Neuroethics and neuroimaging: moving toward transparency

Without exaggeration, it could be said that we are entering a golden age of neuroscience. Informed by recent developments in neuroimaging that allow us to peer into the working brain at both a structural and functional level, neuroscientists are beginning to untangle mechanisms of recovery after brain injury and grapple with age-old questions about brain and mind and their correlates neural mechanisms and consciousness. Neuroimaging, coupled with new diagnostic categories and assessment scales are helping us develop a new diagnostic nosology about disorders of consciousness which will likely improve prognostication and suggest therapeutic advances. Historically such diagnostic refinement has yield therapeutic advances in medicine and there is no reason to doubt that this will be the case for disorders of consciousness, perhaps bringing relief to a marginalized population now on the periphery of the therapeutic agenda. In spite of this promise, the translation of research findings into the clinical context will be difficult. As we move from descriptive categories about disorders of consciousness, like the vegetative or minimally conscious states, to ones further specified by integrating behavioral and neuroimaging findings, humility not hubris should be the virtue that guides the ethical conduct of research and practice.

Does any aspect of mind survive brain damage that typically leads to a persistent vegetative state? Ethical considerations

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness.

Using functional magnetic resonance imaging to detect covert awareness in the vegetative state

The assessment of patients with disorders of consciousness, including the vegetative state, is difficult and depends frequently on subjective interpretations of the observed spontaneous and volitional behavior. For those patients who retain peripheral motor function, rigorous behavioral assessment supported by structural imaging and electrophysiological findings is usually sufficient to establish a patient's level of wakefulness and awareness. However, it is becoming increasingly apparent that in some patients damage to the peripheral motor system may prevent overt responses to command although the cognitive ability to perceive and understand such commands may remain intact. Recent advances in functional neuroimaging suggest a novel solution to this problem; in several cases, so-called activation studies have been used to identify residual cognitive function and conscious awareness in patients who are assumed to be in a vegetative state yet retain cognitive abilities that have evaded detection using standard clinical methods.

Do vegetative patients retain aspects of language comprehension? Evidence from fMRI

A diagnosis of vegetative state is made if a patient demonstrates no evidence of awareness of self or environment, no evidence of sustained, reproducible, purposeful or voluntary behavioural response to sensory stimuli and critically no evidence of language comprehension. For those patients who retain peripheral motor function, rigorous behavioural assessment is usually able to determine retained function. However, some patients do not retain the ability to respond overtly to command and it is becoming increasingly accepted that assessment of these patients should include techniques, which do not rely on any 'motor action' on the part of the patient. Here, we apply a hierarchical functional magnetic resonance imaging (fMRI) auditory processing paradigm to determine the extent of retained language processing in a group of 14 aetiologically heterogeneous patients who met the diagnostic criteria for either the vegetative state (n = 7), the minimally conscious state (n = 5), or who were in a severely disabled condition having emerged from a minimally conscious state (n = 2). Three different levels of speech processing were assessed: (i) Low-level auditory responses were measured using a contrast between a set of auditory stimuli and a silence baseline; (ii) mid-level speech perception processing abilities were assessed by comparing intelligible speech to unintelligible noise stimuli and (iii) high-level semantic aspects of speech processing were assessed by comparing sentences that were made difficult to understand by the presence of words that were semantically ambiguous compared to matched low-ambiguity sentences. As expected the two severely disabled, but conscious patients showed preserved speech processing at all three levels. However, contrary to the diagnostic criteria defining the vegetative state, three patients (1 traumatic, 2 non-traumatic aetiology) demonstrated some evidence of preserved speech processing. The remaining four patients (1 traumatic, 3 non-traumatic aetiology) with a diagnosis of vegetative state showed no significant activation in response to sound compared with silence. These results provide further evidence that a subset of patients fulfilling the behavioural criteria for the vegetative state retain islands of preserved cognitive function.

