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CT scan done after bilateral decompressive craniectomy, evacuation of extradural haematoma and right frontal polectomy.
Source publication
To demonstrate that patients with Prolonged Vegetative State (PVS) can show signs of improvements and important changes and, consequently, to strengthen the necessity to evaluate them with long-term serial follow-ups.
Rehabilitation of patients with severe traumatic brain injury (TBI).
Two people with severe TBI discharged after a long period of in...
Context in source publication
Context 1
... days after the trauma, due to worsening of coma (GCS: 3), the patient underwent bilateral decompressive craniectomy; cleaning of contusive temporal foci, polectomy on front right and dural plastic (Figure 2). Four months after trauma, the patient was hospitalized in the Rehabilitation Department. ...
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Citations
... It is very important to recall that, probably due to the continuous improvements in therapeutic strategies [27], the originally proposed time limits for regaining consciousness in traumatic (12 months) and non-traumatic brain injury (3-6 months) [3] are no longer considered valid. Since the Multi-Society Task Force (MSTF) pivotal epidemiological study of VS/UWS [3], case reports [34][35][36] and large cohort studies [18,21,[37][38][39] have documented late recovery of varying levels of consciousness beyond the above classical time limits, even in vascular and anoxic etiology. For instance, Estraneo et al. found that 20% of patients meeting MSTF criteria for "permanent" VS/UWS eventually improved to MCS [38]. ...
Clinical evolution and prognostic markers in disorders of consciousness (DoC) have not been fully established yet. Several scientific efforts have highlighted that clinical evolution is determined by several factors closely interacting with each other: patient age (likely influencing the physiological process of recovery, e.g., brain plasticity), etiology of brain damage (traumatic vs. non-traumatic), and diagnosis (vegetative state or minimally conscious state, likely related to the severity of brain damage). Time course of clinical evolution has not been fully defined, but to date several studies and international guidelines have suggested that some form of neural plasticity can develop even beyond the time limits originally identified by the Multi-Society Task Force on Vegetative State, and support late recovery of responsiveness and consciousness. Empirical evidence is accumulating about the possible prognostic value of further factors beyond patient age, etiology, and diagnosis. In particular, clinical evaluation by standardized tools and several neurophysiological indices, easy to collect at the bedside in the rehabilitative phase, are able to assess the functional integrity of neuronal populations, and to provide some cues for predicting outcomes. In selected patients advanced neurophysiological and neuroimaging methods can add useful additional diagnostic and prognostic information, particularly in patients in whom “covert” cognition is possibly present (even with the lack of behaviorally evident responses). Nonetheless, diagnosis and prognosis can be made difficult by the presence of clinical complications that also impact care strategies. To fully comprehend long-term evolution of DoC, prospective longitudinal systematic investigations of outcome in large groups of patients are needed. Identification of solid and reliable prognostic markers will help clinicians to update current positions on medical, ethical, and legal issues connected with the management and care of patients with DoC.
... These results were similar with those from Steppacher et al. [7], but they were higher than those reported in other literature [6,9]. We considered that the reasons for these differences might be related to the differences in time to follow-up [4,36] and time from onset to study entry [37]. This may indicate that the initial state of consciousness is not a critical factor for the patient's long-term outcome. ...
Purpose:
To evaluate the long-term survival and functional outcomes of patients with prolonged disorders of consciousness (pDoC) 1-8 years after brain injuries.
Methods:
Retrospective study to assess the long-term survival and functional outcomes of patients with pDoC was conducted. We performed Cox regression and multivariate logistic regression to calculate hazard ratios (HRs) for the outcome of survival and to identify risk factors of the functional outcome.
Results:
We recruited 154 patients with pDoC. The duration of follow-up from disease onset was 1-8 years. The median age was 46 years (IQR, 32-59), and 65.6% (n = 101) of them were men. During the follow-up period, one hundred and ten patients (71.4%) survived; among them, 52 patients had a good outcome. From the overall survival curve, the 1-, 3-, and 8-year survival rates of patients were about 80.5%, 72.0%, and 69.7%, respectively. Cox regression analysis revealed a significant association between the lower APACHE II score (p = 0.005) (cut-off score ≥ 18) and the presence of sleep spindles (p = 0.001) with survival. Logistic regression analysis demonstrated a higher CRS-R score (cut-off score ≥ 7), and presence of sleep spindles were related to a favorable outcome among patients with pDoC.
