Persistent Vegetative State

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Persistent Vegetative State

• SECRETS OF EVALUATION

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CEREBRAL CATACLYSM
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Coma in the ICU

• Persistent Vegetative State
• Locked In Syndrome
• AKINETIC MUTISM
• SEVERE ENCEPHALOPATHY
• LOCKED OUT SYNDROME
• Apallic State

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THE BRAIN IS THE INSTRUMENT
OF AWARENESS
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DECARTES BRAIN
CONSCIOUSNESS
BRAIN
OUTSIDE WORLD
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MODERN VIEW
CONSCIOUSNESS IS IN THE BRAIN
OUTSIDE WORLD
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A MODULAR VIEW OF BRAIN FUNCTION
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Consciousness

• Arousal
• Content

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AROUSAL
BRAINSTEM ARAS
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BRAINSTEM STRUCTURES OF AROUSAL
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MIDBRAIN
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RETICULAR ACTIVATING SYSTEM
WAKES UP THE CORTEX
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CONTENT
CEREBRAL CORTEX
LIMBIC SYSTEM
MEDIAL FRONTAL LOBE
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TO LOSE CONSCIOUSNESS

• Brainstem
• Bilateral Cortices

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ANATOMY OF AWARENESS

• Reticular Activating system
• Thalamus
• Cortex

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MODULAR VIEW OF CORTICAL ACTIVATORS
CORTEX
MEDIAL
LIMBIC
FRONTAL
THALAMUS
THALAMUS
SYSTEM
LOBE
ARAS
LOCUS
PERIAQU
CERULEUS
GRAY
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CEREBRAL CORTEX
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COMA

• CEREBRAL SHUTDOWN
• RENAL SHUTDOWN MODEL
• E.G. SPINAL SHOCK, CONCUSSION

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RECOVERY
COMA
PVS
DEATH
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COMA TIME
PVS
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PVS

• Awake but not aware
• Jennett Plum 1972

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CONCEPT OF PERSISTENT VEGETATIVE STATE

• Arousal but no content to consciousness
• Brain cut off from environment
• Awareness??
• Return of sleep wake cycle
• Preservation of primitive reflexes
• Learned complex behavior incompatible with PVS
• Expectation No return of Sapience

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PVS (DEFN-1)

• No Awareness of Self or Environment
• Intact Sleep-Wake Cycles (awake)
• Preservation of Hypoth. and Autonomic Function
• No Sustained Purposeful or Voluntary Behavioral
  Response

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PVS (DEFN contd)

• No Language Comprehension or Expression
• Bowel and Bladder Incontinence
• Full Chew and Swallow not Present

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PERSISTENT VEGETATIVE STATE

• Severe Bilateral Cortical injury apallic state
• traumatic
• Vascular
• Permanent Damage to brainstem arousal structures

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INCOMPATIBLE WITH PVS

• COORDINATED CHEWING SWALLOWING
• VERBAL OUTPUT
• SUSTAINED VISUAL FOLLOWING
• FOLLOWING COMMANDS
• PURPOSIVE MOVEMENTS
• NORMAL EEG

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PVS (AAN Posn Statement)

• No pain or suffering (sapience gone)
• Artificial nutrition and hydration may be d/cd
• Withdrawing treatment is equivalent to
  withholding it

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PVS (AAN Posn Statement contd)

• Dx of permanent Unconsc can be made with high
  certainty
• Once dxd Medical Care is of no value to the
  patient
• Pts Family Wishes (not Caregiver) are paramount

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PVS

• Lights are on but no one home.

