Summary
Fifteen cases of chronic vegetative state (CVS), following severe head injury and lasting for two years or more, are reported. Vegetative state, in most instances after a period of coma, consists of a return of wakefulness accompanied by an apparent total lack of higher mental activity. A protracted period of vegetative state has been chosen to ensure that the possibility of further recovery could virtually be excluded. The term of CVS could therefore be reasonably used to designate these cases. Moreover, cerebral lesions were then thought to be the same as in neuropathological studies. Severe head injury, responsible for CVS, initially affected adults in 11 cases and children in four cases. The range of duration of the vegetative state was 2 to 14 years, with a mean of five years. The data of clinical study and electrophysiological investigations (EEG, brain stem auditory evoked potentials, somatosensory evoked potentials) are reported. A CT scan was carried out in each case to study the impairment of cerebral hemispheres and brain stem, with particular attention to the ventricular size. The results confirm that in the CVS, lesions affect mainly the hemispheres, while brain stem functions are mainly preserved.
Vegetative State (VS) is the term proposed by Jennett and Plum (1972) to describe the condition that sometimes emerges after a period of coma, after a severe head injury (SHI). This condition consists of a return of wakefulness accompanied by an apparent total lack of higher mental activity. A practical definition of this state characterised by wakefulness without responsiveness is that the eyes open spontaneously and/or in response to verbal stimuli. Sleep-wake cycles exist. The patients can neither obey simple orders nor locate painful stimuli. They utter no comprehensible words. Blood pressure and breathing remain steady.
It is much more difficult to specify exactly how long such a state must persist before it can be confidently declared permanent. Persistent vegetative state, or chronic vegetative state (CVS) is one of the five categories of the Glasgow Outcome Scale (Jennett and Bond, 1975). Bricolo et al (1980) think that the term CVS should never be applied before completion of the first year after the onset of traumatic coma. It actually seems possible to exclude the possibility of any further recovery after unresponsiveness for one year. The term CVS may then be rightfully used to denote this condition.
For such protracted periods of VS, we have tried to state in a retrospective study the clinical and electroencephalographic (EEG) course. It has also appeared to us interesting to report the actual data of evoked potentials (EP) and computerized tomographic (CT) scan.
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References
Adams J.H., Mitchell D.E., Graham D.I., et al: Diffuse brain damage of immediate impact type. Brain 100: 489–502, 1977
Adams J.H., Graham D.I., Murray L.S., et al: Diffuse axonal injury due to non-missile head injury in humans: an analysis of 45 cases. Ann. Neurol. 12: 557–563, 1982
Adams J.H., Graham D.I., Doyle D., et al.: Diffuse axonal injury in head injuries caused by a fall. Lancet 2: 1420–1421, 1984
Arts W.F.M., Van Dongen H.R., Van Hof-Van Duin J., et al.: Unexpected improvement after prolonged post-traumatic vegetative state. J. Neurol. Neurosurg. Psychiat. 48: 1300–1303, 1985
Barge M., De Rougemont J., Chirossel J.P.: Aspects sémiologiques des comas traumatiques. Rev. Electroencéphalogr. Clin. Neurophysiol. 9: 83–90, 1979
Bricolo A., Gentiliomo A., Rosadini G., et al.: Long lasting posttraumatic unconsciousness: a study based on nocturnal EEG and polygraphic recording. Acta Neurol. Scand. 44: 512–532, 1968
Bricolo A., Turazzi S., Faccioli F.: Clinical application of compressed spectral array in long term EEG monitoring of comatose patients. Electroencephalogr. Clin. Neurophysiol. 45: 211–225, 1978
Bricolo A., Turazzi S., Feriotti G.: Prolonged post-traumatic unconsciousness: therapeutic assets and liabilities. J. Neurosurg. 52: 625–634, 1980
Cant B.R., Shaw N.A.: Monitoring by compressed spectral array in prolonged coma. Neurology 34: 35–39, 1984
