Five-year follow-up study of patients with persistent vegetative state

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.

Recovery from prolonged disorders of consciousness: A dual-center prospective cohort study in China

BACKGROUND

Recent innovations in intensive care have improved the prognosis of patients with severe brain injuries and brought more patients with disorders of consciousness (DoC). Data are lacking regarding the long-term outcomes of those patients in China. It is necessary to study the long-term outcomes of patients with prolonged DoC in light of many factors likely to influence crucial decisions about their care and their life.

AIM

To present the preliminary results of a DoC cohort.

METHODS

This was a two-center prospective cohort study of inpatients with vegetative state (VS)/unresponsive wakefulness syndrome (UWS). The study outcomes were the recovery from VS/UWS to minimally conscious state (MCS) and the long-term status of patients with prolonged DoC considered in VS/UWS or MCS for up to 6 years. The patients were evaluated using the Glasgow coma scale, coma recovery scale-revised, and Glasgow outcome scale. The endpoint of follow-up was recovery of full consciousness or death. The changes in the primary clinical outcome improvement in clinical diagnosis were evaluated at 12 mo compared with baseline.

RESULTS

The study population included 93 patients (62 VS/UWS and 31 MCS). The post-injury interval range was 28-634 d. Median follow-up was 20 mo (interquartile range, 12-37 mo). At the endpoint, 33 transitioned to an emergence from MCS or full consciousness, eight had a locked-in syndrome, and there were 35 patients remaining in a VS/UWS and 11 in an MCS. Seven (including one locked-in syndrome) patients (7.5%) died within 12 mo of injury. Compared with the unresponsive group (n = 52) at 12 mo, the responsive group (n = 41) had a higher proportion of males (87.8% vs 63.5%, P = 0.008), shorter time from injury (median, 40.0 d vs 65.5 d, P = 0.006), higher frequency of vascular etiology (68.3% vs 38.5%, P = 0.007), higher Glasgow coma scale score at admission (median, 9 vs 6, P < 0.001), higher coma recovery scale-revised score at admission (median, 9 vs 2.5, P < 0.001), at 1 mo (median, 14 vs 5, P < 0.001), and at 3 mo (median, 20 vs 6, P < 0.001), lower frequency of VS/UWS (36.6% vs 90.0%, P < 0.001), and more favorable Glasgow outcome scale outcome (P < 0.001).

CONCLUSION

Patients with severe DoC, despite having strong predictors of poor prognosis, might recover consciousness after a prolonged time of rehabilitation. An accurate initial diagnosis of patients with DoC is critical for predicting outcome and a long-term regular follow-up is also important.

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.

Application of an Intensive Rehabilitation Program After Very Late Recovery of Consciousness: A Single-Case Neurorehabilitation and Neuroimaging Study

Late recovery of consciousness in vegetative state is considered as an exceptional outcome and has been reported prevalently in patients who suffered a traumatic brain injury. In these patients, the benefits of prolonging the rehabilitation, aimed at the recovery of autonomy in basic everyday activities, has been demonstrated. Here, we describe the application of an intensive multi-professional rehabilitation program carried out on a young female patient, with exceptionally late recovery of consciousness, specifically, after 7 years of vegetative state due to severe brain hemorrhage. Neuropsychological and functional assessment was conducted before and after the end of the rehabilitation program. In addition, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI)-based probabilistic tractography were performed. Two follow-up neuropsychological and functional assessments were also conducted 6 and 29 months after the conclusion of the program. Functional results showed an improvement, maintained over time, in walking with assistance, cognitive efficiency, visual acuity and visual field, dysarthria, and execution of activities of daily living. Moreover, functional and structural magnetic resonance imaging (MRI) data documented the existence of preserved neural networks involved in sensory, motor, and linguistic tasks, which in all likelihood support the recovery process. This report suggests the possibility of undertaking an intensive rehabilitation program in patients who remain for long periods in altered states of consciousness, in spite of early negative prognosis.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.

