Epidemiological studies on patients with a persistent vegetative state

One-Year Demographical and Clinical Indices of Patients with Chronic Disorders of Consciousness

This work aims to evaluate the prognostic value of the demographical and clinical data on long-term outcomes (up to 12 months) in patients with severe acquired brain injury with vegetative state/unresponsive wakefulness syndrome (VS/UWS/UWS) or a minimally conscious state (MCS). Patients (n = 211) with VS/UWS/UWS (n = 123) and MCS (n = 88) were admitted to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology after anoxic brain injury (n = 53), vascular lesions (n = 59), traumatic brain injury (n = 93), and other causes (n = 6). At the beginning of the 12-month study, younger age and a higher score by the Coma Recovery Scale-Revised (CRS-R) predicted a survival. However, no reliable markers of significant positive dynamics of consciousness were found. Based on the etiology, anoxic brain injury has the most unfavorable prognosis. For patients with vascular lesions, the first three months after injury have the most important prognostic value. No correlations were found between survival, increased consciousness, and gender. The demographic and clinical characteristics of patients with chronic DOC can be used to predict long-term mortality in patients with chronic disorders of consciousness. Further research should be devoted to finding reliable predictors of recovery of consciousness.

Recovery of Cognitive and Behavioural Function During Long-term Inpatient Rehabilitation in Patients with Moderate-To-Severe Traumatic Brain Injury: Evaluation of a Retrospective Case Series

OBJECTIVE

To elucidate the characteristics of recovery progression during long-term rehabilitation after moderate-to-severe traumatic brain injury.

METHODS

Longitudinal changes in consciousness, swallowing disorders, activities of daily living, and psychological and behavioural status were studied in 7 patients with moderateto-severe traumatic brain injury, using scores of the National Agency for Automotive Safety & Victim's Aid (NASVA score), Glasgow Coma Scale (GCS), Dysphagia Severity Scale (DSS), Eating Status Scale (ESS), Functional Independence Measure (FIM), Cognitive-related Behavioural Assessment (CBA), and Neuropsychiatric Inventory (NPI). Scores were collected every month until discharge (median 359 days after injury), or until the study end date for those patients who remained hospitalized (432 days).

RESULTS

Patients were qualitatively classified into those who improved well in the early phase, in terms of consciousness, swallowing, and activities of daily living, and those with less or delayed improvement. Psychological and behavioural difficulties appeared to remain less improved than the other functions for longer periods in many patients. Statistical comparisons that included all 7 patients revealed a significant improvement in NASVA score, GCS, DSS, and ESS, but not in FIM, CBA, and NPI at discharge/at the last measurement compared with scores at admission.

CONCLUSION

Swallowing function is more responsive to long-term rehabilitation in patients with moderate-to-severe traumatic brain injury, while neuropsychiatric and behavioural difficulties tend to persist for longer periods.

Multidisciplinary attentive treatment for patients with chronic disorders of consciousness following severe traumatic brain injury in the NASVA of Japan

Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.

How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding?

OBJECTIVE:

To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country.

METHOD:

Identification of studies on people with a PDOC giving information about incidence, and/or prevalence, and/or cause, and/or location of long-term care. Sources included systematic reviews, a new search of MEDLINE (April 2018), and a personal collection of papers. Validating information was sought from existing data on services.

RESULTS:

There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term care in nursing homes, but a significant proportion (10%-15%) may be cared for at home.

CONCLUSION:

Each year, about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time, there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater.

Care pathways models and clinical outcomes in Disorders of consciousness

OBJECTIVE

Patients with Disorders of consciousness, are persons with extremely low functioning levels and represent a challenge for health care systems due to their high needs of facilitating environmental factors. Despite a common Italian health care pathway for these patients, no studies have analyzed information on how each region have implemented it in its welfare system correlating data with patients' clinical outcomes.

MATERIALS AND METHODS

A multicenter observational pilot study was realized. Clinicians collected data on the care pathways of patients with Disorder of consciousness by asking 90 patients' caregivers to complete an ad hoc questionnaire through a structured phone interview. Questionnaire consisted of three sections: sociodemographic data, description of the care pathway done by the patient, and caregiver evaluation of health services and information received.

