Vegetative State Brain Scans

[Oblong]

washingtonpost.com

In 'vegetative state' patients, brain scanners show some alert minds

By Rob Stein
Washington Post Staff Writer
Thursday, February 4, 2010; A01



Many of the patients were labeled with the same grim diagnosis: "vegetative state." Their head injuries, teams of specialists had concluded, condemned them to a netherworld -- alive yet utterly devoid of any awareness of the world around them.

But an international team of scientists decided to try a bold experiment using the latest technology to peek inside the minds of 54 patients to see whether, in fact, they were conscious.

One by one, the men and women were placed inside advanced brain scanners as technicians gave them careful instructions: Imagine you are playing tennis. Imagine you are exploring your home, room by room. For most, the scanner showed nothing.

But, shockingly, for one, then another, and another, and yet two more, the scans flashed exactly like any healthy conscious person's would. These patients, the images clearly indicated, were living silently in their bodies, their minds apparently active. One man could even flawlessly answer detailed yes-or-no questions about his life before his trauma by activating different parts of his brain.

"It was incredible," said Adrian M. Owen, a neuroscientist at the Medical Research Council who led the groundbreaking research described in a paper published online Wednesday by the New England Journal of Medicine. "These are patients who are totally unable to perform functions with their bodies -- even blink an eye or move an eyebrow -- but yet are entirely conscious. It's quite distressing, really, to realize this."

Although Owen and other experts stressed that much more research is needed to confirm findings and refine the technology, they said the results could provide profound insight into human consciousness -- one of the most daunting scientific mysteries -- and lead to ways to better diagnose brain injuries and treat tens of thousands of patients. The technology also offers the tantalizing possibility of being able to finally communicate with some patients and ask, at the very least, whether they are in pain and need relief.

"This should change the way we think about these patients," said Nicholas D. Schiff, an associate professor of neurology and neuroscience at Weill Cornell Medical College in New York City. "I think it's going to have very broad implications."

Wider questions

The research inevitably raised questions about patients such as Terri Schiavo, a Florida woman in a persistent vegetative state whose family dispute over whether to discontinue her care ignited a national debate over the right-to-die issue that led to congressional intervention in 2005. Schiavo's brother, Bobby Schindler, said the new study highlights the limits of medicine to provide an accurate diagnosis.

"I wish this could have been used on my sister to see what could have been done to help her," Schindler said in a telephone interview.

But Owen, Schiff and other experts stressed that the research does not indicate that many patients in vegetative states are necessarily aware or have any hope of recovery. Many, like Schiavo, have suffered much greater danger to their brains for far longer than the patients in the study.

"In some cases, the damage to the brain is so severe that it is simply inconceivable they could produce any responses," Owen said.

As many as 20,000 Americans are in a vegetative state, meaning they are alive and awake but without any apparent sense of awareness, and 100,000 to 300,000 are in a related condition known as a minimally conscious state, in which they exhibit impaired or intermittent awareness. It is unclear what proportion of these patients would be affected by the study's findings.

A growing body of evidence in recent years has indicated that a significant proportion of such patients might have had their conditions misdiagnosed and have more awareness than had been thought.

Responsive minds

In 2006, Owen and his colleagues described the case of a young woman who had been thought to be in a vegetative state whose brain responded identically to a normal brain when placed inside a device known as a functional magnetic resonance imaging (fMRI) scanner and asked to imagine herself playing tennis or exploring her home. The case electrified neuroscientists. But it remained unclear whether her case was a fluke or represented a population of patients who were languishing with misdiagnoses.

Flooded with requests from desperate families to assess their loved ones, Owen and researchers at the University of Liege in Belgium started testing more patients. In the new report, the researchers describe the results from the first 54, including 23 who had a vegetative state diagnosed and 31 whose diagnosis was minimal consciousness.

Five, including the first woman, were able to repeatedly fire their brains in precisely the same way as hundreds of normal volunteers who were put in the fMRIs and asked to imagine themselves hitting a tennis ball, and wandering through their homes. Four of the five had received a vegetative state diagnosis, and one was thought to be only minimally conscious. Three showed signs of awareness during intensive standard bedside tests, but two did not.

The researchers then decided to see if they could use the approach to communicate with a patient. They told a 29-year-old man in Belgium to think about tennis if he wanted his answers to be yes and imagine touring his home for no. They then asked him yes-or-no questions about his life, such as whether his father's name was Thomas and whether he had brothers or sisters. He got every question right by thinking about tennis or being home.

"He could produce no communication with his body," Owen said. "But he could systematically and repeatedly change his brain activity to indicate yes or no with 100 percent accuracy."

Finding a way to communicate with brain-damaged patients has long been a goal of neuroscientists. It has also been the subject of literature and films, including the 2007 film "The Diving Bell and the Butterfly," which told the story of French editor Jean-Dominique Bauby. Bauby, paralyzed in a "locked-in syndrome" by a stroke, could communicate only by blinking his left eye.

But some urged caution, saying that the new technique raised a host of thorny questions.

"If a patient wanted to die, if they were asked, 'Do you want to die?,' could they explain themselves adequately?" said Joseph J. Fins, chief of the division of medical ethics at Weill Cornell Medical College. "If they say yes, what does that mean? If this person said yes but meant maybe, or it was 'sort of yes,' we may not be able to understand that sort of nuance. You have to be very careful."

