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Minerva Anestesiologica 2000 April;66(4):225-31

Copyright © 2000 EDIZIONI MINERVA MEDICA

language: Italian

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

Latronico N., Alongi S., Guarneri B. *, Cappa S. **, Candiani A.

Università degli Studi - Brescia II Servizio di Anestesia e Rianimazione **Laboratorio di Neuropsicologia e Riabilitazione Neuropsicologica *Spedali Civili - Brescia Servizio di Neurofisiopatologia

Coma is the con­di­tion in ­which ­both com­po­nents of con­scious­ness, wake­ful­ness and aware­ness, are ­lost. Therefore, the coma­tose ­patient nei­ther ­opens the ­eyes, nor ­utters com­pre­hen­sible ­words or fol­lows com­mands. In the veg­e­ta­tive ­state (VS), aware­ness (includ­ing all cog­ni­tive func­tion and emo­tion) is ­lost, ­while the veg­e­ta­tive func­tions, includ­ing breath­ing and ­sleep-­wake ­cycles (the wake­ful­ness), per­sist. Usually VS fol­lows a ­state of ­coma ­caused by trau­mat­ic or anox­ic ­brain dam­age. Pathologic ­brain exam­ina­tion dem­on­strates exten­sive sub-cor­ti­cal, ­white mat­ter, bilat­er­al tha­lam­ic, and brain­stem ­lesions in var­i­ous com­bi­na­tions. Bilateral cere­bral cor­ti­cal ­lesions are ­rare, and there­fore cor­tex can be “out of ­action” ­despite unal­tered struc­ture. More rare­ly, VS is ­caused by ­brain devel­op­men­tal mal­for­ma­tions in chil­dren, or meta­bol­ic or degen­er­a­tive dis­eas­es in chil­dren and ­adults. These are the ­only cas­es in ­which ­patients are not coma­tose ­before VS ­becomes appar­ent. After 6-8 ­weeks of ­coma, ­patients ­regain the eye open­ing. In ­such a con­di­tion, the ­term ­coma is no long­er appro­pri­ate. If aware­ness is ­absent, the ­patient can be ­defined as in VS. Finally, the VS is ­defined as per­sis­tent (PVS) ­when it has con­tin­ued for at ­least 1 ­month. The diag­no­sis of VS and PVS are clin­i­cal and ­require assess­ment ­over an ade­quate peri­od of ­time and the ­skills of a mul­ti­dis­ci­pli­nary expe­ri­enced ­team. Diagnosis is ­very com­plex in ­infants young­er ­than 3 ­months, and is not appli­cable to pre­term neo­nates, ­with the ­unique excep­tion of ­infants ­with anen­ce­pha­ly. Among ancil­lary diag­nos­tic ­tools, dynam­ic PET stud­ies ­show prom­ise.