Desmedt J.E., Cheron G.: Central somatosensory conduction in man: neural generators and interpeak latencies of the farfield components recorded from neck and right or left scalp and earlobes. Electroenceph. Clin. Neurophysiol. 50: 382–403, 1980
Dougherty J.H., Rawlinson D.G., Levy D.E., et al: Hypoxic-ischemic brain injury and the vegetative state: Clinical and neuropathologic correlation. Neurology 31: 991–997, 1981
Greenberg R.P., Mayer D.J., Becker D.P., et al: Evaluation of brain function in severe human head trauma with multimodality evoked potentials. Part 1: Evoked brain injury potentials, methods and analysis. J. Neurosurg. 47: 150–162, 1977
Grindal A.B., Suter C., Martinez A.J.: Alpha-pattern coma: 24 cases with nine survivors. Ann. Neurol. 1: 371–377, 1977
Hansotia P., Gottschalk P., Green P., et al: Spindle coma: incidence, clinicopathologic correlates and prognostic value. Neurology 31: 83–87, 1981
Hansotia P.L.: Persistent vegetative state - Review and report of electrodiagnostic studies in eight cases. Arch. Neurol. 42: 1048–1082, 1985
Higashi K., Sakata Y., Hatano M., et al: Epidemiological studies on patients with a persistent vegetative state. J. Neurol. Neurosurg. Psychiat. 40: 876–885, 1977
Higashi K., Hatono M., Abiko S., et al: Five year follow-up study of patients with persistent vegetative state. J. Neurol. Neurosurg. Psychiat. 44: 552–554, 1981
Ingvar D.H., Brun A., Johansson L., et al: Survival after severe cerebral anoxia with destruction of the cerebral cortex: the apallic syndrome. In: Korein (ed); Ann. N. Y. Acad. Sci. 315: 184–214, 1978
Jennett W.B., Plum F.: Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1: 734–737, 1972
Jennett W.B., Bond M.: Assessment of outcome after severe brain damage. Lancet 1: 480–484, 1975
Jennett W.B., Teasdale G.: Predicting the outcome in individual patients after severe head injury. Lancet 1: 1031–1034, 1976
Jennett W.B., Teasdale G.: Aspects of coma after severe head injury. Lancet 1: 878–881, 1977
Jennett W.B., Teadale G.: Management of severe head injuries. Ed 2 FA Davis, Philadelphia, 1981
Karnaze D.S., Marshall L.F., Bickford R.G.: EEG monitoring of clinical coma: The compressed spectral array. Neurology 32: 289–292, 1982
Maccabee P.J., Pinkhasov E.I., Cracco R.Q.: Short latency somatosensory evoked potentials to median nerve stimulation: effect of low frequency filter. EEG clin. Neurophysiol. 55: 34–44, 1983
Narayan R.K., Greenberg R.P., Miller J.D., et al: Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J. Neurosurg. 54: 751–762, 1981
Newlon P.G., Greenberg R.P., Hyatt M.S., et al: The dynamics of neuronal dysfunction and recovery following severe head injury assessed with serial multimodality evoked potentials. J. Neurosurg. 57: 168–177, 1982
Newlon P.G., Greenberg R.P.: Evoked potentials in severe head injury. Trauma 24: 61–66, 1984
Plum F., Posner J.B.: Diagnosis of stupor and coma. 3rd Ed F A Davis, Philadelphia, 1980
Rosenberg G.A., Johnson S.F., Brenner R.P.: Recovery of cognition after prolonged vegetative state. Ann. Neurol. 2: 167–168, 1977
Rosenblum W.I., Greenberg R.P., Seelig J.M., et al: Midbrain lesions: frequent and significant prognostic feature in closed head injury. J. Neurosurgery 9: 613–620, 1981
Sherrington C.S.: Decerebrate rigidity and reflex coordination of movements. Journal of Physiology 22: 319, 1898
Sichez J.P., Melon E., N'Guyen J.P., et al: Surveillance et traitement des traumatisés cräniens avec signes précoces de souffrance axiale. J. Traumatologie 2: 115–123, 1980
Turazzi S., Bricolo A., Pasut M.L.: Review of 1000 consecutive cases of severe head injury treated before the advent of CT scanning. Acta neurochirurgica 72: 167–195, 1984
Young B., Rapp R.P., Norton J.A., et al: Early prediction of outcome in head injured patients. J. Neurosurg. 54: 300–303, 1981
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Danze, F., Brule, J.F. & Haddad, K. Chronic vegetative state after severe head injury: Clinical study; electrophysiological investigations and CT scan in 15 cases. Neurosurg. Rev. 12 (Suppl 1), 477–499 (1989). https://doi.org/10.1007/BF01790694
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DOI: https://doi.org/10.1007/BF01790694