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PubMedDate not supplied

Assessing level of consciousness and cognitive changes from vegetative state to full recovery.

Although investigations addressing cognitive recovery from the vegetative state have been reported, to date there have been no detailed studies of these patients combining both neuropsychology and functional imaging to monitor and record the recovery of consciousness. This paper describes the recovery of a specific vegetative state (VS) case. The patient (OG) remained in the vegetative state for approximately two months, increasing her level of awareness to a minimally conscious state, where she continued for approximately 70 days. In the course of the ensuing 18 months, she was able to reach an acceptable level of cognitive functioning, with partial levels of independence. Throughout this two year period, she received continuous cognitive evaluation, for which several different tools were applied including coma and low functioning scales, full cognitive batteries, and structural and functional magnetic resonance imaging (MRI). We present here preliminary data on fMRI using a word presentation paradigm before and after recovery; we also discuss the difficulty of how to determine level of consciousness using the tools currently available, and the subsequent improvement in different cognitive domains. We confirm that accurate diagnosis and proper cognitive assessment are critical for the rehabilitation of patients with disorders of consciousness.

Adult↗
PubMed2005

Functional neuroimaging during altered states of consciousness: how and what do we measure?

The emergence of functional neuroimaging has extended the doctrine of functional specificity of the brain beyond the primary stages of perception, language, and motor systems to high-level cognitive, personality, and affective systems. This chapter applies functional magnetic resonance imaging to another high-level realm of cognition and neurology to characterize cortical function in patients with disorders of consciousness. At first pass, this objective appears paradoxical because conventional investigations of a cognitive process require experimental manipulation. For example, to map the location of language-sensitive cortex, a language-related task is performed according to a temporal sequence that alternates the task with rest (no-task) periods. Application of this approach to the study of consciousness would require that levels of consciousness be similarly varied, this is an unlikely technique. Alternatively, another strategy is presented here where the focus is on functional brain activity elicited during various passive stimulations of patients who are minimally conscious. Comparisons between patients with altered states of consciousness due to brain injury and healthy subjects may be employed to infer readiness and potential to sustain awareness. As if a behavioral microscope, fMRI enables a view of occluded neural processes to inform medical practitioners about the health of the neurocircuity-mediating cognitive processes. An underlying point of view is that assessment of recovery potential can be enhanced by neuroimaging techniques that reveal the status of residual systems specialized for essential cognitive and volitional tasks for each patient. Thus, development of imaging techniques that assess the functional status of individual unresponsive patients is a primary goal. The structural integrity of injured brains is often compromised depending on the specific traumatic event, and, therefore, images cannot be grouped across patients, as is the standard practice for investigations of cognitive systems in healthy volunteers. This chapter addresses these challenges and discusses technique adaptations associated with passive stimulation, paradigm selection, and individual patient assessments, where there is "zero tolerance for error," and confidence in the results must meet the highest standards of care. Similar adaptations have been previously developed for the purpose of personalized planning for neurosurgical procedures by mapping the locations of essential functional systems such as language, perception, and sensory-motor functions for each individual patient. Rather than addressing the question of "how does the brain do consciousness" with these techniques, this chapter presents methods for assessment of neurocognitive health in specific patients with disorders of consciousness.

Attention↗
PubMed1996

[Acute poisoning with thioridazine].

OBJECTIVE: As previous single case reports have indicated that acute poisoning with thioridazine can be potentially dangerous, an investigation was undertaken to find out whether the risk of severe poisoning in adults and children can be judged from the amount of the drug that has been taken. PATIENTS AND METHODS: In a case-control study 202 medical notes of 202 patients were analysed (141 adults, aged 16-82 years; 61 children, aged 0.3-15 years) in which thioridazine was the only potentially harmful substance taken, the precise amount swallowed was known and the drug was the certain or probable cause of the signs. 30 children were excluded from the study, because their body weight was not known. RESULTS: Mild thioridazine poisoning was characterized by somnolence, tremor, ataxia and dysarthria. The severity of the poisoning and the degree of disorder of consciousness correlated significantly with the amount of thioridazine taken. Severe intoxication with coma and ventricular arrhythmias was observed at a dose of 2 g and more. While the disorder of consciousness completely regressed in the first 24 hours, in a few of the patients the cardiac arrhythmias persisted for up to 28 hours after the drug intake. Charcoal administration seemed to influence the course favourably. CONCLUSION: Prolonged, intensive care supervision and treatment are essential if more than 2 g thioridazine have been swallowed. In addition to standard treatment with gastric lavage charcoal should be given as early as possible to limit absorption.

Adolescent↗
PubMed1998

Three probable cases of Loa loa encephalopathy following ivermectin treatment for onchocerciasis.

Over the past nine years, more than 12 million people exposed to Onchocerca volvulus infection have received at least one dose of ivermectin, almost all without serious adverse reactions. Since 1991, however, several cases with neurologic manifestations, including coma, have been reported after ivermectin treatment of persons infected with O. volvulus who also had concomitant Loa loa infection with very high microfilaremia (> 50,000 microfilariae/ml of blood). In 1995, four criteria were established to define probable cases of Loa encephalopathy temporally related to treatment with ivermectin (PLERI). The present paper describes three PLERI cases recorded in Cameroon and compares them with two others reported previously. Disorders of consciousness began 3-4 days after treatment. The objective neurologic signs were variable. The conditions improved favorably in three patients who benefited from early hospitalization and good nursing; their disorders of consciousness lasted only 2-3 days; the results of clinical examination became normal after one month and electroencephalographic abnormalities disappeared after 5-7 months. Conversely, late diagnosis and delay in proper management in two others probably led to worsening of the condition and to fatal outcome related to the usual complications of coma. In addition to these cases, patients w with high Loa microfilaremia also developed milder neurologic manifestations causing functional impairment lasting for at least one week after treatment. Before launching mass ivermectin distribution programs to control onchocerciasis in central Africa, communities in which the intensity of concomitant L. loa microfilaremia is high need to be identified, and specific educational measures and monitoring strategies should be developed and applied before they are treated.

Adolescent↗
PubMedDate not supplied

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.

Brain↗