Against the odds: a case study of recovery from coma after devastating prognosis

To demonstrate the possibility for hidden rehabilitation potential even following most severe brain injury and the uncertainty of current prognosis factors for coma and unresponsive wakefulness syndrome, we detail the rehabilitation of J. W., after coma from traumatic brain injury. Originally, with many negative prognosis factors and several medical complications, prognosis was devastating. But, with continuing treatment, J. W. improved to a high level of independence in everyday life. This shows the need for rehabilitation research to further specify the “prognostic power” of various combinations of prognosis factors, so that practitioners can come to accurate single‐case recommendations when both positive and negative predictors are present.

Late recovery from post-traumatic vegetative state

AIM

Late recovery of consciousness after 12 months in vegetative state is very rare and is almost invariably associated with severe disability. The aim of this study was to report that late recovery with moderate disability is possible, even after several months in vegetative state.

CASE REPORT

This study describes the case of a 22-year-old male student who recovered consciousness from vegetative state 19 months after a traumatic brain injury which had occurred in December 2000. A further slow recovery of motor and cognitive functions up to a moderate disability was observed over 7 years after the brain injury. The patient now lives in the community, speaks, walks and undertakes daily living as well as outdoor leisure activities independently, has resumed his previous university studies and has a part-time non-competitive job.

CONCLUSIONS

This case demonstrates that attaining a condition of independent living is possible even after more than 1 year of post-traumatic vegetative state, with an improvement of motor and cognitive functions that can continue for years. Cranioplasty and long-term rehabilitation programmes may be among the variables potentially influencing this unexpected recovery.

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.

Care protocol for persistent vegetative states (PVS) and minimally conscious state (MSC) in Lorraine: retrospective study over an 18-year period

OBJECTIVES

Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine.

MATERIAL AND METHOD

Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies).

RESULTS

Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases.

CONCLUSION

The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.

Persistent vegetative state and dementia in the elderly

BACKGROUND

Very few studies have approached the issue of persistent vegetative state (PVS) within the elderly population. This study aims to assess the prevalence, determinants and prognosis of elderly patients with PVS admitted to a long-term geriatric facility.

METHODS

We conducted a cohort study in the setting of a Skilled Geriatric Nursing Department. All patients admitted during a 17-month period (N = 88) were included and tested for a diagnosis of PVS according to the Disability Rating Scale (DRS).

RESULTS

A clinical diagnosis of PVS was given to 15% of patients upon admission, whereas the DRS diagnosed 30.5% of patients as having PVS. During the study period, 12 out of 31 patients with PVS died, with a median survival of 127 days (range: 1-517 days).

CONCLUSION

Our study suggests that PVS is an advanced stage in the natural history of dementia in the elderly. The low proportion of patients with PVS recognized as having this disorder upon admission suggests a low awareness among hospital personnel. Further studies of the prevalence and determinants of PVS in the severely disabled elderly population are warranted.

Guidelines for Quality Management of Apallic Syndrome / Vegetative State

INTRODUCTION

Epidemiology in Europe shows constantly increasing figures for the apallic syndrome (AS)/vegetative state (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage and high-standard activating home nursing for completely dependent end-stage cases secondary to progressive neurological disease. Management of patients in irreversible permanent AS/VS has been the subject of sustained scientific and moral-legal debate over the past decade.

METHODS

A task force on guidelines for quality management of AS/VS was set up under the auspices of the Scientific Panel Neurotraumatology of the European Federation of Neurological Societies to address key issues relating to AS/VS prevalence and quality management. Collection and analysis of scientific data on class II (III) evidence from the literature and recommendations based on the best practice as resulting from the task force members' expertise are in accordance with EFNS Guidance regulations.

FINDINGS

The overall incidence of new AS/VS full stage cases all etiology is 0.5-2/100.000 population per year. About one third are traumatic and two thirds non traumatic cases. Increasing figures for hypoxic brain damage and progressive neurological disease have been noticed. The main conceptual criticism is based on the assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathological findings and the uncertainty of clinical assessment due to varying inclusion criteria. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. This is why sine qua non diagnostics of the clinical features and appropriate treatment of AS/VS patients of "AS full, remission, defect and end stages" require further professional training and expertise for doctors and rehabilitation personnel.