RESULTS

Seventy-three patients were analyzed. Length of hospital stay was different across the health care models and it was associated with improvement in clinical diagnosis. In long-term care units, the diagnosis at admission and the number of caregivers available for each patient (median value = 3) showed an indirect relationship with worsening probability in clinical outcome. Caregivers reported that communication with professionals (42%) and the answer to the need of information were the most critical points in the acute phase, whereas presence of Non-Governmental Organizations (25%) and availability of psychologists for caregivers (21%) were often missing during long-term care. The 65% of caregivers reported they did not know the UN Convention on the Rights of Persons with Disabilities.

CONCLUSION

This study highlights relevant differences in analyzed models, despite a recommended national pathway of care. Future public health considerations and actions are needed to guarantee equity and standardization of the care process in all European countries.

Automatic detection of periods of slow wave sleep based on intracranial depth electrode recordings

BACKGROUND

An automated process for sleep staging based on intracranial EEG data alone is needed to facilitate research into the neural processes occurring during slow wave sleep (SWS). Current manual methods for sleep scoring require a full polysomnography (PSG) set-up, including electrooculography (EOG), electromyography (EMG), and scalp electroencephalography (EEG). This set-up can be technically difficult to place in the presence of intracranial EEG electrodes. There is thus a need for a method for sleep staging based on intracranial recordings alone.

NEW METHOD

Here we show a reliable automated method for the detection of periods of SWS solely based on intracranial EEG recordings. The method utilizes the ratio of spectral power in delta, theta, and spindle frequencies relative to alpha and beta frequencies to classify 30-s segments as SWS or not.

RESULTS

We evaluated this new method by comparing its performance against visually scored patients (n=9), in which we also recorded EOG and EMG simultaneously. Our method had a mean positive predictive value of 64% across all nights. Also, an ROC analysis of the performance of our algorithm compared to manually labeled nights revealed a mean average area under the curve of 0.91 across all nights.

COMPARISON WITH EXISTING METHOD

Our method had an average kappa score of 0.72 when compared to visual sleep scoring by an independent blinded sleep scorer.

CONCLUSION

This shows that this simple method is capable of differentiating between SWS and non-SWS epochs reliably based solely on intracranial EEG recordings.

WITHDRAWN: The unresponsive-wakefulness syndrome: A seismic shift in etiology?

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Researching patients in the vegetative state: Difficulties of studying this patient group

It is now generally accepted that all patient groups should benefit from the potential advances in knowledge and understanding that result from clinical research. Despite this principle, patients in the vegetative state remain a group that has been chronically under-researched by neuroscientists because complex ethical questions and logistical dilemmas are raised by such research.

The vegetative state is one of the best known but least understood of neurological conditions. It affects a small but significant number of people who make a poor recovery after sustaining a brain injury and has been brought to public attention through high profile cases in the UK and the USA. This paper defines the vegetative state and explores four important issues that should be considered when planning clinical research in this field. It is demonstrated that not only is it possible to undertake such research but also that there needs to be more of it so that greater numbers of patients and their families will benefit.

Cardiopulmonary arrest is the most frequent cause of the unresponsive wakefulness syndrome: A prospective population-based cohort study in Austria

BACKGROUND

The "Unresponsive wakefulness syndrome" (UWS) or previously termed vegetative state is a possible consequence of severe brain damage where individuals just open their eyes but show no conscious behavioural reaction. While head trauma has previously been considered the prevailing cause, clinical experience suggests shows that cardiopulmonary arrest plays an increasingly important role. We therefore attempted to study this hypothesis in a well-defined region of Austria.

METHODS

Prospective population-based cohort study to calculate the incidence and aetiologies of the UWS. All facilities in the state of Styria (n=38), which are involved in the medical care of patients with brain damage, participated. Among the adult population of Styria (n=1010,164) we identified all individuals who developed UWS over a one year period. The diagnosis was based on a formal neurologic evaluation at least 4 weeks after the brain damage and had to be in line with the criteria of the "Multi-society Task Force on Persistent Vegetative State".

RESULTS

We identified 19 individual with UWS which correspond to an annual incidence of 1.88/100,000 people. Male gender predominated (78.9%) and the mean age was 57.8 years (age range 18-78 years). The most frequent cause of UWS was cerebral hypoxia in the wake of cardiopulmonary resuscitation (63%), cerebral bleeding (21%) and brain trauma (16%).

CONCLUSIONS

Cardiopulmonary resuscitation has become the major cause of UWS which leads to an increasing incidence with age. These aspects may become even more prominent with the ageing of our population and need to be considered in the organisation of care.

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.

Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury

OBJECTIVE

To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission.