The accuracy of surrogate decisions in intensive care scenarios

Critically ill patients are often unable to make decisions about life-sustaining treatments and surrogate decision-makers are relied upon. However, it is unclear how accurately the surrogates' decisions reflect patients' intentions and expectations. We interviewed 36 pairs of patients and their appointed surrogate decision-makers about their decisions regarding nine treatments in each of three scenarios. The scenarios were persistent vegetative state, coma with likely neurological damage and chronic disease with dementia. The patients were interviewed 24 hours after they had undergone elective surgery under general anaesthesia. The surrogates were interviewed separately by the same interviewer. There was poor agreement between decisions made by the patients and their surrogates. The patients' and surrogates' summary scores (median (interquartile range) [range]) for treatments were 0 (0-4) [0-9] vs 8 (0-9) [0-9] for the vegetative state scenario, 3 (0-9) [0-9] vs 9 (0-9) [0-9] for the coma scenario and 3 (0-9) [0-9] vs 9 (4-9) [0-9] for the chronic disease scenario. The significantly higher surrogate scores suggest that the surrogates' decisions would have resulted in the patients having far more treatment than the patients would have wanted. In our participants, there was poor agreement between the decisions made by surrogates and patients. Further study is needed on measures such as facilitated discussions, advance directives and the difficulties that surrogates face, in order to improve the accuracy of surrogates' decisions and respect of patients' autonomy.

Comment on "Detecting awareness in the vegetative state"

In a report of a single patient in a persistent vegetative state, Owen et al. (Brevia, 8 September 2006, p. 1402) claimed that the presence of task-specific brain activation in response to verbal command implies both covert conscious awareness and a capacity for intention. We argue that neither can be securely inferred from the evidence presented.

Development of a music therapy assessment tool for patients in low awareness states

People in low awareness states following profound brain injury typically demonstrate subtle changes in functional behaviors which challenge the sensitivity of measurement tools. Failure to identify and measure changes in functioning can lead to misdiagnosis and withdrawal of treatment with this population. Thus, the development of tools which are sensitive to responsiveness is of central concern. As the auditory modality has been found to be particularly sensitive in identifying responses indicating awareness, a convincing case can be made for music therapy as a treatment medium. However, little has been recommended about protocols for intervention or tools for measuring patient responses within the music therapy setting. This paper presents the rationale for an assessment tool specifically designed to measure responses in the music therapy setting with patients who are diagnosed as minimally conscious or in a vegetative state. Developed over fourteen years as part of interdisciplinary assessment and treatment, the music therapy assessment tool for low awareness states (MATLAS) contains fourteen items which rate behavioral responses across a number of domains. The tool can provide important information for interdisciplinary assessment and treatment particularly in the auditory and communication domains. Recommendations are made for testing its reliability and validity through research.

Detecting awareness in the vegetative state

We used functional magnetic resonance imaging to demonstrate preserved conscious awareness in a patient fulfilling the criteria for a diagnosis of vegetative state. When asked to imagine playing tennis or moving around her home, the patient activated predicted cortical areas in a manner indistinguishable from that of healthy volunteers.

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.

Extreme measures: a personal story of letting go

The decision to withdraw life support from a loved one, especially in the absence of an advance directive, can be complicated and painful. This article is the author's personal account of her brother's brain injury, his resulting condition, and the choice made to allow his death. In addition, the author discusses how this experience affected her perspective on Terri Schiavo's death.

What would Terri want? On the psychological challenges of surrogate decision making

The Terri Schiavo case was unique in the media attention it garnered, but the decision making challenges faced by Terri's family are common ones encountered by all families who must make choices about the use of life-sustaining medical treatment for an incapacitated loved one. This article highlights three key issues that were particularly problematic in the Schiavo case, but that represent general psychological challenges inherent to the task of surrogate decision making. The 3 central points of uncertainty, and therefore conflict, in the Schiavo case concerned: (a) the appropriate standard by which medical decisions for Terri should be made, (b) the specific nature of Terri's wishes about the use of life-sustaining medical technology, and (c) the true extent of disability and prognosis for recovery represented by Terri's medical condition. No simple remedy is possible that will resolve all of the uncertainties inherent to surrogate decision making, but some general strategies for improving the quality of end-of-life medical decisions are discussed.

Implications of the Schiavo case for understanding family caregiving issues at the end of life

The case of Mrs. Terri Schiavo illustrates common themes in family caregiving at the end of life but is distinctive from most family caregiving situations in other ways. As occurred in Mrs. Schiavo's case, family members do act as both caregivers and decisionmakers for their loved ones at the end of life, often without the benefit of written advance directives. Family stress and conflict may result, yet seldom lead to court proceedings, legislative intervention, and media coverage as occurred in the Schiavo case. The importance of informal conflict resolution and the limitations of adversarial legal approaches are discussed.

Drug induced arousal from the permanent vegetative state

BACKGROUND

Zolpidem is an omega 1 specific indirect GABA agonist that is used for insomnia, but may have efficacy in brain damage. The long term efficacy of zolpidem in the permanent vegetative state is described in three patients.

