Trastornos prolongados de conciencia postinjuria cerebral aguda / Prolonged disorders of consciousness after an acute brain injury

Only a fraction of patients in coma secondary to a primary acute brain injury develop a vegetative state (VS). At least 20% of patients show late transitions to a minimally conscious states (MCS). They are particularly common in young adults with traumatic brain injury. The main problems faced by clinicians are the diagnostic accuracy of VS and MCS as well as the usefulness of sophisticated paraclinical investigations. Specific therapies are of limited effectiveness. This population is vulnerable to misdiagnosis and limited access to medical care and rehabilitation, thus generating ethical problems.

[Prolonged disorders of consciousness after an acute brain injury]. / Trastornos prolongados de conciencia postinjuria cerebral aguda.

Only a fraction of patients in coma secondary to a primary acute brain injury develop a vegetative state (VS). At least 20% of patients show late transitions to a minimally conscious states (MCS). They are particularly common in young adults with traumatic brain injury. The main problems faced by clinicians are the diagnostic accuracy of VS and MCS as well as the usefulness of sophisticated paraclinical investigations. Specific therapies are of limited effectiveness. This population is vulnerable to misdiagnosis and limited access to medical care and rehabilitation, thus generating ethical problems.

Minimally Conscious State: Evolution of Concept, Diagnosis and Treatment.

The study of consciousness disorders is a scientific challenge, and clinical differentiation among the various sorts of alterations in consciousness is difficult. Persistent vegetative state was defined in 1972, but years later cases appeared in which diagnosed patients showed signs of cognitive activity, and therefore could not be considered vegetative. Minimally conscious state was defined in 2002. This article discusses minimally conscious state based on a literature review and the author's clinical experience. A brief historical outline is given, starting from 1886 when Horsley analyzed level of consciousness. The article reviews criteria for defining minimally conscious state, as well as the differential diagnosis from persistent vegetative state, brain death, coma, locked-in syndrome and akinetic mutism. Modern discoveries of residual cognitive functioning and new neural correlates have contributed to increased knowledge of this condition. Regardless, minimally conscious state continues to be a challenge for neuroscientists around the world, with issues still to be resolved. KEYWORDS Consciousness, consciousness disorders, minimally conscious state, persistent vegetative state, coma, akinetic mutism, brain death, neurosciences, locked-in syndrome, coma, Cuba.

Perceptions of nurses caring for pregnant women in vegetative states.

PURPOSE: To explore the perceptions of labor and delivery nurses caring for women in persistent vegetative states with viable pregnancies. STUDY DESIGN AND METHOD: For this qualitative research study, participants included a purposive sample of 13 RNs who provided bedside care to pregnant women in persistent vegetative states. The researchers simultaneously collected and analyzed data from the participants. When the researchers achieved saturation of the data, they presented their results to the participants for corroboration. RESULTS: The nurses reported both knowledge deficits and skill deficits in caring for this patient population. Nurses described emotional responses related to perceived limited support from administration, and reported seeking education from other sources. Although considered experts in labor and delivery care, the obstetrical nurses in this study reported feeling like novices when caring for patients with a diagnosis of persistent vegetative state. The nurses' caregiving concerns were found to originate in their ethical beliefs of beneficence and nonmaleficence. CLINICAL IMPLICATIONS: When a patient presents to an obstetrical unit with an uncommon multidisciplinary severe complication such as vegetative state, the nurses perceived the need for support in order to give the best care. This includes education, a multidisciplinary team approach, and continued instruction throughout the patient's stay. Although nurses consider themselves experts within their practice area, they admit shortcomings when unusual complications are apparent.

A Cuban perspective on management of persistent vegetative state.

The Cuban Group for Study of Disorders of Consciousness is developing several research protocols to search for possible preservation of residual brain and autonomic functions in cases of persistent vegetative and minimally conscious states. We present examples showing the importance of 3D anatomic reconstruction of brain structures and MRI tractography for assessing white matter connectivity. We also present results of use of proton magnetic resonance spectroscopy technique to follow up cognitive recovery in persistent vegetative state patients transitioning to minimally conscious state. We have demonstrated recognition of a mother's voice with emotional content after zolpidem administration, indicating high-level residual linguistic processing and brain activation despite the patient's apparent inability to communicate. Hence we differ with current thinking that, by definition, subjects in persistent vegetative state are isolated from the outside world and cannot experience pain and suffering. We also consider "vegetative state" a pejorative term that should be replaced. KEYWORDS Persistent vegetative state, minimally conscious state, consciousness disorders, magnetic resonance imaging, electroencephalography, heart rate variability.

[Persistent vegetative state. Paradigm of current discussion on alterations of consciousness]. / Estado vegetativo persistente. Paradigma de discusión actual sobre alteraciones de la conciencia.

INTRODUCTION: The vegetative state is the current paradigm of discussions about the alterations of conscience. DEVELOPMENT: Although accepted by most investigators, it is still controversial. The dilemma starts with the denomination itself. In this paper we propose the denomination persistent vegetative state . We start with a historical review of the integration of consciousness. We also give epidemiological data and point out the clinical features, complementary tests and anatomical findings. The patients are classified into three grades for prognosis. Grade III includes those with the worst prognosis, who have no sleep waking cycles with or without opening their eyes. This section emphasises cases of prolonged survival and of late recovery who made almost complete recovery of their intellectual functions. We state that treatment is based on two aspects: treatment of the underlying disease and general measures and emphasise the need for a multidisciplinary team. From the bio ethical point of view, it should be remembered that the patients are alive and cannot be considered in the same group as the brain dead, in whom all encephalic function has been lost. CONCLUSIONS: It is not ethical to decide to suspend medical treatment when it is known that there is a possibility of recovery of the structural anatomy and function. We are morally obliged to maintain qualified medical attention. It has been shown scientifically that we not only should, but can, obtain the recovery of these patients, in spite of the serious damage suffered by their nervous system