Health

Most patients with severe traumatic brain injury (TBI) are unconscious for a period of time. A few patients remain unconscious permanently. The following discussion applies to both sets of patients – those who are temporarily passing through an unconscious state and those who are unconscious for a long time. There are different stages of impaired consciousness. The first and deepest stage is a coma, followed by vegetative state. Once a person regains consciousness, he has left the vegetative state and is considered to be minimally conscious.

In a coma, the patient’s eyes are closed. Once a patient’s eyes open by themselves, he can be considered to have emerged from coma. However, just because a patient’s eyes are open does not mean he is conscious. To be conscious means to be aware of oneself or one’s surroundings. If a person’s eyes are open but he is still unconscious, the patient is said to be in a vegetative state. This term does not mean that the person is a “vegetable.” It means that the person is awake (because his eyes are open) but is not yet conscious. A person could be in a vegetative state for just a few hours (before regaining consciousness) or for the rest of his life. Simply being in a vegetative state does not imply anything about the future outcome or prognosis.

The next state after vegetative state is called the minimally conscious state. A person is said to be in a minimally conscious state when he performs actions that show awareness of himself or his surroundings. However, because these actions are limited or not always present, the patient is not yet considered to be fully conscious. Examples of actions or behaviors that would indicate that someone is conscious include consistently following objects or people with his eyes, following requests (such as: “show me two fingers”), or saying words. If a patient consistently does any of these behaviors, he is considered to be conscious. If he shows more advanced behaviors, such as carrying on a conversation or using objects (like a spoon), then he is considered to be out of the minimally conscious state.

Sometimes it is hard to tell if a person is demonstrating some of the behaviors mentioned. Some behaviors may only be a reflex (meaning that the body does it automatically without a person having to be conscious). Examples of behaviors that might be reflexes include yawning or being startled at loud noises. In evaluating patients, it is very helpful for different people (both family and staff) to observe the patient at different times. This is because a patient’s performance can vary. The patient may be more responsive in the evening (when most of the staff has gone), or he may respond to some people better than others. Patients do often respond to family members more than to staff. On the other hand, family members can sometimes be confused about which behaviors are signs of consciousness and which ones might just be reflexes. For this reason, it is important that the staff and family share their observations with each other. One reason that observation and examination are so important is that there are currently no tests that definitively allow one to diagnose if someone is in a vegetative state or is minimally conscious. In particular, MRIs (even functional MRIs) do not make the diagnosis.

There are two major goals in treating patients who are in a vegetative or minimally conscious state. The first is to prevent medical and physical complications in the body. The idea behind this is to make sure that the ‘body is ready’ whenever the patient recovers consciousness. In addition to appropriate medical and nursing care, physical and occupational therapies can help. For instance, they can help in maintaining the range of motion in a patient’s limbs.

In addition to preventing complications, another goal of treatment is to help the brain recover faster or better. Unfortunately, there are almost no treatments to speed recovery that have been proven to work. Most patients will be started on medications to help stimulate the brain (neurostimulants).

Table 5. Some Stimulants Used in Disorders of Consciousness

(Sample Brand Names in Parentheses)

So far only one has been found to work in studies (amantadine). This does not mean that other neurostimulants will not work, only that they have not been studied. However, there have been reports of many of them helping individual patients. One of the more interesting reports found that a sleeping pill (zolpidem) seemed to increase alertness in some patients who were minimally conscious.

Two non-drug treatments that have not been found to be effective in studies are sensory stimulation and deep-brain stimulation. Sensory stimulation involves providing the patient with higher than normal stimulation through vision, sound, etc. Deep brain stimulation is a surgical treatment. At the present time, there is no evidence to recommend the use of either treatment after TBI.

Predicting how long someone will remain in a vegetative or minimally conscious state is still very difficult. It is also difficult to predict what a person’s long-term condition will be after he has been in these states for a while. In general, the longer someone has been in a vegetative or minimally conscious state, the less likely he will regain consciousness or have a good outcome. Specifically, it would be rare for someone to regain consciousness after being in a vegetative state for over a year. For patients who have been in a vegetative state less than a year, there are some guidelines that can give some idea of what to expect.

Table 6. One-Year Outcome in Patients Still in a Vegetative State 3 Months after a TBI*

* Adapted from “Medical Aspects of the Persistent Vegetative State—Second of Two Parts” in New England Journal of Medicine June 2, 1994 pp. 1572-1579

The table indicates what one might expect for a person who is still in a vegetative state three months after the injury. As indicated, patients who have been in a vegetative state for three months still have a significant chance of recovering consciousness (35 percent) and even possibly being able to live on their own (16 percent). It is important to note that the table only refers to patients in a vegetative state and does not apply to patients who are minimally conscious. In general, patients who are minimally conscious will have a better outcome. There have been some reports of patients getting better after years of being in a vegetative or minimally conscious state. Although extremely rare, it does appear that some of these reports are genuine. At least one of these patients is being studied by scientists to try to explain what allowed for improvement in his case.