METHOD

Two motor vehicle accident patients and one near drowning patient, all of them in the permanent vegetative state for at least three years, were rated according to the Glasgow Coma and Rancho Los Amigos scale before and after zolpidem application. Long term response to daily application of this drug was monitored for 3-6 years.

RESULTS

All patients were aroused transiently every morning after zolpidem. Glasgow Coma Scale scores ranged from 6-9/15 before to 10-15/15 after zolpidem. Rancho Los Amigos Cognitive scores ranged from I-II before to V-VII afterward. Drug efficacy did not decrease and there were no long term side effects after 3-6 years daily use.

CONCLUSION

Zolpidem appears an effective drug to restore brain function to some patients in the permanent vegetative state.

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.

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.

fMRI reveals large-scale network activation in minimally conscious patients

BACKGROUND

The minimally conscious state (MCS) resulting from severe brain damage refers to a subset of patients who demonstrate unequivocal, but intermittent, behavioral evidence of awareness of self or their environment. Although clinical examination may suggest residual cognitive function, neurobiological correlates of putative cognition in MCS have not been demonstrated.

OBJECTIVE

To test the hypothesis that MCS patients retain active cerebral networks that underlie cognitive function even though command following and communication abilities are inconsistent.

METHODS

fMRI was employed to investigate cortical responses to passive language and tactile stimulation in two male adults with severe brain injuries leading to MCS and in seven healthy volunteers.

RESULTS

In the case of the patient language-related tasks, auditory stimulation with personalized narratives elicited cortical activity in the superior and middle temporal gyrus. The healthy volunteers imaged during comparable passive language stimulation demonstrated responses similar to the patients' responses. However, when the narratives were presented as a time-reversed signal, and therefore without linguistic content, the MCS patients demonstrated markedly reduced responses as compared with volunteer subjects, suggesting reduced engagement for "linguistically" meaningless stimuli.

CONCLUSIONS

The first fMRI maps of cortical activity associated with language processing and tactile stimulation of patients in the minimally conscious state (MCS) are presented. These findings of active cortical networks that serve language functions suggest that some MCS patients may retain widely distributed cortical systems with potential for cognitive and sensory function despite their inability to follow simple instructions or communicate reliably.

[Allowing a patient in a vegetative state to die in hospital under the direction of a nursing-home physician]

In the case of a 52-year-old man, who was in a vegetative state after resuscitation following an unwitnessed cardiac arrest, the nursing-home physician assumed responsibility for the total treatment in a transfer unit of the hospital. His systematic, multidisciplinary approach enabled direction of the complex situation in which many medical and paramedical personnel were involved. When an airway infection occurred as a complication shortly after responsibility for the patient had been assumed, the nursing-home physician could take a well-considered decision to withdraw medical treatment on the basis of the treatment plan which had been formulated in a short time and contact with the family. In clinical practice it is difficult to determine the most appropriate moment to withdraw all medical therapy, including artificial nutrition and hydration, in order to prevent a hopeless vegetative state. This case illustrates how hospital physicians and nursing-home physicians may cooperate during the 'waiting phase' of the clinical course of a vegetative state. A hopeless vegetative state can be prevented by using these transmural possibilities for cooperation, including an early input of knowledge and experience about the long-term course of a vegetative state.

The minimally conscious state: defining the borders of consciousness

There is no agreement as to where the limits of consciousness lie, or even if these putative borders exist. Problems inherent to the study of consciousness continue to confound efforts to establish a universally accepted theory of consciousness. Consequently, clinical definitions of consciousness and unconsciousness are unavoidably arbitrary. Recently, a condition of severely altered consciousness has been described, which characterizes the borderzone between the vegetative state and so-called "normal" consciousness. This condition, referred to as the minimally conscious state (MCS), is distinguished from the vegetative state by the presence of minimal but clearly discernible behavioral evidence of self or environmental awareness. This chapter reviews the diagnostic criteria, pathophysiology, prognostic relevance, neurobehavioral assessment procedures and treatment implications associated with MCS.