DESIGN

Retrospective study.

SETTING

Rehabilitation center.

PARTICIPANTS

From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Recovery of consciousness and the FIM instrument.

RESULTS

Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology.

CONCLUSIONS

Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.

Do rehospitalization rates differ among injury severity levels in the NIDRR Traumatic Brain Injury Model Systems program?

OBJECTIVE

To compare the rate and nature of rehospitalization in a cohort of patients enrolled in the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems (TBIMS) who have disorders of consciousness (DOC) at the time of rehabilitation admission with those in persons with moderate or severe traumatic brain injury (TBI) but without DOC at rehabilitation admission.

DESIGN

Prospective observational study.

SETTING

Inpatient rehabilitation within TBIMS with annual follow-up.

PARTICIPANTS

Of 9028 persons enrolled from 1988 to 2009 (N=9028), 366 from 20 centers met criteria for DOC at rehabilitation admission and follow-up data, and another 5132 individuals met criteria for moderate (n=769) or severe TBI (n=4363).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants and/or their family members completed follow-up data collection including questions about frequency and nature of rehospitalizations at 1 year postinjury. For the subset of participants with DOC, additional follow-up was conducted at 2 and 5 years postinjury.

RESULTS

The DOC group demonstrated an overall 2-fold increase in rehospitalization in the first year postinjury relative to those with moderate or severe TBI without DOC. Persons with DOC at rehabilitation admission have a higher rate of rehospitalization across several categories than persons with moderate or severe TBI.

CONCLUSIONS

Although the specific details of rehospitalization are unknown, greater injury severity resulting in DOC status on rehabilitation admission has long-term implications. Data highlight the need for a longitudinal approach to patient management.

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs

Few studies address the course of recovery from prolonged disorders of consciousness (DOC) after severe traumatic brain injury (TBI). This study examined acute and long-term outcomes of persons with DOC admitted to acute inpatient rehabilitation within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS). Of 9028 persons enrolled from 1988 to 2009, 396 from 20 centers met study criteria. Participants were primarily male (73%), Caucasian (67%), injured in motor vehicle collision (66%), with a median age of 28, and emergency department Glasgow Coma Scale (GCS) score of 3. Participant status was evaluated at acute rehabilitation admission and discharge and at 1, 2, and 5 years post-injury. During inpatient rehabilitation, 268 of 396 (68%) regained consciousness and 91 (23%) emerged from post-traumatic amnesia (PTA). Participants demonstrated significant improvements on GCS (z=16.135, p≤0.001) and Functional Independence Measure (FIM) (z=15.584, p≤0.001) from rehabilitation admission (median GCS=9; FIM=18) to discharge (median GCS=14; FIM=43). Of 337 with at least one follow-up visit, 28 (8%) had died by 2.1 years (mean) after discharge. Among survivors, 66 (21%) improved to become capable of living without in-house supervision, and 63 demonstrated employment potential using the Disability Rating Scale (DRS). Participants with follow-up data at 1, 2, and 5 years post-injury (n=108) demonstrated significant improvement across all follow-up evaluations on the FIM Cognitive and Supervision Rating Scale (p<0.01). Significant improvements were observed on the DRS and FIM Motor at 1 and 2 years post-injury (p<0.01). Persons with DOC at the time of admission to inpatient rehabilitation showed functional improvement throughout early recovery and in years post-injury.

Events and decision-making in the long-term care of Dutch nursing home patients in a vegetative state

OBJECTIVE

To clarify characteristics of long-term care and treatment of patients in a vegetative state.

DESIGN

Qualitative, descriptive study in a Dutch nursing home.

METHODS

Review of clinical records of patients in a vegetative state after acute brain damage between 1978-2002.

RESULTS

Five patients received intensive care of a multi-disciplinary team and showed considerable co-morbidity. There was no standard scenario for end-of-life decisions. Physicians play a more proactive role by evaluating the total medical treatment instead of withholding therapy in case of incidental complications. The families' attitude is a crucial factor in their ultimate decision.

CONCLUSIONS

There is no standard solution to alleviate the fate of patients in a vegetative state and their families. Withdrawing all medical treatment, including artificial nutrition and hydration, can be an acceptable scenario for letting the patient die. More research is needed to identify the factors that contribute to acceptance of the physician's decision by the family.

