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NEUROLOGY TODAY EDITOR-IN-CHIEF STEVEN P. RINGEL, MD, COMMENTS ON “WILLFUL MODULATION OF BRAIN ACTIVITY IN DISORDERS OF CONSCIOUSNESS”

The seven year long legal case of whether to disconnect the life support Terri Schiavo, a young woman in a persistent vegetative state (PVS), drew widespread media attention and involvement of politicians and advocacy groups. Since then, journalists have continued to report studies that shed light on whether there is any preserved cognition in patients diagnosed by neurologists to have PVS or a minimally conscious state.

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DR. STEVEN P. RINGEL

The nuances of these conditions and of study findings are easily misinterpreted by the anxious families and friends, and neurologists are left to explain misunderstandings that follow these sensationalized news reports. Non-medical people who read Jean-Dominique Bauby's book The Diving Bell and the Butterfly or saw the movie version understandably have difficulty differentiating between their loved one with PVS and Bauby, who remained cognitively intact following a brainstem stroke that caused him to be “locked in.”

The Feb. 3 study in The New England Journal of Medicine, “Willful Modulation of Brain Activity in Disorders of Consciousness,” has once again been highlighted in news stories throughout the country. Because of the findings, which identified minimal signs of awareness in a small number of patients, it is likely that in the future neurologists will be asked to perform fMRI in severely brain injured patients and will have to interpret what the findings mean.

As pointed out by Allan H. Ropper, MD, in an accompanying editorial, this study provides important new information, but it is not likely to help neurologists at the bedside who must allay the angst of hopeful families and friends observing their loved one in a vegetative or minimal cognitive state.

HOW TO RESPOND TO THE MEDIA FRENZY

Within days of the Feb. 3 report more than 60 news organizations heralded the New England Journal of Medicine (NEJM2007; 448:600–603.) findings as a feat of human consciousness. Maybe people with these disorders of consciousness are really awake and doctors sealed their fate with a misdiagnosis, the reports cried out.

The problem with any such media frenzy is that many families who are nursing a loved one in an unconscious state may feel that they need to have a similar workup to find out whether there is any level of awareness inside.

In an accompanying editorial in the same issue of the NEJM, Alan H. Ropper, MD, professor of neurology and executive vice-chair of neurology at Brigham and Women's Hospital, said three points should be emphasized when explaining these results to patients: “First, in this study, brain activation was detected in very few patients. Second activation was only in some patients with traumatic brain injury, not in patients with global ischemia and anoxia. Third, cortical activation does not provide evidence of an internal ‘stream of thought’ (William James's term), memory, self-awareness, reflection, synthesis of experience, symbolic representations, or — just as important — anxiety, despair, or awareness of one's predicament.”

“Watching a relative or friend in a persistent vegetative state or minimally conscious state is anguishing and often a source of dissension within families and between physicians and families,” Dr. Ropper wrote. “More likely, from my experience, magnetic resonance imaging will be no more persuasive to hopeful families than the physician's pessimistic clinical assessment. It will always be difficult to prove a lack of a mental life than to demonstrate its presence.”

Dr. Ropper suggested that fMRI may be of benefit to “supplement conventional neurological exams in the classification and prognosis of patients in coma.”

Still, the study's findings open the field to more questions to be answered. Among them, should all head-injured patients have access to a brain scan to find out if they can hear or respond to commands? And who will pay for the scans and the added rehabilitation that may be demanded to try to get a person to a place where they are mentally able to think about tennis?

References

Monti MM, Vanhaudenhuyse A, Laureys S, et al. Willful modulation of brain activity in disorders of consciousness. N Engl J Med 2010; E-pub 2010 Feb. 3.
    Schiff ND, Giacino JT, Rezai AR, et al Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature 2007; 448:600–603.