Event-related potential measures of consciousness: two equations with three unknowns

This is a brief review of event-related brain potentials (ERPs) as indices of cortical information processing in conditions in which conscious perception of stimuli is supposed to be absent: sleep, coma, vegetative state, general anesthesia, neglect as well as presentation of subliminal or masked stimuli. Exogenous ERP components such as N1 and P2 are much more likely to remain in all these conditions than endogenous components. Further, all varieties of the late posterior positive ERP waves (e.g., P3b, P600, late positive complex) are most difficult to be elicited in such conditions, indicating that the cortical activity underlying the late posterior positivity may have a particularly close relationship to brain mechanisms of conscious perception. Contrary to what might be expected, reliable ERP effects indicating complex analysis of semantic stimulus features (i.e., meaning) can be recorded without conscious awareness, generally, as easy as (in some conditions, even easier than) ERP components related to rather simple physical stimulus features. It should be emphasized, however, that we never should overestimate our confidence about the degree of subjects' unawareness. Particularly in the conditions in which no behavioral response can be obtained (e.g., sleep, coma, anesthesia), residual conscious processing, at least in some subjects and on some trials, cannot be ruled out.

Persistent But Reversible Coma in Encephalitis

INTRODUCTION

Nontraumatic coma in adults has a poor prognosis, and late recovery of consciousness is unlikely. Functional recovery is usually extremely poor. However, a few nontraumatic comatose patients have shown late recovery of both awareness and function.

METHODS

A retrospective survey was conducted by reviewing the medical records of all inpatients to our department during the 1990s. Patients with persistent but reversible nontraumatic coma were identified according to the following criteria: (a) deep coma with a Glasgow Coma Scale (GCS) score of 7 or less on admission; (b) nontraumatic cause; (c) persistence of unconsciousness for longer than 1 month; and (d) subsequent recovery of GCS (total) to normal. The clinical spectrum of patients meeting these criteria was evaluated.

RESULTS

Six patients (ages 16-75 years) met the criteria. Viral encephalitis was diagnosed in five (two with herpes simplex virus, two with cytomegalovirus, and one with Epstein-Barr virus or cytomegalovirus). Two young female patients with encephalitis manifested extremely protracted coma persisting for 3 and 18 months, respectively. Complications included nonconvulsive status epilepticus in two patients and relative overdose of clonazepam in one patient.

CONCLUSION

Recognition of the clinical spectrum of persistent but reversible nontraumatic coma is important.

Using a hierarchical approach to investigate residual auditory cognition in persistent vegetative state

Persistent vegetative state is arguably one of the least understood and most ethically troublesome neurological conditions in modern medicine. The term describes a rare disorder in which patients who emerge from coma appear to be awake, but show no signs of awareness. In recent years, a number of studies have demonstrated an important role for functional neuroimaging in the identification of residual cognitive function in patients meeting the clinical criteria for persistent vegetative state. Such studies, when successful, may be particularly useful where there is a concern about the accuracy of the diagnosis and the possibility that residual cognitive function has remained undetected. Unfortunately, functional neuroimaging in persistent vegetative state is extremely complex and subject to numerous methodological, clinical and theoretical difficulties. In this chapter, we argue that in order to most effectively define the degree and extent of preserved cognitive function in persistent vegetative state, a hierarchical approach to cognition is required. To illustrate this point, a series of functional neuroimaging paradigms in the auditory domain are described, which systematically increase in complexity in terms of the auditory and/or linguistic processes required and, therefore, the degree of preserved cognition that can be inferred from "normal" patterns of activation in persistent vegetative patients. Preliminary results in a small series of patients provide a strong basis for the systematic study of possible residual cognitive function in persistent vegetative state.

Further recovery in a potential treatment withdrawal case 10 years after brain injury

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.

Auditory processing in severely brain injured patients: differences between the minimally conscious state and the persistent vegetative state

BACKGROUND

The minimally conscious state (MCS) is a recently defined clinical condition; it differs from the persistent vegetative state (PVS) by the presence of inconsistent, but clearly discernible, behavioral evidence of consciousness.

OBJECTIVE

To study auditory processing among patients who are in an MCS, patients who are in a PVS, and healthy control subjects.

METHODS

By means of (15)O-radiolabeled water-positron emission tomography, we measured changes in regional cerebral blood flow induced by auditory click stimuli in 5 patients in an MCS, 15 patients in a PVS, and 18 healthy controls.

RESULTS

In both patients in an MCS and the healthy controls, auditory stimulation activated bilateral superior temporal gyri (Brodmann areas 41, 42, and 22). In patients in a PVS, the activation was restricted to Brodmann areas 41 and 42 bilaterally. We also showed that, compared with patients in a PVS, patients in an MCS demonstrated a stronger functional connectivity between the secondary auditory cortex and temporal and prefrontal association cortices.