A multimodal approach to the assessment of patients with disorders of consciousness

Unlike other neurological conditions, the heterogeneous pathology linked to disorders of consciousness currently excludes a distinction between the vegetative and minimally conscious states based upon pathological presentation. The clinical assessment is therefore made on the basis of the patient's clinical history and exhibited behaviour. This creates a particular challenge for the clinician who has to decide whether a certain behaviour, which might be inconsistent or incomplete, reflects a conscious or an unconscious process. In an alarmingly high number of cases, identified during clinical audit, this decision process has been shown to be particularly fallible. The behavioural assessment is not only highly subjective, but also dependent upon the ability of the patient to move or speak; it is the only way someone can demonstrate they are aware. To address this problem we propose a multimodal approach, which integrates objective tools, such as electrophysiology and functional brain imaging, with traditional behavioural scales. Together this approach informs the clinical decision process and resolves many of the dilemmas faced by clinicians interpreting solely behavioural indices. This approach not only provides objective information regarding the integrity of residual cognitive function, but also removes the dependency on the patient to move or speak by using specially designed paradigms that do not require a motor output in order to reveal awareness of self or environment. To demonstrate this approach we describe the case of BW, who sustained a traumatic brain injury seven months prior to investigation. BW was admitted to a five-day assessment programme, which implemented our multimodal approach. On behavioural assessment BW demonstrated evidence of orientation and visual pursuit. However, he showed no response to written or verbal command, despite holding command cards and scanning text. Electrophysiology confirmed that he retained a preserved neural axis supporting vision and hearing, and suggested some evidence that he was able to create a basic memory trace. A hierarchical fMRI auditory paradigm suggested he was able to perceive sound and speech, but revealed no evidence of speech comprehension or ability to respond to command. This was corroborated in the visual modality using a hierarchical paradigm demonstrating that he was able to perceive motion, objects and faces, but retained no evidence of being able to respond to command. We briefly review work by other teams advocating the use of brain imaging and electrophysiology and discuss the steps that are now required in order to create an international standard for the assessment of persons with impaired consciousness after brain injury.

Chronic disorders of consciousness

The vegetative state and the minimally conscious state are disorders of consciousness that can be acute and reversible or chronic and irreversible. Diffuse lesions of the thalami, cortical neurons, or the white-matter tracts that connect them cause the vegetative state, which is wakefulness without awareness. Functional imaging with PET and functional MRI shows activation of primary cortical areas with stimulation, but not of secondary areas or distributed neural networks that would indicate awareness. Vegetative state has a poor prognosis for recovery of awareness when present for more than a year in traumatic cases and for 3 months in non-traumatic cases. Patients in minimally conscious state are poorly responsive to stimuli, but show intermittent awareness behaviours. Indeed, findings of preliminary functional imaging studies suggest that some patients could have substantially intact awareness. The outcomes of minimally conscious state are variable. Stimulation treatments have been disappointing in vegetative state but occasionally improve minimally conscious state. Treatment decisions for patients in vegetative state or minimally conscious state should follow established ethical and legal principles and accepted practice guidelines of professional medical specialty societies.

Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes

OBJECTIVES

To establish the prevalence of vegetative state in Dutch nursing homes, describe the patient characteristics, and highlight the possible influence of medical decisions at the end of life.

DESIGN

A cross-sectional survey. The vegetative state was defined according to the Multi Society Task Force on PVS. All Dutch nursing homes were approached to provide data on patients in a vegetative state. In cases of doubt, the researcher discussed the diagnosis with the patient's physician and, if necessary, examined the patient. Information on patients in a vegetative state in care between 2000 and September 2003 and end of life decisions for them were also recorded.

RESULTS

All nursing homes and physicians participated. After assessment of 12 doubtful patients, 32 met the criteria of vegetative state lasting longer than one month, a prevalence of 2/1,000,000. Of these, 30 patients' data were analysed: age 9-90 years; 73% female; duration of vegetative state 2 months-20 years (26 surviving >1 year, 13 >5 years). Stroke was the commonest cause. Between 2000 and September 2003, there were 76 patients in a vegetative state in care of whom 34 died of complications and nine after withdrawal of artificial nutrition and hydration.

CONCLUSIONS

The prevalence of vegetative state in Dutch nursing homes has been established for the first time. The figures are lower than suggested in the literature. The study included a heterogeneous group of patients, of which a substantial number survived for many years. The results cannot be explained by a policy of systematically withdrawing artificial nutrition and hydration.

