BACKGROUND: Patients with persistent vegetative state (PVS) show no evidence of awareness of self or their environment, and those with minimally conscious state (MCS) have severely impaired consciousness with minimal but definite behavioral evidence of self or environmental awareness after stroke. Neuroimaging and clinical characteristics separating these two close consciousness states after stroke were insufficiently studied. METHODS: We conducted a hospital-based cohort study of all patients with stroke (2011 to 2017) who underwent 3T magnetic resonance imaging and consciousness assessment after 3 months of inclusion. Univariate and multivariate regression analyses were used to estimate the relative risk of neuroimaging markers for differentiation of PVS and MCS. RESULTS: Of 3,600 eligible subjects, 323 patients (0.09%) had PVS and 93 (0.02%) had MCS (mean age, 62.25±13.4 years). Higher stroke volume was strongly associated with PVS compared to MCS (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98 to 1.00; P=0.001). On univariate analysis, cingulate gyrus (OR, 2.7; 95% CI, 1.62 to 4.36; P=0.001) and corpus callosum (OR, 2.1; 95% CI, 1.28 to 3.44; P=0.003) involvement was significantly associated with PVS. However, on multivariate analysis, only cingulate gyrus involvement was independently associated with PVS (OR, 2.2; 95% CI, 1.33 to 3.72; P=0.002). CONCLUSION: Our results indicate that PVS and MCS are different consciousness states according to clinical and neuroimaging findings. To predict outcome, cognitive performance of these patients should be well questioned after stroke.
Cognition Disorders ; Cohort Studies ; Consciousness ; Corpus Callosum ; Gyrus Cinguli ; Humans ; Magnetic Resonance Imaging ; Multivariate Analysis ; Neuroimaging ; Persistent Vegetative State ; Stroke Volume ; Stroke

The Supreme Court decision made on May 21, 2009 about the withdrawal of futile life-prolonging medical care from a persistently vegetative patient provided a legal basis for patients to consent to death with dignity, and also spurred a lively debate in Korea. The legal grounding of this decision was based on the principles of human dignity, worth, and the right to pursue happiness articulated in the Article 10 of the Constitution. The Death with Dignity Act was legislated to regulate decisions about life-prolonging medical care on February 3, 2016, after extensive debate and a focus on consensus that led to two revisions. However, the issue has not been completely resolved. First, the definition of the process of dying is unclear, because the points that determine whether a patient is dying are different from a simple assessment of whether an artificial ventilator should be attached or detached. Second, the purpose of this law is the protection of human dignity, worth, and the right to pursue happiness. However, nutrition, fluids, and oxygen must continue to be supplied, even after cessation of life-prolonging medical care. Is providing a continuous supply of nutrition, fluids, and oxygen a reasonable way to satisfy the goals of Article 10 of the Constitution? Third, if the withdrawal of life-prolonging medical care is possible based on the family's agreement without the patient's input, what is the legal value of advance directives? In conclusion, it may be necessary to partially revise the law regulating decisions on the withdrawal of life-prolonging medical care through further debate.
Advance Directives ; Consensus ; Constitution and Bylaws ; Happiness ; Humans ; Jurisprudence ; Korea ; Oxygen ; Persistent Vegetative State ; Personhood ; Right to Die ; Supreme Court Decisions ; Ventilators, Mechanical

Persistent vegetative state (PVS) is a clinical condition wherein the cerebral cortex loses its function although brain stem function remains relatively intact. It has high mortality and disability rates. Although treatment for PVS is extensively studied in developed countries, little breakthrough has been made. In China, many PVS patients who were treated with traditional Chinese medicine (TCM) and acupuncture therapy were reported to have regained consciousness. In our department, we have been investigating TCM diagnosis and treatment methods for PVS for many years and have summarized a set of curative programs. Our patient is a male and 5 years and 3 months of age. He had traumatic brain injury and had been unconscious for three months on admission. Considering his condition, we adopted Xingnao Kaiqiao acupuncture, oral Angong Niuhuang Wan, and Xingnaojing intravenous drip. After the 50-day treatment, his health significantly improved and is nearly similar to that of a healthy child, indicating that the treatment is effective for PVS. Therefore, we decided to report the case and treatment methods.
Acupuncture Therapy ; methods ; Biological Products ; Brain Injuries, Traumatic ; complications ; Child, Preschool ; China ; Drugs, Chinese Herbal ; administration & dosage ; Humans ; Male ; Medicine, Chinese Traditional ; methods ; Persistent Vegetative State ; therapy ; Treatment Outcome