INTERPRETATION

Management of AS aims at the social reintegration of patients or has to guarantee humanistic active nursing if treatment fails. Outcome depends on the cause and duration of AS/VS as well as patient's age. There is no single AS/VS specific laboratory investigation, no specific regimen or stimulating intervention to be recommended for improving higher cerebral functioning. Quality management requires at least 3 years of advanced training and permanent education to gain approval of qualification for AS/VS treatment and expertise. Sine qua non areas covering AS/VS institutions for early and long-term rehabilitation are required on a population base (prevalence of 2/100.000/year) to quicken functional restoration and to prevent or treat complications. Caring homes are needed for respectful humane nursing including basal sensor-motor stimulating techniques. Passive euthanasia is considered an act of mercy by physicians in terms of withholding treatment; however, ethical and legal issues with regard to withdrawal of nutrition and hydration and end of life discussions raise deep concerns. The aim of the guideline is to provide management guidance (on the best medical evidence class II and III or task force expertise) for neurologists, neurosurgeons, other physicians working with AS/VS patients, neurorehabilitation personnel, patients, next-of-kin, and health authorities.

Epidemiology and prognosis of coma in daytime television dramas

OBJECTIVE

To determine how soap operas portray, and possibly misrepresent, the likelihood of recovery for patients in coma.

DESIGN

Retrospective cohort study.

SETTING

Nine soap operas in the United States reviewed between 1 January 1995 and 15 May 2005.

SUBJECTS

64 characters who experienced a period of unconsciousness lasting at least 24 hours. Their final status at the end of the follow-up period was compared with pooled data from a meta-analysis.

RESULTS

Comas lasted a median of 13 days (interquartile range 7-25 days). Fifty seven (89%) patients recovered fully, five (8%) died, and two (3%) remained in a vegetative state. Mortality for non-traumatic and traumatic coma was significantly lower than would be predicted from the meta-analysis data (non-traumatic 4% v 53%; traumatic 6% v 67%; Fisher's exact test both P < 0.001). On the day that patients regained consciousness, most (49/57; 86%) had no evidence of limited function, cognitive deficit, or residual disability needing rehabilitation. Compared with meta-analysis data, patients in this sample had a much better than expected chance of returning to normal function (non-traumatic 91% v 1%; traumatic 89% v 7%; both P < 0.001).

CONCLUSIONS

The portrayal of coma in soap operas is overly optimistic. Although these programmes are presented as fiction, they may contribute to unrealistic expectations of recovery.

The vegetative and minimally conscious states: current knowledge and remaining questions

In the last 2 decades, the minimally conscious state has been distinguished conceptually from the vegetative state and operational criteria for these diagnoses have been published. Standardized and individualized assessment tools have been developed to assist with the diagnosis of severe disorders of consciousness and the measurement of clinical improvement. The natural course of recovery and the importance of key prognostic predictors have been elucidated. Important advances have also been made in defining the similarities and differences in the pathophysiology of these two states, and functional imaging modalities have begun to explicate the neural substrate underlying the behavioral features of these disorders. Research on the efficacy of treatments for severe disorders of consciousness lags behind, due to the practical and ethical difficulties in executing large rigorously controlled clinical trials. The past and future scientific developments in this area provide an important background for continuing discussions of the ethical controversies surrounding end-of-life decision making and resource allocation.

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.

The uncertainty of certainty in clinical ethics

Physicians accept fallibility in technical matters as a condition of medical practice. When it comes to moral considerations, physicians are often loathe to act without a good deal more certitude and seem less willing to accept error. This article argues that ethics is intrinsic to medical decision making, that error is the inevitable risk of any action and that inaction (clearly action by default) carries even greater risk of error. Whether in the moral or the technical sphere, error must be accepted by physicians as part of the learning process which informs and enriches future decisions. Moral virtue, it is concluded, resides more in the making of a decision and in the agony of making it than it does in the potentially fallible decision itself.

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.

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.

Persistent vegetative state: clinical and ethical issues

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family.

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.