Levodopa treatment for patients in persistent vegetative or minimally conscious states

The persistent vegetative state (PVS) and the minimally conscious state (MCS) are conditions of altered consciousness after severe brain damage due to a variety of pathologies. However, the specific pathophysiological mechanisms and a therapeutic strategy for intervention have not as yet been established. We review previous reports of levodopa treatment for patients in PVS, MCS, or other mental disorders, and have focused on five representative cases: four of PVS and one of MCS after severe brain injury. In summary, our review suggests the effectiveness of levodopa treatment is probably dependent upon the following criteria: (1) Diagnosis of PVS or MCS as distinct from other related conditions, (2) Concomitant symptoms of parkinsonism, and (3) Concomitant neuroradiological findings of high intensity lesions in the dopaminergic pathway on T2 weighted MRI. The apparent success of levodopa in the five cases described may reflect a specific subgroup of PVS and MCS patients, where the administration of levodopa is effective. However, we should not regard PVS or MCS as a single entity, since levodopa is unlikely to be effective in all cases. Therapeutic strategies should aim to identify the key pathophysiological mechanism for each patient and target interventions accordingly.

Moderate and severe traumatic brain injury: epidemiologic, imaging and neuropathologic perspectives

This article examines 3 contexts in which moderate or severe traumatic brain injury can be approached. The epidemiologic background of moderate and severe traumatic brain injury is presented, with particular attention paid to new findings from the study of a national hospital inpatient database. We review aspects of neuroimaging and how new imaging modalities can reveal fine detail about traumatic brain injury. Finally we examine the current state of neuropathologic evaluation of, and recent developments in, understanding of the neural disruptions that occur following traumatic brain injury, together with cellular reactions to these disruptions.

Prevalence of persistent vegetative state/apallic syndrome in Vienna

The aim of the project was to survey the hospital prevalence of apallic syndrome in a federal state in Austria at an exact point in time. To achieve this, a point prevalence study was carried out on 28 November 2001 in the Vienna region. The central element was a questionnaire, which provided an exact recording of the patients' condition. An additional preliminary task was to check all the discharge diagnoses in the hospitals of the Vienna Hospital Association (Wiener Krankenanstalten Verbund) between 1996 and 2000 according to the ICD-9 diagnoses for apallic syndrome. These data should serve to cross-check the recorded results. All hospitals (n = 48) and nursing facilities (n = 44) in Vienna were included in this investigation. As the aim of the study was to record the prevalence of apallic syndrome in the population of Vienna, four patients of the group with full-stage apallic syndrome (n = 36) were excluded as they were from other federal states. In total, 32 hospital patients who met the clinical criteria for apallic syndrome (full-stage) were recorded. The point prevalence of apallic syndrome was 1.9/100,000 inhabitants. As a result of this study, the exact survey of hospital prevalence of apallic syndrome could be found. As a consequence, the Viennese government has developed a rehabilitation concept for patients with apallic syndrome in Vienna.

Life expectancy of children in vegetative and minimally conscious states

We determined estimates of survival in children, 3-15 years of age, in the vegetative state (VS) (n = 564), immobile minimally conscious state (MCS) (n = 705), and mobile MCS (n = 3,806). Data were extracted from the annual Client Development Evaluation Reports of the California Department of Developmental Services between 1988 and 1997 using the operational definitions for these three states on the basis of 15 descriptive behavioral categories. Patients were also categorized according to the following four etiologies: acquired (traumatic and nontraumatic) brain injury; perinatal/genetic; degenerative; and unknown/undetermined. The percentage of patients surviving 8 years was 63%, 65%, and 81%, for the VS, immobile MCS, and mobile MCS, respectively. Children in the VS and MCSs with acquired brain injury had lower mortality rates and those with degenerative diseases the highest mortality rates. We observed little difference in survival between patients in the VS and immobile MCS, suggesting that the presence of consciousness is not a critical variable in determining life expectancy. Furthermore, survival was much greater for patients in the mobile MCS than for those in the immobile MCS, suggesting that mobility is more important in predicting survival than the level of consciousness.

Coma prognosis in children. Part I: definitional and methodological challenges

Prediction of outcome from coma is a frequent and important task of neurologists. It is difficult enough in adult patients and even more difficult in children. Part I of this review considers some of the methodological problems and caveats besetting clinical research in this field: the very definition of coma, definition of the study population and outcome variables, study design, the fallacy of self-fulfilling prophecy, early death rate from nonneurologic causes resulting in low statistical power, and invalid attempts to compensate for that by combining outcome categories, lumping together age groups, short and inhomogeneous follow-up, and failure to provide confidence intervals. Part II reviews the clinical pediatric coma-prognosis literature, first according to etiology and then according to electrodiagnostic tests.