Adult ; Biomarkers ; analysis ; Brain Injuries, Traumatic ; metabolism ; Humans ; Persistent Vegetative State ; metabolism ; Proteins ; metabolism ; Tears ; metabolism

The vegetative state is a complex condition with unclear mechanisms and limited diagnostic, prognostic, and therapeutic methods. In this study, we aimed to explore the proteomic profile of tears from patients in a traumatic vegetative state and identify potential diagnostic markers using tears-a body fluid that can be collected non-invasively. Using iTRAQ quantitative proteomic technology, in the discovery phase, tear samples collected from 16 patients in a traumatic vegetative state and 16 normal individuals were analyzed. Among 1080 identified tear proteins, 57 were upregulated and 15 were downregulated in the patients compared to the controls. Bioinformatics analysis revealed that the differentially-expressed proteins were mainly involved in the wound response and immune response signaling pathways. Furthermore, we verified the levels of 7 differentially-expressed proteins in tears from 50 traumatic vegetative state patients and 50 normal controls (including the samples used in the discovery phase) using ELISA. The results showed that this 7-protein panel had a high discrimination ability for traumatic vegetative state (area under the curve = 0.999). In summary, the altered tear proteomic profile identified in this study provides a basis for potential tear protein markers for diagnosis and prognosis of the traumatic vegetative state and also provides novel insights into the mechanisms of traumatic vegetative state.
Adult ; Aged ; Aged, 80 and over ; Biomarkers ; metabolism ; Chromatography, Liquid ; Enzyme-Linked Immunosorbent Assay ; Eye Proteins ; metabolism ; Female ; Humans ; Male ; Mass Spectrometry ; Middle Aged ; Persistent Vegetative State ; metabolism ; Proteome ; Proteomics ; ROC Curve ; Tears ; metabolism ; Young Adult

Adult ; Aged ; Coma ; physiopathology ; Consciousness ; physiology ; Consciousness Disorders ; physiopathology ; therapy ; Female ; Humans ; Male ; Middle Aged ; Persistent Vegetative State ; physiopathology ; Photic Stimulation ; methods ; Recovery of Function ; physiology ; Treatment Outcome

Neuroimaging has opened new opportunities to study the neural correlates of consciousness, and provided additional information concerning diagnosis, prognosis, and therapeutic interventions in patients with disorders of consciousness. Here, we aim to review neuroimaging studies in chronic disorders of consciousness from the viewpoint of the brain network, focusing on positron emission tomography, functional MRI, functional near-infrared spectroscopy, electrophysiology, and diffusion MRI. To accelerate basic research on disorders of consciousness and provide a panoramic view of unconsciousness, we propose that it is urgent to integrate different techniques at various spatiotemporal scales, and to merge fragmented findings into a uniform "Brainnetome" (Brain-net-ome) research framework.
Animals ; Brain ; physiology ; Chronic Disease ; Consciousness ; physiology ; Consciousness Disorders ; physiopathology ; Humans ; Neuroimaging ; methods ; Persistent Vegetative State