Sleep abnormalities in traumatic apallic syndrome

Sleep patterns in 10 patients with traumatic apallic syndrome were studied, together with 10 healthy controls matched for sex and age. All patients underwent neurological examination, brain CT, and polysomnographic recording within six months (mean 99 (SD 45) range 47-180 days) from the onset of symptoms. Clinical follow up was performed six months after enrollment in the study. Sleep patterns were recorded in nine out of 10 patients. In the tenth patient there was no rhythm resembling physiological sleep. This patient was the only one who remained in a persistent vegetative state and died before the six month follow up. The severity of neurological deficit at follow up was significantly related to the duration of coma. There was no significant difference between patients and controls with respect to sleep architecture. The time spent awake after sleep onset was longer in patients than controls. Our data highlight the presence of sleep fragmentation in traumatic apallic syndrome, which might be due to changes in brain structures responsible for sleep maintenance. The absence of sleep-wake cycles might indicate a poor outcome.

Outcome of post-traumatic unawareness persisting for more than a month

From 1986 to the end of 1991, 19 patients with persisting post-traumatic unawareness were admitted for rehabilitation. Criteria for admission were head trauma, Glasgow coma scale score < or = 8 points, and at least a one month duration of unawareness. Out of 19 patients, 12 patients (63%) regained consciousness, 11 patients (58%) within the first year and one patient (5%) within the second year. The mean duration of unawareness in the patients who recovered consciousness was 190 (range 62-440) days. In the recovery group, according to the Glasgow outcome scale, seven out of 12 patients (58%) were moderately disabled and five (42%) were severely disabled at the moment of discharge from rehabilitation. All the 12 patients who regained consciousness live with their families, and none had to be kept in an institution. The data confirm that awakening from post-traumatic unawareness is possible after a long period. Therefore, post-traumatic unawareness persisting for more than a month should not be considered an irreversible condition, because an outcome that might be regarded by some as being acceptable is possible even in patients with very severe brain damage.

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.

Presence of Klùver-Bucy syndrome as a positive prognostic feature for the remission of traumatic prolonged disturbances of consciousness

After severe brain injury a prolonged disturbance of consciousness may occur, sometimes with transient apallic syndrome (awakening without awareness of self and surroundings). Klùver-Bucy is described in the literature as a typical post-traumatic remission phase, in which the patients show an increase of oral automatisms and/or of sexual drive. The study describes Klùver-Bucy syndrome as a sign associated with favourable prognosis in the outcome of traumatic disturbances of consciousness in survivors of head trauma. Seventy-seven patients who had suffered severe brain injury due to traffic accidents entered into the study. All had experienced a relatively benign clinical course since they recovered full awareness, that is were able to communicate with their relatives. The occurrence of prolonged coma, of apallic syndrome and of Klùver-Bucy syndrome are related to outcome date in regards to the patient's work and family function at a mean of 32 months later. In particular, the duration of the apallic syndrome (duration of unconsciousness) was significantly correlated with the global outcome of the patients (p < 0.001).

Concepts and diagnosis of brain death

The different concepts of brain death are subject to controversial debate. It is outlined that only the whole-brain concept, that is the irreversible loss of all functions of the entire brain, is consistent with the death of man. Cortical death or brain-stem death should not be considered in this respect. The operational procedure for determining brain death is outlined with special regard to those cases in which a definite diagnosis cannot be made clinically. It is shown that apnea testing must be accompanied by blood-gas analysis, as it may take 15 min for the PaCO2 to achieve the desired level of 8 kPa. The problem with CNS-depressing drugs and their metabolites interfering with the clinical diagnosis--e.g. sedatives, barbiturates, opioids--is described, and it is stressed that, in these cases, the cerebral panangiography (digital subtraction angiography with catheter tip in the aortic arch) is the gold standard for the final and definite proof of brain death.