CONCLUSIONS

Although assumptions about the level of consciousness in severely brain injured patients are difficult to make, our findings suggest that the cerebral activity observed in patients in an MCS is more likely to lead to higher-order integrative processes, thought to be necessary for the gain of conscious auditory perception.

Respect for the developmentally disabled and forgoing life-sustaining treatment

A developmentally disabled person should be treated at all times as a unique individual and not as some anonymous "disabled person." The developmentally disabled should not be subjected to invasive medical treatment that is unduly burdensome or nonbeneficial, or be forced to endure a quality of life not meaningful to them as individuals. They have a right to refuse or accept treatment that a surrogate must exercise on behalf of each individual in a responsible and careful manner. Three cases and a preliminary approach to the ethical analysis of decisions to allow developmentally disabled persons to die by forgoing medical treatment are offered. The "best interests" of a developmentally disabled individual, properly understood, can serve as a useful and ethically defensible standard for determining the ethical propriety of surrogate decision making about forgoing life-sustaining medical treatment of the disabled.

Emotional adjustment following cognitive recovery from 'persistent vegetative state': psychological and personal perspectives

Previously, the cognitive recovery of a 26 year old woman, Kate, who developed a severe encephalomyelopathy and was in a 'minimally conscious/persistent vegetative state' for 6 months was reported. After 6 months, Kate began to respond to her environment and, at 2 years post-illness, neuropsychological assessment indicated that Kate was functioning within the normal range on tests of general intellectual functioning, executive functioning and most memory functions (with the exception of visual recognition memory). Although Kate has a severe dysarthria necessitating the use of a communication board and severe physical disabilities that require her to use a wheelchair, she has demonstrated an almost complete cognitive recovery and is among a tiny percentage of minimally conscious patients to do so. This single case report describes the emotional factors central to Kate's rehabilitation. Using a newly developed model of cognitive rehabilitation as a framework, the pivotal role that emotional and psychological factors played in Kate's adjustment to the consequences of her illness and the role of psychotherapeutic intervention in facilitating this adjustment are discussed.

Early rehabilitative concepts in therapy of the comatose brain injured patients

OBJECTIVES

To evaluate the changes of vegetative parameters and behavioural assessment in comatose patients after severe brain injury during the Multimodal-Early-Onset-Stimulation (MEOS) in early rehabilitation.

MATERIAL AND METHODS

We studied 16 predominantly male (3:1) patients, age mean 43.6 (16-77) years. Mean coma duration was 22.2 (8-41) days, therapy duration (MEOS) 9.8 (1-30) days. The initial GCS was 6.6 (3-9), KRS 5.3 (0-15). Including criteria for therapy: Severe head trauma, coma for at least 48 hours (GCS < 8), vegetative stability, normal intracranial pressure, abandon of mechanical ventilation, sedation and severe infections. MEOS was finished in achieving GCS > 9, follow-up investigations were made after 2 years.

RESULTS

We identified significant changes in two vegetative parameters (heart/respiratory frequencies), even in deep coma (GCS 3-4). Most significant changes were caused by tactile and acoustic stimulation. Standardized behavioural assessment turned out to be particularly advisable in cases of medium coma (GCS 5-7). Stimulation of tactile and acoustic senses resulted mainly in mimical, head and eye movements. Follow-up was possible in 14 patients: One remained in a vegetative state (GOS 2), two exhibited severe neurologic/neuropsychologic deficits, depending on care (GOS 3), six substained major functional deficits (GOS 4), at though they were able to perform the tasks of daily life on their own, three patients reached GOS 5. Two returned to their former jobs.

DISCUSSION AND CONCLUSION

The present results indicate that stimulation therapy should be based on a close observation of patterns of behaviour, and, at least in deep coma stages, involve the registration of vegetative parameters. It may be sensitive to identify parameters predicting a favourable or unfavourable outcome. Preliminary data seem to support the hypothesis that the absence of any response to external stimuli is indicative of an unfavourable outcome.