Conclusions:
Sleep spindles are correlated with both long-term survival and long-term functional outcome in pDoC patients.
... To our knowledge, there is no study to date in the medical literature that has used similar methodology and comparable sample size. Researchers in this area are instead concentrating on mid-term or long-term follow-up outcomes in these patients, or assessing the effectiveness of professional rehabilitation programs [18][19][20][21][22][23][24]. ...
Purpose
A significant percentage of patients are discharged from intensive care units (ICU) with disorders of counciousness (DoC). The aim of this retrospective, case-control study was to compare patients discharged from the ICU in a vegetative state (VS) or minimally conscious state (MCS) and the rest of ICU survivors, and to identify independent predictors of DoC among ICU survivors.
Methods
Data from 14,368 adult ICU survivors identified in a Silesian Registry of Intensive Care Units (active in the Silesian Region of Poland between October 2010 and December 2019) were analyzed. Patients discharged from the ICU in a VS or MCS were compared to the remaining ICU survivors. Pre-admission and admission variables that independently influence ICU discharge with DoC were identified.
Results
Among the 14,368 analyzed adult ICU survivors, 1,064 (7.4%) were discharged from the ICU in a VS or MCS. The percentage of patients discharged from the ICU with DoC was similar in all age groups. Compared to non- DoC ICU patients, they had a higher mean APACHE II and SAPS III score at admission. Independent variables affecting ICU discharge with DoC included unconsciousness at ICU admission, cardiac arrest and craniocerebral trauma as primary cause of ICU admission, as well as a history of previous chronic neurological disorders and cerebral stroke ( p <0.001).
Conclusion
Discharge in a VS and MCS was relatively frequent among ICU survivors. Discharge with DoC was more likely among patients who were unconscious at admission and admitted to the ICU due to cardiac arrest or craniocerebral trauma.
... 14 The study also demonstrated a higher chance of recovery in the post-anoxic brain injury sub-group (21.4%) than in earlier published studies which were in the form of case reports. [15][16][17][18][19][20][21] that a third of patients in MCS with mixed aetiologies improved more than 1 year post ictus. 22 In this study however, Glasgow Outcome Scale was used as main outcome measure with no specific attention to improvement of awareness/ responses to given stimuli . ...
Sleep is a physiological state where memory processing, learning and brain plasticity occur. Patients with prolonged disorders of consciousness (PDOC) show no or minimal signs of awareness of themselves or their environment but appear to have sleep-wake cycles. The main aim of this thesis was to investigate effect of circadian rhythm and sleep optimization on brain functions of patients with PDOC. In the first instance, sleep and circadian rhythms of patients with PDOC were investigated using polysomnography and saliva melatonin measurements. The investigations that were performed at the baseline suggested that both circadian rhythmicity and sleep were severely deranged in PDOC patients. This was followed by the interventional stage of the research where an attempt was made to optimize circadian rhythm and sleep by giving blue light, caffeine and melatonin in a small cohort of patients. To measure the effects of the intervention, we used a variety of assessments: Coma Recovery Scale-Revised (CRS-R) to measure changes in awareness; PSG for assessment of sleep, melatonin for assessment of circadian rhythm; and, event-related potential measures including mismatch negativity (MMN) and subject’s own name (SON) paradigms. Our results showed that it is possible to improve sleep and circadian rhythms of patients with PDOC, and most importantly, this improvement leads to increase in Coma Recovery Scale-Revised scores. Individually, those patients who responded well to the intervention also showed improvements in their functional brain imaging assessments.
... Much clinical research has focused on rehabilitation outcomes in relation to the period of time elapsed since severe acquired brain injury. 1 According to the historic study of the Multi-Society Task Force on Persistent Vegetative State, 1 the probability of recovery of consciousness could be considered negligible after 12 months of vegetative state in the case of traumatic brain injury and 3 months in the case of non-traumatic brain injury. Since then, many papers describing anecdotal cases of late recovery of consciousness have been published, [2][3][4][5][6] and recently case series have been reported of patients who regained consciousness after an interval greater than 12 months in the case of traumatic brain injury and greater than 6 months in the case of non-traumatic brain injury (anoxic and vascular brain injury). 7 When patients come out of vegetative state, in most cases they enter minimal conscious state or a state of severe disability. ...