Brain-injured persons in an altered state of consciousness: measures and intervention strategies

We evaluated the states of consciousness of seven persons who had sustained a severe head injury, and describe the behavioural manifestations associated with four treatment strategies. The subjects were between the ages of 19 and 55 and were recruited from both acute and long-term care facilities; all were in an altered state of consciousness. The severity of the injury was measured by time in coma, the scores on the Glasgow Coma Scale [1] and the Coma Near Coma Scale [2]. Structured interventions consisted of visual, auditory, olfactory, gustatory and tactile stimulation; behaviour was measured using the Disability Rating Scale [3, 4] and a portion of the Levels of Cognitive Functioning Scale [5]. Sensory-motor indications were recorded using a questionnaire developed by Freeman [6] and a quality-of-life instrument, developed for use with individuals having multiple disabilities [7], was adapted for the purpose of this study. Our results suggest that the use of structured interventions in the first 24 months following severe head injury is associated with a trend towards improved auditory and visual skills performance, manual performance, swallowing and language. Whereas initially no subject had any form of verbalization, by the final evaluation five subjects had some form of communication, either verbal or non-verbal.

The therapeutic potential of bromocriptine in neuropsychological rehabilitation of patients with acquired brain damage

1. Activation of neuropsychological rehabilitation by pharmacological agents is a promising therapeutic strategy. 2. Reports of single cases and case series claim improvement of akinetic mutism, non-fluent aphasia, apathy, attentional and other neuropsychiatric disturbances after treatment with bromocriptine, a D2 dopamine receptor agonist. 3. A critical review of published reports and own experiences discusses the results in the light of pharmacological and neurobiological considerations. 4. Dopaminergic stimulation after certain kinds of brain damage might influence neuronal recovery and/or substitute dopaminergical linked functions after destruction of the corresponding neurons. 5. Although controlled clinical studies are very difficult to design and such evidence is still lacking, preliminary recommendations are given with regard to differential indications, drug regime and evaluation criteria.

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.

Life expectancy of children in a persistent vegetative state

The persistent vegetative state (PVS) is a state of wakeful unconsciousness occurring in adults and children. Despite preservation of vegetative functions, PVS patients have a shortened life-span, although accurate information concerning this issue remains limited. The survival of children in PVS was examined to determine whether age, etiology of the vegetative state, or type of residence in which the patient lived affected the estimated survival. The data of 155,851 developmentally disabled California state residents were reviewed using the Client Development Evaluation Report (CDER). Criteria from the CDER were selected to define the vegetative state and included: lack of interaction with peers; absence of auditory, visual, and expressive or receptive language function; no hand or arm use; inability to eat, sit, roll over, or lift head; and no bowel or bladder control. There were 847 patients who met these criteria on the initial and follow-up CDERs. A product limit survival model was used to develop survival curves and to calculate the median survival time for patients grouped by age, etiology, and type of residence. Median survival (yrs) for patients who remained in PVS for the following age groups was: < 1 yr: 2.6, 1 < 2 yrs: 4.2, 2-6 yrs: 5.2, 7-18 yrs: 7.0, > or = 19 yrs: 9.9. Median survival based on etiology varied from 3.0 to 8.6 years; no consistent relationship existed between etiology and duration of survival. Survival (yrs) for patients younger than age 18 years based on type of residence included: own home: 4.5, institutions: 5.2, skilled nursing facility/private hospital: 3.2, and other community care facilities: 3.7.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

The Westmead Head Injury Project. Physical and social outcomes following severe head injury

This study reports the physical outcomes of 181 survivors of severe head injury [Glasgow Coma Score (GCS) 8 or less] following aggressive head injury management which included early triage, evacuation and resuscitation, the use of ventilation in the Intensive Care Unit and intracranial pressure (ICP) measurement and control. At the conclusion of the study period of 2 years after the head injury, 71% had achieved a Glasgow Outcome Score (GOS) of 1, 17% GOS 2, 10% GOS 3 and 2% GOS 4. Physical recovery continued during the 2 years. Locomotor independence was achieved in 93% despite a motor disorder in 59%. About 90% were considered independent for basic life functions, e.g. feeding, bathing, dressing or toileting. Speech disorders were present in 19%. A return to an occupation, either a job or studies, at or below the pre-morbid level was achieved in 68%. Most patients were cared for at home by family or relatives. The majority of patients make a reasonable physical recovery following severe head injury with independence in locomotion and basic life skills. It was our impression that the neuropsychological sequelae of cognitive and behavioural disorders were a major impediment to re-assimilation into society.

