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"Persistent vegetative state"
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The undead : organ harvesting, the ice-water test, beating-heart cadavers-- how medicine is blurring the line between life and death
Science writer Dick Teresi examines how death is determined by the medical community and explores organ trafficking, brain death, and near-death experiences.
Book
Cognitive Motor Dissociation in Disorders of Consciousness
Among 241 persons with disorders of consciousness who had no observable response to commands, 25% had a verifiable response to commands on EEG or functional MRI, a condition known as cognitive motor dissociation.
Journal Article
Unbury Carol : a novel
\"Carol Evers is a woman with a dark secret. She has died many times...but her many deaths are not final: They are comas, a waking slumber indistinguishable from death, each lasting days. Only two people know of Carol's eerie condition. One is her husband, Dwight, who married Carol for her fortune, and--when she lapses into another coma--plots to seize it by proclaiming her dead and quickly burying her...alive. The other is her lost love, the infamous outlaw James Moxie. When word of Carol's dreadful fate reaches him, Moxie rides the Trail again to save his beloved from an early, unnatural grave. And all the while, awake and aware, Carol fights to free herself from the crippling darkness that binds her--summoning her own fierce will to survive\"--Amazon.com.
Book
Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension
In a trial comparing decompressive craniectomy with medical therapy in patients with traumatic brain injury and raised intracranial pressure refractory to medical therapy, decompressive craniectomy resulted in lower mortality and higher rates of vegetative state and severe disability.
After traumatic brain injury (TBI), intracranial pressure can be elevated owing to a mass effect from intracranial hematomas, contusions, diffuse brain swelling, or hydrocephalus.
1
Intracranial hypertension can lead to brain ischemia by reducing the cerebral perfusion pressure.
2
Intracranial hypertension after TBI is associated with an increased risk of death in most studies.
3
,
4
The monitoring of intracranial pressure and the administration of interventions to lower intracranial pressure are routinely used in patients with TBI, despite the lack of level 1 evidence.
5
Decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying . . .
Journal Article
Cognitive and neurophysiological effects of bilateral tDCS neuromodulation in patients with minimally conscious state
The minimally conscious state (MCS) is a clinical condition characterized by severely reduced but present awareness of self and the environment. Transcranial direct current stimulation (tDCS) has shown promising potential. The aim of this quasi-randomised control study was to investigate the effects of bilateral of tDCS applied to the right and left dorsolateral prefrontal cortex (DLPFC) on neurophysiological and cognitive outcomes in 28 patients with MCS. Participants were quasi-randomly assigned to one of two groups: experimental group with tDCS over both DLPFC, and a control group, which received sham tDCS. Neurophysiological assessments included event-related potentials (ERPs) analysis (N200 and P300) and EEG beta band study. Clinical outcomes were measured using ad hoc psychometric battery, including Coma Recovery Scale-Revised (CRS-R), Levels of Cognitive Functioning Scale (LCFS), and Functional Independence Measure (FIM). The findings revealed a significant improvement in ERP latencies and increased beta band rhythms in the experimental group, indicating enhanced neural responsiveness to cognitive stimuli. Additionally, significant improvements were observed in clinical measures of awareness and functional capacity. These findings suggest that tDCS may represent a promising therapeutic option for enhancing both neurophysiological responses and cognitive functioning in patients with MCS.
Journal Article
Placebo-Controlled Trial of Amantadine for Severe Traumatic Brain Injury
In this placebo-controlled trial of patients in a vegetative or minimally conscious state, amantadine accelerated functional recovery. Recovery slowed after amantadine was discontinued, and functional outcomes at 6 weeks were similar in the amantadine and placebo groups.
Severe traumatic brain injury is a catastrophic event that frequently has devastating familial, economic, and societal consequences. Traumatic brain injury is the most common cause of death and disability in persons between 15 and 30 years of age.
1
The most severe injuries can result in prolonged disorders of consciousness. Approximately 10 to 15% of patients with severe traumatic brain injury are discharged from acute care in a vegetative state,
2
a condition in which there is wakefulness without behavioral evidence of conscious awareness.
3
The estimated prevalence of a minimally conscious state,
4
which is distinguished from a vegetative state by the presence . . .
Journal Article
Willful Modulation of Brain Activity in Disorders of Consciousness
In this study involving 54 patients in a vegetative or minimally conscious state, the use of functional magnetic resonance imaging (MRI) to assess responses during mental-imagery tasks showed that 5 patients were able to willfully modulate their brain activation. These findings suggest that functional MRI can be used to demonstrate evidence of awareness and cognition that cannot be detected by means of clinical assessment.
