousal, in order to improve his participation in the rehabilitation programme. Beyond the results (which were equivocal), the clinical difficulties in conducting single case study designs in rehabilitation are discussed. Ways to minimize these difficulties are proposed.

Adult↗

PubMed2005

The minimally conscious state and recovery potential: a follow-up study 2 to 5 years after traumatic brain injury.

OBJECTIVE: To document recovery in persons who were in the minimally conscious state (MCS) for at least 1 month after traumatic brain injury (TBI). DESIGN: Patient series. SETTING: Participants who had been discharged from an inpatient rehabilitation unit. PARTICIPANTS: Eighteen people with TBI and their relatives. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Western Neuro Sensory Stimulation Profile, Disability Rating Scale (DRS), FIM instrument, Dementia Rating Scale, and Sydney Psychosocial Reintegration Scale (SPRS). RESULTS: Level of functioning at follow-up varied from extremely severe disability or greater on the DRS (n=4) to mild disability (n=1). These outcomes were corroborated by results of the FIM and the Dementia Rating Scale. All participants experienced some (44%) or major (56%) change in their level of psychosocial functioning on the SPRS compared with their preinjury level. There were no significant correlations between duration of time in the MCS and outcome on FIM, DRS, or SPRS. CONCLUSIONS: These results highlight the heterogeneity of outcome even after a prolonged duration of MCS after TBI. A large proportion of the patients was functionally independent in basic daily activities, although all experienced residual impairments and disabilities. The low correlation coefficients between duration of MCS and the outcome measures suggest that prognostic statements based on length of time a person is in the MCS cannot be made with confidence.

Adult↗

PubMed2026

Modulation of heart rate and heart rate variability during animal-assisted treatment of patients in a minimally conscious state: A randomized controlled crossover study.

BACKGROUND: Animal-assisted treatment (AATx) is a promising and increasingly used approach in neurorehabilitation, yet its psychophysiological effects remain largely unexplored. Patients in a minimally conscious state (MCS) show severely altered consciousness with minimal but definite behavioral signs of awareness. Because behavioral assessment in this population is limited, psychophysiological measures such as heart rate (HR) and heart rate variability (HRV) may offer valuable insights into autonomic regulation during therapy. AIM: The present study investigated whether AATx influences HR and HRV compared to treatment as usual (TAU). METHODS: A randomized controlled crossover design with repeated measures was conducted. HR and HRV data were recorded using an Empatica E4 wristband, and linear mixed-effects models were fitted for each outcome variable. The analytic sample included twenty-one patients with MCS who completed at least one of the four sessions. RESULTS: We found a significant decrease in mean HR (estimate = -12.75, p = .041) and a significant increase in the standard deviation of normal-to-normal intervals (SDNN) (estimate = 15.76, p = .020) during AATx compared to TAU from the pretreatment to the posttreatment phase, indicating enhanced parasympathetic activation and greater autonomic flexibility. Other HRV parameters revealed no significant effects of AATx, though trends were consistent with the hypotheses. CONCLUSIONS: These findings provide preliminary physiological evidence that AATx can modulate autonomic activity in MCS patients. Despite limitations related to sample size and recording quality, the results highlight the potential of AATx as an emotionally engaging intervention in early neurorehabilitation.

Humans↗

PubMed1984

Ethical issues in the treatment of patients with a remitting vegetative state.

A case of remitting vegetative state is presented illustrating the need to draw a distinction between persistent and remitting vegetative states in brain-damaged patients. Standard ethical considerations regarding dying patients cannot be universally applied to remitting vegetative states, which are best handled in a context of an ethics of discretion, rather than an ethics of rules. Ethical obligations towards such persons are presented. When the patient cannot assent to withdrawal of treatment, it is suggested that decisions be made on the side of preserving life until the course becomes evidently downhill.

Aged↗

PubMed2000