The persistent vegetative state in children: report of the Child Neurology Society Ethics Committee

Increasing concern about children in a persistent vegetative state (PVS) prompted a survey of members of the Child Neurology Society regarding aspects of the diagnosis and management of this disorder. Major findings of those responding to this survey (26% response rate) were as follows: (1) 93% believed that a diagnosis of PVS can be made in children, but only 16% believed that this applied to infants younger than 2 months and 70% in the 2-month to 2-year group; (2) a period of 3 to 6 months was believed to be the minimum observation period required before a diagnosis of PVS could be made; (3) 86% believed that the age of the patient would affect the duration of time needed to make the diagnosis of PVS; (4) 78% thought a diagnosis of PVS could be made in children with severe congenital brain malformations; (5) 75% believed that neurodiagnostic studies would be of value and supportive of the clinical diagnosis of PVS; (6) members' opinions as to the average life expectancy (in years) for the following age groups after the patients were considered vegetative were: newborn to 2 months, 4.1; 2 months to 2 years, 5.5; 2 to 7 years, 7.3; and more than 7 years, 7.4; (7) 20% believed that infants and children in a PVS experience pain and suffering; and (8) 75% "never" withhold fluid and nutrition from infants and children in a PVS and 28% "always" give medication for pain and suffering.(ABSTRACT TRUNCATED AT 250 WORDS)

Recovery of cognition from persistent vegetative state in a child with normal somatosensory evoked potentials

The absence of bilateral early cortical SEPs in a PVS due to nontraumatic coma is usually associated with failure to recover cognition or awareness, although rarely patients with bilaterally absent cortical SEPs in posttraumatic PVS may regain cognition. On the other hand, normal cortical SEPs in nontraumatic coma may be related to favorable outcomes as shown in this patient and other reports. Our patient is unique in that he had had serial normal SEPs, was in a PVS for 7 1/2 months, and recovered cognition, but not without cost in terms of damage to intellectual capability. Further long-term clinical follow-up studies to correlate clinical outcome with serial SEP data may be indicated.

The life expectancy of profoundly handicapped people with mental retardation

BACKGROUND

The life expectancy of people with mental retardation is shorter than that of the general population. Exact estimates of the length of survival for mentally retarded persons at especially high risk are not available, however.

METHODS

We collected data on mortality and other factors for 99,543 persons with developmental disabilities, including mental retardation, who received services from the California Department of Developmental Services between March 1984 and October 1987. Three subgroups were selected on the basis of the four characteristics identified in previous studies as the best predictors of mortality among mentally retarded people (deficits in cognitive function, limitations on mobility, incontinence, and inability to eat without assistance). In all three subgroups, the subjects had severe deficits in cognitive function and were incontinent; the subjects in subgroup 1 (n = 1550) were immobile and required tube feeding; those in subgroup 2 (n = 4513) were immobile but could eat with assistance; those in subgroup 3 (n = 997) were mobile (but not ambulatory) and could eat with assistance. Life tables were generated for each of the three subgroups.

RESULTS

Immobile subjects were found to have a much shorter life expectancy than those who could move about. Those who also required tube feeding (subgroup 1) had a very short life expectancy (i.e., four to five additional years). Those who could eat if fed by others (subgroup 2) had an average life expectancy of approximately eight additional years. In contrast, those who were mobile though not ambulatory (subgroup 3) had a life expectancy of about 23 additional years.

CONCLUSIONS

Severe mental retardation is associated with a decrease in life expectancy, particularly for those who were immobile.

[Persistent alpha-vegetative state]

After briefly reviewing the concepts of "coma" and "alpha-coma", we report the case of a patient with presumable Pick's disease who spent several weeks in a vegetative state with a normal and reactive EEG in the alpha range in the later stages of her illness. We (a) emphasize some implications of the appearance of the eyes in such patients, b) stress the importance of distinguishing alpha activity from true alpha rhythm and (c) suggest the category "alpha-coma" should include only those individuals bearing evidence of disorders of the junctional tegmentum of the pons and midbrain. In a complementary way, we propose that patients in a persistent vegetative state displaying normal EEG should be separately classified as persistent "alpha-vegetative state".