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.
... Only 22% of minimally conscious state (MCS; minimal and inconsistent awareness) and 17% of unresponsive wakefulness syndrome (UWS; vegetative state; open-eyes, no evidence of awareness) patients return to an approximation of their former levels of functioning 4 years after injury 1 ; bearing in mind that disorder of consciousness (DOC) is associated with an increased risk of death, [2][3][4] and that exceptionally, late, satisfactory recovery occurs (e.g. [5][6][7][8] ). Among foremost concerns are expectations of significant recovery offset by very low rates of discharge to the home environment without disability, and the predicament of permanent DOC, which should be considered at 6 months post stroke, 12 months post trauma in UWS, and between three and 5 years or less in MCS. 9 Expectations come from drug-based, 10 physical and nonpharmacological interventions. ...
Objective
The efficacy of deep brain stimulation in disorders of consciousness remains inconclusive. We investigated bilateral 30‐Hz low‐frequency stimulation designed to overdrive neuronal activity by dual pallido‐thalamic targeting, using the Coma Recovery Scale Revised (CRS‐R) to assess conscious behavior.
Methods
We conducted a prospective, single center, observational 11‐month pilot study comprising four phases: baseline (2 months); surgery and titration (1 month); blind, random, crossover, 1.5‐month ON and OFF periods; and unblinded, 5‐month stimulation ON. Five adult patients were included: one unresponsive‐wakefulness‐syndrome male (traumatic brain injury); and four patients in a minimally conscious state, one male (traumatic brain injury) and three females (two hemorrhagic strokes and one traumatic brain injury). Primary outcome measures focused on CRS‐R scores. Secondary outcome measures focused notably on baseline brain metabolism and variation in activity (stimulation ON – baseline) using normalized fluorodeoxyglucose positron emission tomography maps. Statistical analysis used random‐effect models.
Results
The two male patients (one minimally conscious and one unresponsive wakefulness syndrome) showed improved mean CRS‐R scores (stimulation ON vs. baseline), in auditory, visual and oromotor/verbal subscores, and visual subscores respectively. The metabolism of the medial cortices (low at baseline in all five patients) increased specifically in the two responders.
Interpretation
Our findings show there were robust but limited individual clinical benefits, mainly in visual and auditory processes. Overall modifications seem linked to the modulation of thalamo‐cortico‐basal and tegmental loops activating default mode network cortices. Specifically, in the two responders there was an increase in medial cortex activity related to internal awareness.
... These records were then reviewed in full and discrepancies resolved by consensus. Following this process, 18 records were retained for inclusion in this review (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57). Data extraction was completed across three categories relating to (i) participant characteristics, (ii) programme information, and (iii) study design and outcomes. ...
... These measures highlighted the very severe nature of the injuries sustained by participants. GCS was reported in six studies, with participants in five studies having an initial GCS of 8 or below (40,43,44,47,55). In the remaining study, 81.9% of participants were reported to have had an initial GCS of 8 or below (45). ...
... For example, the participants in one study ranged from 11 to 36 years post-injury (47). Only four studies included participants who had commenced intervention in the first year post-injury (40,41,50,53). ...
Primary Objective: Many adults with very severe acquired brain injury (ABI) do not receive adequate rehabilitation, limiting their recovery and leading to admission to inappropriate living environments. The aim of this scoping review was to map the existing literature relating to the nature and outcomes of rehabilitation programmes for adults experiencing prolonged recovery after very severe ABI.
Design: A comprehensive scoping of the literature was undertaken, including systematic searching of databases, grey literature, and hand searching. Eligible studies had to report on (a) extended rehabilitation for (b) adults with very severe ABI and complex support needs and describe (c) the outcomes of the intervention.
Results: From an initial total of 17,829 citations, 18 records were retained for review. Data extraction focused on (i) participant characteristics, (ii) programme information, and (iii) programme outcomes. Studies were characterised by substantial diversity. However, findings suggested that extended rehabilitation assisted participants to live more independently in more home-like environments and contributed towards significant savings in their lifetime care costs.
