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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care

Official Journal of the Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care
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Minerva Anestesiologica 2000 April;66(4):233-40

language: Italian

Approach to the patient in a vegetative state. Part II: differential diagnosis

Latronico N., Alongi S., Facchi E., Taricco M., Candiani A.

Università degli Studi - Brescia II Servizio di Anestesia e Rianimazione (LC, AC) Clinica Neurologica (LAV) Spedali Civili - Brescia Servizio di Neurofisiopatologia (LA) Azienda Ospedaliera «G. Salvini» Ospedale di Passirana - Rho (Milano) Unità Operativa di Riabilitazione (MT)


A pre­req­ui­site to the diag­no­sis of veg­e­ta­tive ­state is the exclu­sion of appar­ent­ly sim­i­lar syn­dromes, in ­which the ­patient ­retains the con­scious­ness par­tial­ly or ­even com­plete­ly. ­Some syn­dromes are not sep­ar­ate nos­o­log­i­cal ­entities and ­should be aban­doned: the apal­lic ­state, the neo­cor­ti­cal ­death, the decer­e­brate and decor­ti­cate ­state, the ­alpha-­coma, the vig­il or pro­longed or irre­ver­sible ­coma are ­among ­them. ­Three con­di­tions ­deserve spe­cial con­sid­er­a­tion. The ­term ­locked-in syn­drome ­describes a ­patient com­plete­ly par­a­lysed and ­mute, but ful­ly con­scious, and is usu­al­ly ­caused by ischem­ic ­lesions of the ­pons. Sev­er­al var­i­ants do ­exist, ­either in the caus­es and ­site of ­lesion. ­Some ­patients may ­become par­a­lysed and ­mute, but con­scious ­because of poly­neu­rop­a­thies, ­that is in the ­absence of any ­lesions of the cen­tral ner­vous ­system. The aki­net­ic mut­ism is a ­rare con­di­tion char­ac­ter­ised by ­loss of ­speech and near­ly ­absent bod­i­ly move­ments. Pain­ful stim­u­la­tion may ­cause appro­pri­ate with­draw­ing, and wake­ful­ness and ­self-aware­ness may be pre­served, but cog­ni­tive impair­ment is usu­al­ly ­present. It ­must be empha­sised ­that ­this con­di­tion can be due to poten­tial­ly treat­able ­lesions, ­such as hydro­ceph­a­lus and cran­i­oph­a­ryn­gio­ma. The ­term “min­i­mal­ly respon­sive” or “min­i­mal­ly con­scious” ­describes severe­ly dis­abled ­patients in ­whom mean­ing­ful respons­es can be dem­on­strat­ed, ­although incon­stant­ly. ­This con­di­tion, the ­true diag­nos­tic chal­lenge, ­often rep­re­sents a tran­si­tion ­phase of veg­e­ta­tive ­patients recov­er­ing con­scious­ness. Phy­si­cians, phys­io­ther­a­pists and ­patient’s rel­a­tives ­should ­work all togeth­er to ­reach a cor­rect diag­no­sis, by ­using cur­rent avail­able meth­ods to moni­tor­ize the recov­ery of con­scious­ness

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