'Near PVS': a new medico-legal syndrome?

This paper addresses the current medico-legal issues surrounding PVS (Permanent Vegetative State), including: the lack of a unified definition of the acronym PVS, the varying criteria for diagnosis of PVS, and the issue of patients who maintain a minimal degree of consciousness and cannot be categorized as PVS patients. First, we analyse the differing medical definitions and criteria for diagnosis in vegetative conditions. We also ask what part 'consciousness' plays in treatment decisions made by the family, the healthcare team, and the courts, by analysing a unique Irish case of a patient in a state deemed by the courts as 'near PVS'. The paper demonstrates that there is now a legal dichotomy in vegetative patients. However, the manner in which the court treated these patients is the same. Underlying this discussion we hope to demonstrate how medical practice is subject to legal decisions and thus the importance of establishing uniform medical guidelines to assist the non-medical professional.

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.

Motor profile of patients in minimally responsive and persistent vegetative states

The purpose of this descriptive clinical study is to document the motor characteristics of patients in minimally responsive and persistent vegetative states. Twelve subjects, presenting a prolonged altered state of consciousness (x = 7.82 years, range 2-27), aged 27-78 years (x = 50, SD = 15.26) were evaluated, using standardized protocols, on the following variables: passive range of motion, observed movements, reflexes, tonus, postural status and reactions. The subjects' level of awareness and responsivity were measured with the Coma/Near Coma (CNC) scale at each of the three data collection sessions. While group CNC scores were stable over the three sessions, fluctuations in the level of awareness of individual subjects was recorded, confirming the heterogeneity of this clientele. Abnormal primitive reflexes were present in all subjects, with the flexor withdrawal (75%), the tonic labyrinthine (36%) and the body-on-body righting reaction (25%) being the most frequently observed. All subjects presented altered tonus, considerable posturing and varied degrees of reduced range of joint motion. A range of abnormal (e.g. chewing, clonus) and normal patterned (e.g. bridging, scratching) movement behaviours was recorded, but these did not translate into functional use, such as rolling. Collectively, the findings stress the complexity of the motor profile of patients in minimally responsive and vegetative states, and suggest the need for physiotherapists to become more actively involved in the evaluation and treatment of this clientele.

Post-traumatic apallic syndrome following head injury. Part 2: Treatment

There is no doubt that vegetative patients need the appropriate medical and nursing procedures as well as family involvement, education and counselling. Additional structured stimulation programmes are used for the treatment of coma and vegetative state. The theoretical foundation is derived from animal studies. The relevance of the results for the rehabilitation of head-injured human patients remains questionable, because all animal studies involve the use of cerebral lesions different from those found in human head-injured patients. The studies of human sensory stimulation give more an orientation than a definitive statement. Very recently, hypotheses concerning sensory regulation have begun to be evaluated. Further investigations are required to provide a more definite conclusion.

Post-traumatic apallic syndrome following head injury. Part 1: clinical characteristics

Epidemiological studies made within the western countries indicate an incidence of 200-300 traumatic head injuries per 100 000 residents each year. Severe head injuries account for 5-25% of all head injuries; 10-14% of all severe head-injured patients develop into a vegetative state, in which a sleep-wake rhythm is apparent, but however in which there is no evidence of awakeness or reactivity to the environment. The most commonly used labels, in the German and international literature, for these patients are 'vegetative state', 'apallic syndrome' and 'coma vigile'. This clinical characterization is not sufficient. It is necessary to employ additional criteria to distinguish subsets of vegetative patients e.g. computerized tomography, magnetic resonance imaging, single photon emission tomography, electroencephalography, brainstem reflexes, evoked potentials, assessment scales, age, premorbid brain disorders. Diagnostic and prognostic parameters must form the basis for various decisions relating to patients' care and intervention.

Persistent vegetative state: which sensory-motor variables should the physiotherapist measure?