[Walt]

Amazing and frightening at the same time.

[eastside billee]

So, just abort them.

[DaYooperASBDT]

Two words. Wow. If my math is right that was 5 out of 54, or about 9%. Small sample, but a fascinating result.

[billms]

Originally Posted by eastside billee

So, just abort them.

I wrote two different responses to your comment that had parallel form but with Jesus in them - but deleted them out of the desire to not piss off some friends (Roger, Melody, and others for example) just to point out how you've been insulting and disrespectful to a whole group of people most of whom you don't know. Nobody wants to just go out aborting people - you know that - but you just wanted to be a jerk and don't mind misrepresenting and diminishing others people's views just so you can ridicule them. Hey - I'm fine with that. The only reason I pointed this out is that you keep complaining about other people being jerks and ruining threads billee - when you need to take a look in the mirror.

[Blue Square Thing]

Originally Posted by DaYooperASBDT

Two words. Wow. If my math is right that was 5 out of 54, or about 9%. Small sample, but a fascinating result.

Interestingly the reports I've read say 4/23 of the persistent vegetative status patients. Very interesting research - Giving the 'unconscious' a voice - health - 03 February 2010 - New Scientist is the NS summary; an editorial at In conversation with 'vegetative' patients - opinion - 03 February 2010 - New Scientist

The research itself is presented here: NEJM -- Willful Modulation of Brain Activity in Disorders of Consciousness It's reasonably accessible.

[Blue Square Thing]

Originally Posted by eastside billee

So, just abort them.

The conscious ones or the ones showing signs of cognition?

[baseballbruce30]

this could increase the turnover rate in the congress, the senate and for that matter any other parliamentary body ...

[Blue Square Thing]

Originally Posted by baseballbruce30

this could increase the turnover rate in the congress, the senate and for that matter any other parliamentary body ...

No, I'd think it would reduce it. Should a politician be in a pv state then they may be able to be shown to be showing signs of cognition so may get reelected I suppose. I doubt that anyone is an apparent pv state would be reelected at present, although in some constituencies I suppose anything's possible.

[MrDeeds]

Frightening.

[billms]

Originally Posted by MrDeeds

Frightening.

QFT

[Blue Square Thing]

Originally Posted by MrDeeds

Frightening.

I'm sorry, what is?

[billms]

I assumed he meant the notion of being trapped in such a state and yet having some degree of awareness.

[djhutch]

That's what I think he meant, & I agree.

[Blue Square Thing]

Originally Posted by billms

I assumed he meant the notion of being trapped in such a state and yet having some degree of awareness.

Ta - makes sense now.

[hueytaxi]

Originally Posted by billms

I wrote two different responses to your comment that had parallel form but with Jesus in them - but deleted them out of the desire to not piss off some friends (Roger, Melody, and others for example) just to point out how you've been insulting and disrespectful to a whole group of people most of whom you don't know. Nobody wants to just go out aborting people - you know that - but you just wanted to be a jerk and don't mind misrepresenting and diminishing others people's views just so you can ridicule them. Hey - I'm fine with that. The only reason I pointed this out is that you keep complaining about other people being jerks and ruining threads billee - when you need to take a look in the mirror.

While I appreciate your thoughts, please don't allow me to influence your posts. My tail feathers can be unruffled once again and I'll still respect your opinions. If it is too much for me, I'll most likely post something that I personally think (at the time) deep and meaningful.

[billms]

Well, while it certainly may seem to many here that I take a "I don't give a damn if somebody misinterprets what I say or gets offended by it thats *their* fault", its not true. I just bite my tongue less than some here!

[ToledoTigerFan]

Originally Posted by billms

I wrote two different responses to your comment that had parallel form but with Jesus in them - but deleted them out of the desire to not piss off some friends (Roger, Melody, and others for example) just to point out how you've been insulting and disrespectful to a whole group of people most of whom you don't know. Nobody wants to just go out aborting people - you know that - but you just wanted to be a jerk and don't mind misrepresenting and diminishing others people's views just so you can ridicule them. Hey - I'm fine with that. The only reason I pointed this out is that you keep complaining about other people being jerks and ruining threads billee - when you need to take a look in the mirror.

Amen. I also can say this has been discussed in private messages for some time now.

[ToledoTigerFan]

Originally Posted by MrDeeds

Frightening.

It IS frightening. One wonders how aware they are of their current situation, though. They're able to recollect past events and locations, but are they aware of where they are now? Are they capable of learning and retaining new information? And if they ARE aware of their situation, do they consider their lives meaningful enough to continue living like that. Perhaps there is a way to take their minimally consciousness and use that to remove the cobwebs(for lack of a proper medical term).

[Melody]

Our local paper is carrying a series about a kid who was shot in the head about 20 years or so ago. The point of the story is about his life since the shooting, what was involved in his recovery (such as it's been, he's still a paraplegic). But one thing I found interesting was his account of being able to hear discussions around him and being totally aware of his surroundings yet unable to communicate. After a couple of weeks, a nurse said something funny and he suddenly laughed. His family and medical staff had been with him 24/7 up to that point and did not know that he'd been awake the entire time. But for quite a while after that could only communicate by blinking his eyes. The laugh was kind of an involuntary thing.

I think that if cognition can be established beyond reasonable doubt, and they will that life support be withdrawn, that's what needs to happen.