Agitation assessment in severe traumatic brain injury: methodological and clinical issues

The aim of this single case study was to evaluate the applicability of a graphic and statistical time-series analyses in the observation of an agitation disturbance in a 16-year-old patient who had sustained a severe traumatic brain injury. The agitation was measured using the Agitated Behaviour Scale. The experimental model was of the A-B type: phase A corresponded to the period of vegetative state, and phase B to the period following the reawakening from coma. The data were submitted to visual and statistical analysis by the split-middle trend line method, function of autocorrelation, and C statistic. The results show the different nature and frequency of the agitated behaviour during the vegetative state and after reawakening from coma. The application of a statistical analysis to establish whether the behavioural disturbance is random or a response to the environment allows the adoption of specific and potentially more efficacious treatments.

Cognitive recovery from "persistent vegetative state": psychological and personal perspectives

This study reports on the case of a young woman who, at the age of 26, developed a severe encephalomyelopathy and was in a vegetative state or minimally conscious state for 6 months. She showed a sleep-wake cycle, but no evidence of cognitive functioning. Six months after her illness, she began to respond to her environment and eventually returned home to the care of her parents, with regular periods of respite care in a home for people with severe physical disabilities. She remains in a wheelchair with a severe dysarthria and communicates via a letter board. Two years after her illness, staff at the home requested an assessment of her cognitive functioning. On the WAIS-R verbal scale and the Raven's Progressive Matrices, the woman's scores were in the normal range. So too were her recognition of real versus nonsense words and her memory functioning (apart from a visual recognition memory test which was in the impaired range). Although she enjoyed the tests, she became distressed when asked about her illness and previous hospitalization. She was reassessed 1 year later, when there were few significant changes in her test scores but she could talk about her illness and hospitalization without becoming distressed. She was angry, however, about her experiences in the first hospital. Further tests suggested good executive functioning. In short, this woman's cognitive functioning is in the normal range for most tasks assessed, despite a severe physical disability and dysarthria, and despite the fact that she was vegetative for 6 months. Although some recovery following 6 months of being vegetative/minimally conscious is not unknown, it is rare, particularly for those with non-traumatic injuries, and the majority of people similarly affected remain with significant cognitive deficits. This client has, by and large, made an almost complete cognitive recovery. She feels positive about her life now and says the formal assessment showed people she was not stupid and this made her happy. The paper concludes with the young woman's own comments and views about what happened to her and her present feelings.

Neuropsychological assessment of a potential "euthanasia" case: a 5 year follow up

McMillan reported a neuropsychological assessment procedure which was used to determine whether or not there was evidence for sentience in a young woman who had been rendered tetraplegic and anarthric as a result of a road traffic accident. An application to court had been made to withdraw feeding and this was supported by medical evidence which gave the view that the individual was functioning little beyond vegetative state, had a poor quality of life and had little prospect of further recovery. Evidence for an ability to communicate reliably was found including for a wish to continue living, and as a consequence the application to court was withdrawn. This paper describes further recovery 2-4 years after the original assessment (i.e. 4-6 years post-injury). At follow-up, she remained dependent for all care, but was now feeding orally and was talking. She could learn new information, some of which she retained for at least 12 months and had greater insight into her condition. She now reported low mood and some pain. As before, she consistently reported a wish to live. The implications of the follow-up are discussed in the context of assumptions made about quality of life and decision making about euthanasia in brain injured people who are severely disabled, but are not in a vegetative state.

Words without mind

A woman (LR), unconscious for 20 years, spontaneously produces infrequent, isolated words unrelated to any environmental context. Fluorodeoxy-glucose-positron emission tomography (FDG-PET) imaging coregistered with magnetic resonance imaging (MRI) revealed a mean brain metabolism equivalent to deep anesthesia. Nevertheless, PET imaging demonstrated islands of modestly higher metabolism that included Broca's and Wernicke's areas. Functional brain imaging with magnetoencephalographic (MEG) imaging, a technique providing a temporal resolution of better than 1 msec, identified preserved dynamic patterns of spontaneous and evoked brain activity in response to sensory stimulation. Specifically, we examined spontaneous gamma-band activity (near 40 Hz) and its reset or modification during early auditory processing, a measure that correlated with human perception of sensory stimuli (Joliot, Ribary, & Llinás, 1994). Evidence of abnormal and incomplete gamma-band responses appeared in the left hemisphere only in response to auditory or somatosensory stimulation. MEG single-dipole reconstructions localized to the auditory cortex in the left hemisphere and overlapped with metabolically active regions identified by FDG-PET. The observation demonstrates that isolated neuronal groups may express well-defined fragments of activity in a severely damaged, unconscious brain. The motor fixed-action pattern character of her expressed words supports the notion of brain modularity in word generation.

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.