This study used a modified Delphi technique to establish a list of core items which should be included in the measurement, by the physical therapist, of sensory-motor capacities of persons in a persistent vegetative state. Twenty-eight physical therapists with a mean of 5.9 years of experience working with this clientele participated in the study and identified 105 items as being important in the evaluation of the PVS patient (Round I). The study planning committee reduced these to 20 categories and asked the therapists to rate each category of items (a 5-point scale) as to it's importance (Round II). Physiotherapists identified 14 variables as being 'extremely' or 'very important' to include in such an evaluation. These included: tonus, voluntary movement on request, postural reactions, passive range of motion, tolerance to verticalization and postural status. These results are being used to develop a quantitative assessment instrument to be used by the physical therapist working with the PVS patient.

Electrodermal response and outcome from severe brain injury

The relation of electrodermal response measures to outcome from early post-traumatic vegetative state (VS) was investigated in 15 brain-injured and five control subjects. Brain-injured subjects were in acute VS or persistent VS (PVS), or had recovered from acute VS (RVS). Significant group differences were found on all electrodermal response measures, primarily due to the greater amplitude, number and consistency of responses in control subjects. Group differences in electrodermal habituation and orientation to auditory tones reflected the absence of orientation in most RVS subjects and the absence of both habituation and orientation PVS subjects. The groups differed in their response to matching faces and names. All of the control subjects, two of five RVS subjects and none of five acute subjects produced significant responses. Surprisingly, two PVS subjects also produced significant responses. For acute subjects a positive outcome at 6 months post-trauma was associated with early electrodermal startle amplitude and baseline lability. These results indicate that electrodermal responsiveness is generally reduced following acute VS, even in subjects with a relatively good recovery. Greater electrodermal activity in early VS may be associated with better potential for recovery.

Medical aspects of the persistent vegetative state (1)

This consensus statement of the Multi-Society Task Force summarizes current knowledge of the medical aspects of the persistent vegetative state in adults and children. The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations. The clinical course and outcome of a persistent vegetative state depend on its cause. Three categories of disorder can cause such a state: acute traumatic and non-traumatic brain injuries; degenerative and metabolic brain disorders, and severe congenital malformations of the nervous system. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months in adults and children. Recovery from a nontraumatic persistent vegetative state after three months is exceedingly rare in both adults and children. Patients with degenerative or metabolic disorders or congenital malformations who remain in a persistent vegetative state for several months are unlikely to recover consciousness. The life span of adults and children in such a state is substantially reduced. For most such patients, life expectancy ranges from 2 to 5 years; survival beyond 10 years is unusual.

Outcome of children with prolonged unconsciousness and vegetative states

The outcomes of 60 children unconscious for 90 days or longer following acquired brain injury are reported. Eight children who died had remained in persistent vegetative states. As expected, most neurologic improvement occurred within the first year after injury, although some delayed improvements were observed. Outcomes were strongly correlated with causes of brain injury. Better cognitive and motor function was observed with nonanoxic injuries. No child in this report with anoxic brain injury regained functional cognitive or motor skills, although 3 became socially responsive. The remarkable contrast with adults following acquired brain injury is the significantly longer survival of children. The only children who died had remained in persistent vegetative states.

Early ischaemia after severe head injury. Preliminary results in patients with diffuse brain injuries

Ischaemic brain lesions still have a high prevalence in fatally head injured patients and are the single most important cause of secondary brain damage. The present study was undertaken to explore the acute phase of severely head injured patients in order to detect early ischaemia using Robertson's approach of estimating cerebral blood flow (CBF) from calculated arterio-jugular differences of oxygen (AVDO2), lactates (AVDL), and the lactate-oxygen index (LOI). Twenty-eight cases with severe head injury were included (Glasgow Coma Scale Score below or equal to 8). All patients but one had a non-missile head injury. All the patients had a diffuse brain injury according to the admission CT scan. ICP measured at the time of admission was below 20 mmHg in 17 cases (61%). All patients were evaluated with the ischaemia score (IS) devised in our center to evaluate risk factors for developing ischaemia. Mean time from injury to the first AVDO2/AVDL study was 23.9 +/- 9.9 hours. According to Robertson's criteria, 13 patients (46%) had a calculated LOI (-AVDL/AVDO2) value above or equal to 0.08 and therefore an ischaemia/infarction pattern in the first 24 hours after the accident. Of the 15 patients without the ischaemia/infarction pattern, in three cases the CBF was below the metabolic demands and therefore in a situation of compensated hypoperfusion. No patient in our series had hyperaemia. Comparing different variables in ischaemic and non-ischaemic patients, only arterial haemoglobin and ischaemia score (IS) was significantly different in both groups. The ischaemia score had mean of 4.3 +/- 1.7 in the ischaemic group and 2.7 +/- 1.4 in non-ischaemic patients (p = 0.01). It is concluded that ischaemia is highly prevalent in the early period after severe head injury. Factors potentially responsible of early ischaemia are discussed.