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RECOVERY
PVS
DEATH
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RECOVERY IN PVS

• NONTRAUMATIC
• VERY RARE AFTER 3 MOS.
• TRAUMATIC
• VERY RARE AFTER 1 YEAR

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COMA VIGIL

• RETURN OF SLEEP WAKE CYCLES
• AWAKE BUT UNAWARE
• EYES OPEN
• NO EVIDENCE OF COGNITION
• MINIMAL VISUAL FOLLOWING AND REACTION TO THREAT
• NO OR MINIMAL SPONT. MOTOR MOVT
• NOW CALLED PVS

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APALLIC STATE

• NO CLOAK OR MANTLE (No Cortex)
• Kretchmer 1941
• Eyes Open
• Primitive Visual Following
• Uncommunicative and Unresponsive

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ENCEPHALOPATHY

• REVERSIBLE PROCESS AFFECTING BRAIN FUNCTION
• METABOLIC
• INFECTIOUS

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NEUROWELTANSCHUUNG
ASSOCIATIVE
AFFERENT
EFFERENT
EFFERENT
AFFERENT
OUTSIDE WORLD
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ARTIST
ASSOCIATIVE
AFFERENT
EFFERENT
OUTSIDE WORLD
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ATHLETE, ENTREPRENEUR
ASSOCIATIVE
EFFERENT
AFFERENT
OUTSIDE WORLD
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PHILOSOPHER, MATHEMATICIAN
ASSOCIATIVE
EFFERENT
AFFERENT
WORLD
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LOCKED-IN SYNDROM DE-EFFERENTED STATE
AMPUTATED EFFERENT LIMB
ASSOCIATIVE
AFFERENT
OUTSIDE WORLD
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PONS
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LOCKED-IN

• De-efferented state
• No motor output

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LOCKED-IN

• Bilateral basal pontine stroke
• Severe Guillian-Barre
• Severe Myasthenia
• Myopathy

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LOCKED-IN SYNDROME

• De-Efferented State
• Consciousness Maintained
• vertical willful eye movements
• Altered REM sleep
• Absent horizontal eye movements
• Lesion in Ventral Pons

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PSEUDO-COMA

• Locked in Syndrome
• Locked out Syndrome

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QUINLANS BRAIN DEAFFERENTED LOCKED-OUT
ASOCIATIVE BRAIN
EFFERENT
OUTSIDE WORLD
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LOCKED-OUT

• De-afferented state
• Cutting off Sensory Input to Brain

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THALAMUS
NO ONEBUT THRU ME
AFFERENT WAYSTATION TO CORTEX
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THALAMUS
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LOCKED-OUT

• Bilateral Thalamic lesions
• Disconnection from Environment
• amputation of sensory function

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MEDIAL FRONTAL LOBE
MOTIVATION PUSH
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AKINETIC MUTISM

• Cairns 1941 patient w/ craniopharyngioma
• Eyes open giving promise of Speech
• Bilateral CINGULATE Gyrus Destruction
• Or lesion in anterior third ventricle

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AKINETIC MUTISM (Vigilant Type)

• Bouts of Excitement or Agitation
• Intermittent aimless aggressivity
• Restless
• More alert and ready to be Aroused
• Lesion subfrontal or Cintulate, orbitomedial
  frontal lobes

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AKINETIC MUTISM (somnolent type)

• Inertia, somnolence, lethargy, abulia
• paralysis of vertical gaze and other eye
  movements
• Primitive Visual Following
• Diencephalo-mesencephalic Jxn at post. extent of
  iiird Ventr.
• Bifurc. or Basilar Mesenceph. Brrs.

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AKINETIC MUTISM

• Circumscribed Vascular Lesions
• Patients may not be entirely mute

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LIMBIC SYSTEM
EMOTIONAL COLOR
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LOCUS CERULEUS
PERIAQUEDUCTAL GRAY
DREAM AND SLOW WAVE SLEEP
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PROGNOSIS
HOW MUCH VISIBLE DAMAGE??
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CEREBRAL HEMORRHAGE
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HUGE FATAL STROKE
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LARGE EMBOLISM
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HYPERTENSIVE ENCEPHALOPATHY
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MODULAR VIEW OF AWARENESS
HOW TO EVALUATE STATES OF AWARENESS
WHAT ACTUALLY HAPPENS
PROGNOSIS