Written by authors with over 20 years of experience in the rehabilitation of patients in a persistent vegetative state, this practical text bridges a gap in the specialized literature by providing neurologists, emergency physicians, physiatrists, and internists, as well as therapists, with a new set of tools to make rapid progress in the treatment of these patients whose improvement is wholly dependent upon them.
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A second equally relevant aspect covered in this book is the relationship of the care-giving physician with the patient's family. Particular attention is given to the approach the physician must take towards family members of the patient lacking mental activity. A third section illustrates the structural and instrumental devices useful in planning and operating a unit specialized in the treatment of patients in the persistent vegetative state, with particular attention given to the rules governing the unit. The Post-traumatic Vegetative State.
Leon Sazbon. Clinical Picture. Prognostic Value of Neurological Signs. Download preview PDF. Skip to main content. Advertisement Hide. Prognosis of the posttraumatic vegetative state. Authors Authors and affiliations R. Braakman W. Jennett J. This is a preview of subscription content, log in to check access.
Neurosurgery 6: — Google Scholar. Jennett B, Plum F Persistent vegetative state after brain damage. A syndrome in search of a name. As in brain dead organ donors, the organ procurement is performed only after the donor is declared dead. Here, confirmatory testing needs to document that the comatose patients has no chances of recovery Bernat et al.
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Coma is a state of unarousable unresponsiveness in which the patient lies with the eye closed and has no awareness of self and surroundings Posner et al. These patients will never open their eyes even when intensively stimulated. To be clearly distinguished from syncope, concussion, or other states of transient unconsciousness, coma must persist for at least one hour. In general, comatose patients who survive begin to awaken and recover within 2 to 4 weeks. This recovery may sometimes go no further than the vegetative state or the minimally conscious state.
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There are two main causes for coma: 1 bihemispheric diffuse cortical or white matter damage or 2 brainstem lesions bilaterally affecting the subcortical reticular arousing systems. After 3 days of observation, absence of pupillary or corneal reflexes, stereotyped or absent motor response to noxious stimulation, iso-electrical or burst suppression pattern EEG, bilateral absent cortical responses on somatosensory evoked potentials, and for anoxic coma biochemical markers such as high levels of serum neuron-specific enolase are known to herald bad outcome.
Prognosis in traumatic coma survivors is known to be better than in anoxic cases Laureys et al. The EEG in patients who are in coma is characterized by an important general slowing. After some days to weeks comatose patients will eventually open their eyes. The vegetative state may be a transition to further recovery, or not. It can be diagnosed soon after a brain injury and can be partially or totally reversible or it may progress to a permanent vegetative state or death.
Many people in vegetative state regain consciousness in the first month after brain injury. However, after a month, the patient is said to be in a persistent vegetative state and the probability of recovery diminishes as more time passes. If patients show no sign of awareness one year after a traumatic brain injury or three months after brain damage from lack of oxygen, the chances of recovery are considered close to zero, and the patient is considered in a permanent vegetative state The Multi-Society Task Force on PVS, However, rare cases of patients who recover after this interval have been reported Childs and Mercer, It is very important to stress the difference between persistent and permanent vegetative state which are, unfortunately, too often abbreviated identically as PVS, causing unnecessary confusion Laureys et al.
When there is no recovery after a specified period depending on etiology three to twelve months the state can be declared permanent and withholding and withdrawal of treatment can be discussed Jennett, ; Laureys et al. We have at present no validated diagnostic nor prognostic markers for patients in a vegetative state. Recent data indicate that damage to the corpus callosum and brainstem indicate bad outcome in traumatic vegetative state Carpentier et al.
Importantly, we have to stress that vegetative state is not brain death. Contrary to brain death, the vegetative state can be partially or completely reversible.
Unlike vegetative patients who have their eyes spontaneously open, patients in brain death never show eye opening. Moreover, contrary to brain death, vegetative patients can breathe spontaneously without assistance and have preserved brainstem reflexes and hypothalamic functioning. Additionally, positron emission tomography PET studies have showed clear differences between brain metabolism of vegetative and brain death patients Figure 3.
Predicting Recovery from Post-Traumatic Vegetative State
Electroencephalography shows an important general slowing of the electrical brain activity of patients in vegetative state. Somatosensory evoked potentials may show preserved primary somatosensory cortical potentials and brainstem auditory evoked potentials often show preserved brainstem potentials in vegetative patients.
Recent data show that the P is not a reliable marker of awareness but rather signs automatic processing, as it could be recorded in well-documented vegetative state patients who never recovered Perrin et al. In some vegetative patients who subsequently recovered, global metabolic rates for glucose metabolism did not show substantial changes Figure 4. In patients in a vegetative state, the activity of primary somatosensory cortex was isolated and disconnected from the rest of the brain, in particular from the frontoparietal network believed to be critical for conscious perception Laureys et al.
Neurology | The Post-Traumatic Vegetative State
The criteria for the minimally conscious state were recently proposed in Giacino et al. The minimally conscious state describes patients who are unable to communicate their thoughts and feelings, but who demonstrate inconsistent but reproducible behavioral evidence of awareness of self or environment.
Patients in a minimally conscious state have to show at least one of the following behaviors: oriented response to noxious stimuli, sustained visual pursuit, command following, intelligible verbalization or emotional or motor behaviors that are contingent upon the presence of specific eliciting stimuli such as episodes of crying that are precipitated by family voices only. Like the vegetative state, the minimally conscious state may be chronic and sometimes permanent.
Some patients who have remained in the minimally conscious state for years were shown to slow recover to meaningful lives Voss et al. The emergence from the minimally conscious state is defined by the ability to use functional interactive communication or functional use of objects Giacino et al. Given that the criteria for the minimally conscious state have only recently been introduced, there are few clinical studies of patients in this condition.
Similar as for the vegetative state, traumatic etiology has a better prognosis than non-traumatic anoxic minimally conscious state. Preliminary data show that overall outcome is better than for the vegetative state Giacino et al. The electroencephalogram shows a general slowing of the electrical brain activity in patients in a minimally conscious state.
Neuroimaging has shows that minimally conscious patients differ from vegetative patients in their metabolic activity in the precuneus and posterior cingulate cortex Laureys et al. In addition, in patients in a minimally conscious state, auditory stimuli trigger higher-order cortical activity normally not observed in the vegetative state Boly et al.
A recent fMRI study reported a young women considered as being in a vegetative state while she showed indistinguishable brain activity from these observed in healthy people when we asked her to imaging playing tennis and visiting her house Owen et al. Despite the clinical diagnosis that the patient was in a vegetative state, she understood the tasks and repeatedly performed them and hence must have been conscious.
A few months after the study, the patient evolved towards a minimally conscious state. The results of this study should not be misinterpreted as evidence that all patients in a vegetative state may actually be conscious. The most likely explanation of these results is that the patient was already beginning the transition to the minimally conscious state at the time of the experiment. A study conducted by Di et al. In addition, MRI studies permit to visualize the extent of brain damage, and new advances in MRI scanning, such as diffusion tensor imaging and spectroscopy, can also offering prognostic information Galanaud et al.
This technique can also shed light on mechanisms of recovery from the minimally conscious state.
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For example, an MRI diffusion tensor imaging study identified axonal regrowth in the brain of a patient who emerged from a minimally conscious state after 19 years of silence Voss et al. The locked-in syndrome describes patients who are awake and conscious but have no means of producing speech, limb, or facial movements. Brainstem lesions are its most common cause.