November 14, 2012
Some Apparently Vegetative Patients Are Aware And Can Follow Commands
April Flowers for redOrbit.com - Your Universe Online
Alex Seaman is 20 years old, and for the last year and a half, he's been a patient at the Royal Hospital for Neuro-disability. He is awake and even has his eyes open at times, but Alex has no apparent awareness and is unable to talk or respond with his body.
"What I´d like to know is, if he recognizes us, if he is aware and if he´s happy," said his mother, Sally Seaman, to UK reporter Fergus Walsh.
Alex has had several bouts of critical illness in the 18 months he's been in the hospital, including pneumonia and infection, making it impossible for caregivers to make a full assessment of his injuries. They believe he could be vegetative — which means he is awake, but with no awareness of himself or the outside world.
Alex and his family have been given a rare opportunity for Alex to be part of a research project at Addenbrooke's Hospital, Cambridge. The study will discover if Alex has a functioning mind trapped in an unresponsive body. Using functional magnetic resonance imaging (fMRI), a team of Cambridge University neuroscientists at the Wolfson Brain Imaging Centre has been looking for hidden awareness in otherwise unresponsive patients.
Increased blood flow can reveal the parts of the brain, which are active when someone is thinking, and this increased blood flow is measurable using fMRI.
BBC's Panorama program has followed Alex and a number of other young men with severe brain injuries in Britain and Canada for the past year. The patients were asked to imagine playing tennis or walking around their house. Such imaginings, in healthy patients, produce two distinct patterns of brain activity which the scanner can pinpoint.
Professor Adrian Owen published research two years ago showing nearly one in five apparently vegetative patients were aware and able to follow commands in the scanner.
Alex responds and can perform both the tennis and house tasks, against all odds. Alex was also shown photographs of faces and buildings. These images were flashed on a screen, and the scan results suggest Alex may be able to recognize the faces of his family and his girlfriend, Jess.
His mother says, "It gives us something to work with, and shows you should never give up, no matter how bleak it looks."
Another patient in the study, Scott Routley, is in Canada where Professor Owen is currently based. Scott, 39, was injured in a car crash 12 years ago, and has been unresponsive ever since. Scott's confirmation, under the scanner, that he feels no pain is a breakthrough event. It is the first time any brain-injured patient has been asked to answer something clinically relevant to their care.
“Scott has been able to show he has a conscious, thinking mind. We have scanned him several times and his pattern of brain activity shows he is clearly choosing to answer our questions. We believe he knows who and where he is," Professor Owen, who led the study at the Brain and Mind Institute of Western Ontario, told Walsh. Owen says that medical textbooks might need rewriting based on Scott and his ability to answer questions.
Prof Bryan Young at University Hospital, London has been Scott's neurologist for a decade. Young said the scan results overturned all the behavioral assessments that had been made over the years.
"I was impressed and amazed that he was able to show these cognitive responses. He had the clinical picture of a typical vegetative patient and showed no spontaneous movements that looked meaningful," he told BBC News
Since Scott responded in the scanner, observational assessments continue to suggest that he is vegetative.
Scott responding is not really a surprise to his parents, Anne and Jim, though. They were already convinced that Scott sometimes responded by lifting his thumb or moving his eyes. But the sure knowledge that he can answer questions raises fears.
"In the back of your mind you´re always wondering is he happy?" says Anne. "Does he want to go on with his life? Not that we´d do anything to stop that. We´ll always be there for him."
Whether the Routleys would do anything or not, the question has a great deal of relevance for patients in Britain. More than 40 vegetative patients have been allowed to die over the last two decades through the withdrawal of their feeding tubes. Such actions have to be approved by the courts. The question is whether this technology could change such decisions in the future.
Professor Owen does not see his study as a pathway for allowing patients to decide their fate.
"Just because a patient can answer yes and no questions, doesn´t necessarily mean they have the cognitive faculties, the understanding to decide whether to live or die."
The families involved in Owen's study have no intention of giving up on their sons. Miraculous events do happen, sometimes.
Stewart Newman was released earlier this year from RHN. Newman was injured in a car accident five years ago. Today, he communicates using a letter-board and by giving a thumbs-up, accompanied by a big smile. When asked what it was like to be trapped in his body, Newman replied, "I would scream at a wall."
Another patient, Steven Graham, demonstrated that he had created new memories since his brain injury. Asked if his sister had a daughter, Graham answered yes. His niece was born after his car crash five years previously.
Not every patient was able to respond, however. At least one scanned by the fMRI was completely unable to show awareness.
This study might give a voice to these patients, a voice they have been denied by conventional medicine.
As Alex´s mother, Sally, said to him: "The tests show you are in there and we´ve just got to fight to get you back out again."
Prof Owen said, “Asking a patient something important to them has been our aim for many years. In future, we could ask what we could do to improve their quality of life. It could be simple things like the entertainment we provide or the times of day they are washed and fed.”