In patients in a vegetative or minimally conscious state, the use of functional MRI to assess responses during mental-imagery tasks showed that 5 patients were able to willfully modulate their brain activation.
In recent years, improvements in intensive care have led to an increase in the number of patients who survive severe brain injury. Although some of these patients go on to have a good recovery, others awaken from the acute comatose state but do not show any signs of awareness. If repeated examinations yield no evidence of a sustained, reproducible, purposeful, or voluntary behavioral response to visual, auditory, tactile, or noxious stimuli, a diagnosis of a vegetative state — or “wakefulness without awareness” — is made.
1
–
5
Some patients remain in a vegetative state permanently. Others eventually show inconsistent but reproducible . . .
Journal Article
Minimally conscious state “plus”: diagnostic criteria and relation to functional recovery
Background
We investigated the relationship between three language-dependent behaviors (i.e., command-following, intelligible verbalization, and intentional communication) and the functional status of patients with disorders of consciousness (DoC). We hypothesized that patients in minimally conscious state (MCS) who retain behavioral evidence of preserved language function would have similar levels of functional disability, while patients who lack these behaviors would demonstrate significantly greater disability. We reasoned that these results could then be used to establish empirically-based diagnostic criteria for
MCS
+.
Methods
In this retrospective cohort study we included rehabilitation inpatients diagnosed with DoC following severe-acquired brain injury (MCS = 57; vegetative state/unresponsive wakefulness syndrome [VS/UWS] = 63); women: 46; mean age: 47 ± 19 years; traumatic etiology: 68; time post-injury: 40 ± 23 days). We compared the scores of the Disability Rating Scale score (DRS) at time of transition from VS/UWS to MCS or from
MCS
– to
MCS
+, and at discharge between groups.
Results
Level of disability on the DRS was similar in patients with any combination of the three language-related behaviors. MCS patients with no behavioral evidence of language function (i.e.,
MCS
–) were more functionally impaired than patients with
MCS
+ at time of transition and at discharge.
Conclusions
Command-following, intelligible verbalization, and intentional communication are not associated with different levels of functional disability. Thus, the
MCS
+ syndrome can be diagnosed based on the presence of any one of these language-related behaviors. Patients in
MCS
+ may evidence less functional disability compared to those in MCS who fail to demonstrate language function (i.e.,
MCS
–).
Journal Article
Preserved Feedforward But Impaired Top-Down Processes in the Vegetative State
Frontoparietal cortex is involved in the explicit processing (awareness) of stimuli. Frontoparietal activation has also been found in studies of subliminal stimulus processing. We hypothesized that an impairment of top-down processes, involved in recurrent neuronal message-passing and the generation of long-latency electrophysiological responses, might provide a more reliable correlate of consciousness in severely brain-damaged patients, than frontoparietal responses. We measured effective connectivity during a mismatch negativity paradigm and found that the only significant difference between patients in a vegetative state and controls was an impairment of backward connectivity from frontal to temporal cortices. This result emphasizes the importance of top-down projections in recurrent processing that involve high-order associative cortices for conscious perception.
Journal Article
The vegetative state
Summary points The vegetative state is a complex neurological condition in which patients appear to be awake but show no sign of awareness of themselves or their environment Current clinical methods of diagnosis are limited in scope, evidenced by a high rate (about 40%) of misdiagnosis (that is, patients who are aware are considered to be unconscious) The main causes of misdiagnosis are associated with a patient's disability (such as blindness), confusion in terminology, and lack of experience of this relatively rare condition Furthermore, standard behavioural assessments cannot distinguish an aware (that is, minimally conscious) but completely immobile patient from a non-aware patient (one with vegetative state) In such behaviourally non-responsive patients, functional neuroimaging methods (such as magnetic resonance imaging or electroencephalography) can detect residual cognition and awareness and can even establish two way communication, without requiring any behavioural output from patients Current guidelines should therefore be modified to include functional neuroimaging as an independent source of diagnostically relevant information The vegetative state may develop suddenly (as a consequence of traumatic or non-traumatic brain injury, such as hypoxia or anoxia; infection; or haemorrhage) or gradually (in the course of a neurodegenerative disorder, such as Alzheimer's disease). Misdiagnosis has many implications for a patient's care-such as day to day management, access to early interventions, and quality of life-and has ethical and legal ramifications pertaining to decisions on the discontinuation of life supporting therapies. 2 w2-w4 Overall, our understanding of the vegetative state is incomplete. The 2003 guidance from the UK's Royal...
Journal Article