Recovery of patients after four months or more in the persistent vegetative state

A retrospective review was made of the case notes of 43 consecutive patients admitted to a unit specialising in the rehabilitation of people in the persistent vegetative state. Eleven of these patients regained awareness four months or more after suffering brain damage. The time to the first reported incidence of eye tracking was between four months and three years, and the time to the first response to command was between four and 12 months. Only one patient was eventually unable to communicate, six could use non-verbal methods of indicating at least a yes or no response, and four were able to speak. Six patients remained totally dependent while two became independent in daily activities. Four patients became independent in feeding, three required help, and four remained on gastrostomy feeding. Thus some patients can regain awareness after more than four months in a vegetative state, and, although few reach full independence, most can achieve an improved quality of life within the limitations of their disabilities. The recovery period is prolonged and may continue for several years. Even patients with profound brain damage should be offered the opportunity of a specialist rehabilitation programme.

Medical futility, treatment withdrawal and the persistent vegetative state

Why do we persist in the relentless pursuit of artificial nourishment and other treatments to maintain a permanently unconscious existence? In facing the future, if not the present world-wide reality of a huge number of persistent vegetative state (PVS) patients, will they be treated because of our ethical commitment to their humanity, or because of an ethical paralysis in the face of biotechnical progress? The PVS patient is cut off from the normal patterns of human connection and communication, with a life unlike other forms of human existence. Why the struggle to justify ending a life which, it is said, has suffered an irreversible loss of the content of consciousness? Elsewhere, the authors have addressed the ethical controversies and confusion engendered by ambiguous terminology, misuse of medical facts and the differing interpretations of what constitutes 'effective' treatment: in particular, the issue of whether in fact artificial nutrition and hydration is a medical treatment, or simply part of the obligatory care owed to all patients, permanently unconscious or not. In this paper, we intend to argue that recent analyses of medical futility, its meaning and ethical implications, despite an absence of public consensus, permit some tentative re-evaluation of our ethical obligations to the PVS patient.

Course and outcome of patients in vegetative state of nontraumatic aetiology

A follow up study is reported of 100 consecutive unconscious patients admitted to an intensive care coma facility with a history of 30 days or more of unconsciousness of nontraumatic cause. Twenty recovered consciousness, all within 5 months of injury. 31 of the remaining patients died within 6 months following injury, while 49 continued unconscious until death. The mean life expectancy of these 49 was 26-34 months from that time. All 20 patients who recovered awareness continued to suffer from major disability. The prognosis for life or death and for recovery or not of consciousness was not significantly correlated with age or aetiology of the vegetative state. Among those who recovered consciousness, the younger patients showed somewhat better results in three parameters of function: locomotion, ADL and day-placement, but not in cognition, behaviour or speech accuracy and fluency. The overall results for these nontraumatic patients with postcomatose unawareness are clearly worse than those for patients with a similar period of unconsciousness following craniocerebral trauma.

Epidemiological findings in traumatic post-comatose unawareness

We have examined the epidemiological background of 134 consecutive patients admitted to our centre who suffered from post-traumatic unconsciousness of over 1 month's duration. The incidence of such unconsciousness in Israel is estimated as 4 per 1,000,000, or one case in 410 hospitalizations for head trauma. The cause of trauma was a road accident in 69% of cases. Among victims, pedestrians and cyclists were more likely than four-wheeled vehicle drivers and their passengers to suffer from prolonged unconsciousness, from which they were less likely to recover.

Medical complications and mortality of patients in the postcomatose unawareness (PC-U) state

Almost half of all patients with traumatic brain injury who remain unconscious for more than one month will not recover consciousness and will remain in a state of prolonged postcomatose unawareness (PC-U). The aim of this work is to present the survival rate and medical complications of such patients. The survival time of the 62 patients studied ranged from 2 to 115 months, with a median of 15.5 +/- 22 months. Cumulative mortality figures were 15% at 3 months, 40% at 6 months and 60% and the end of the first year. The figures at the end of the second, third and fifth years were 86%, 87% and 94%, respectively. This type of data may aid in decisions regarding the management of these patients. The longer survival with better treatment of patients in a state of PC-U poses severe ethical, medical, legal and economic problems with which society will have to deal.