OBJECTIVE: Despite recent advances in medicine, no significant improvement has been achieved in therapeutic outcomes for severe traumatic brain injury (TBI). In the treatment of severe multiple traumas, accurate judgment and prompt action corresponding to rapid pathophysiological changes are required. Therefore, we developed the “All-in-One” therapeutic strategy for severe TBI. In this report, we present the therapeutic concept and discuss its efficacy and limitations. METHODS: From April 2007 to December 2015, 439 patients diagnosed as having traumatic intracranial injuries were treated at our institution. Among them, 158 patients were treated surgically. The “All-in-One” therapeutic strategy was adopted to enforce all selectable treatments for these patients at the initial stages. The outline of this strategy is as follows: first, prompt trepanation surgery in the emergency room (ER); second, extensive decompression craniotomy (DC) in the operating room (OR); and finally, combined mild hypothermia and moderate barbiturate (H-B) therapy for 3 to 5 days. We performed these approaches on a regular basis rather than stepwise rule. If necessary, internal ecompression surgery and external ventricular drainage were performed in cases in which intracranial pressure could not be controlled. RESULTS: Trepanation surgery in the ER was performed in 97 cases; among these cases, 46 had hematoma removal surgery and also underwent DC in the OR. Craniotomy was not enforced unless the consciousness level and pupil findings did not improve after previous treatments. H-B therapy was administered in 56 cases. Internal decompression surgery, including evacuation of traumatic intracerebral hematoma, was additionally performed in 12 cases. Three months after injury, the Glasgow Outcome Scale (GOS) score yielded the following results: good recovery in 25 cases (16%), mild disability in 28 (18%), severe disability in 33 (21%), persistent vegetative state in 9 (6%), and death in 63 (40%). Furthermore, 27 (36%) of the 76 most severe patients who had an abnormal response of bilateral eye pupils were life-saving. Because many cases of a GOS score of ≤5 are included in this study, this result must be satisfactory. CONCLUSION: This therapeutic strategy without any lose in the appropriate treatment timing can improve the outcomes of the most severe TBI cases. We think that the breakthrough in the treatment of severe TBI will depend on the shift in the treatment policy.
Brain Injuries* ; Consciousness ; Craniotomy ; Decompression ; Drainage ; Emergency Service, Hospital ; Glasgow Outcome Scale ; Hematoma ; Humans ; Hypothermia ; Intracranial Pressure ; Judgment ; Multiple Trauma ; Operating Rooms ; Persistent Vegetative State ; Pupil ; Trephining

OBJECTIVE: To determine the validity and reliability of the Korean version of the Coma Recovery Scale-Revised (K-CRSR) for evaluation of patients with a severe brain lesion. METHODS: With permission from Giacino, the developer of the Coma Recovery Scale Revised (CRSR), the scale was translated into Korean and back-translated into English by a Korean physiatrist highly proficient in English, and then verified by the original developer. Adult patients with a severe brain lesion following traumatic brain injury, stroke, or hypoxic brain injury were examined. To assess the inter-rater reliability, all patients were tested with K-CRSR by two physiatrists individually. To determine intra-rater reliability, the same test was re-administered by the same physiatrists after three days. RESULTS: Inter-rater reliability (k=0.929, p < 0.01) and intra-rater reliability (k=0.938, p < 0.01) were both high for total K-CRSR scores. Inter- and intra-rater agreement rates were very high (94.9% and 97.4%, respectively). The total K-CRSR score was significantly correlated with K-GCS (r=0.894, p < 0.01), demonstrating sufficient concurrent validity. CONCLUSION: K-CRSR is a reliable and valid instrument for the assessment of patients with brain injury by trained physiatrists. This scale is useful in differentiating patients in minimally conscious state from those in vegetative state.
Adult ; Brain ; Brain Injuries ; Coma* ; Consciousness ; Humans ; Persistent Vegetative State ; Reproducibility of Results ; Stroke

The aim of this study is to investigate the nutritional status in vegetative state (VS) and minimally conscious state (MCS) patients, and to identify correlation between the duration from onset and indices indicating nutritional status. This study included a total of 37 VS and MCS patients. For nutrition assessment, the body mass index (BMI), biochemical parameters such as hemoglobin, total lymphocyte count, albumin and cholesterol levels were measured. The mean BMI was 21.31 ± 2.81 kg/m2. Only 4 patients (10.81%) were classified as underweight, 24 patients (64.86%) had normal BMI, 6 patients (16.22%) were overweight, and 3 patients (8.11%) were obese. The partial correlation coefficients showed that duration from onset has a positive correlation with BMI, and a negative correlation with cholesterol level. This study suggests that regular and properly prescribed enteral feeding in VS and MCS patients would supply stable and appropriate nutrition. Further study is needed with additional nutrition assessments reflecting muscle mass.
Body Mass Index ; Cholesterol ; Enteral Nutrition ; Humans ; Lymphocyte Count ; Malnutrition ; Nutrition Assessment* ; Nutritional Status ; Overweight ; Persistent Vegetative State ; Thinness