Conclusions: Extended specialised rehabilitation can maximise the independence and participation of adults with very severe ABI. Advocacy is required to ensure that adults with very severe injuries have access to individually tailored, non-time-limited intervention programmes.
... This is important, because, in times of declining financial support for the healthcare systems, and an increasing legalization of euthanasia [30], it depends on the public whether 'the right to die' will be the only right conceded to UWS patients. However, given previous results on brain functions [19,[50][51][52] as well as unexpected late recovery [26,57], there should also be other rights conferred to patients. Those rights could include, but are not limited to, the right of a correct diagnosis, the right for an empirically tested prognosis, the right for treatment and the right for inclusion into activities of daily living [29]. ...
Background
The extent to which people ascribe mind to others has been shown to predict the extent to which human rights are conferred. Therefore, in the context of disorders of consciousness (DOC), mind ascription can influence end of life decisions. A previous US-American study indicated that participants ascribed even less mind to patients with unresponsive-wakefulness-syndrome (UWS) than to the dead. Results were explained in terms of implicit dualism and religious beliefs, as highly religious people ascribed least mind to UWS. Here, we addresses mind ascription to UWS patients in Germany. Methods
We investigate the perception of UWS patients in a large German sample (N = 910) and compare the results to the previous US data, addressing possible cultural differences. We further assess effects of medical expertise, age, gender, socio-economic status and subjective knowledge about UWS in the German sample. ResultsUnlike the US sample, German participants did not perceive UWS patients as “more dead than dead”, ascribing either equal (on 3 of 5 items) or more (on 2 items) mental abilities to UWS patients than to the dead. Likewise, an effect of implicit dualism was not replicated and German medically trained participants ascribed more capabilities to UWS patients than did a non-medical sample. Within the German sample, age, gender, religiosity and socio-economic status explained about 15% of the variability of mind ascription. Age and religiosity were individually significant predictors, younger and more religious people ascribing more mind. Gender had no effect. Conclusion
Results are consistent with cross-cultural differences in the perception of UWS between Germany and the USA, Germans ascribing more mind to UWS patients. The German sample ascribed as much or more but not less mind to a UWS patient than to a deceased, although within group variance was large, calling for further research. Mind ascription is vital, because, in times of declining resources for healthcare systems, and an increasing legalization of euthanasia, public opinion will influence UWS patients’ rights and whether ‘the right to die’ will be the only right conceded to them.
... In 1995, the American Congress of Rehabilitation Medicine suggested avoiding strong time-based prognostic statements (i.e., not to use the term "permanent") even when time elapsed after onset was longer than the time limits proposed by the MSTF [16]. More recently, further case reports [17][18][19] and cohort studies [20][21][22] have documented late recovery of variable levels of consciousness beyond the classical temporal limits even in vascular and anoxic VS/ UWS patients. Therefore, late emergence from VS/UWS or recovery of full consciousness cannot be longer considered as an exception even well beyond time limits proposed by the MSTF, independently of etiology although probability of late recovery is thought to be higher in traumatic VS/UWS patients and strongly associated with younger age [21,22]. ...
In patients with prolonged disorders of consciousness (DOC), clinical evolution is determined by several factors closely interacting with each other: etiology, patient’s age (likely influencing the physiological process of recovery, e.g., brain plasticity), the duration of DOC (likely related to the severity of brain damage), the structural and functional integrity of neuronal populations (as assessed by neurophysiological and neuroimaging methods), and the presence of clinical complications that could impact care strategies.
... Late recovery from VS (albeit with persistent severe cognitive impairment) may therefore be more common than thought, and in fact recent articles on patients with acute or post-acute VS report a more favourable long-term prognosis for VS and MCS than in the past (Eilander et al., 2005;Faran et al., 2006;Fins et al., 2007;Sarà et al., 2007;Whyte et al., 2009). Avesani et al. stress the importance of constant followup of patients with consciousness disorders, to allow adequate monitoring of any changes in their clinical picture, especially when their baseline condition is particularly severe (Avesani et al., 2006). They described 2 people diagnosed with VS who, at respectively 6 and 12 months after their original trauma, had achieved a moderate level of functional independence following a significant motor and cognitive recovery. ...
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.
