[Paleopsych] NYT: Signs of Awareness Seen in Brain-Injured Patients
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Tue Feb 8 21:22:39 UTC 2005
The New York Times > Science > Signs of Awareness Seen in Brain-Injured Patients
By BENEDICT CAREY
Thousands of brain-damaged people who are treated as if they are
almost completely unaware may in fact hear and register what is going
on around them but be unable to respond, a new brain-imaging study
The findings, if repeated in follow-up experiments, could have
sweeping implications for how to care best for these patients. Some
experts said the study, which appeared yesterday in the journal
Neurology, could also have consequences for legal cases in which
parties dispute the mental state of an unresponsive patient.
The research showed that the brain-imaging technology, magnetic
resonance imaging, can be a powerful tool to help doctors and family
members determine whether a person has lost all awareness or is still
somewhat mentally engaged, experts said.
"This study gave me goose bumps, because it shows this possibility of
this profound isolation, that these people are there, that they've
been there all along, even though we've been treating them as if
they're not," said Dr. Joseph Fins, chief of the medical ethics
division of New York Presbyterian Hospital-Weill Cornell Medical
Center. Dr. Fins was not involved in the study but collaborates with
its authors on other projects.
Other experts warned that the new research was more suggestive than
conclusive, and that it did not mean that unresponsive people with
brain damage were more likely to recover or that treatment was yet
But they said the study did open a window on a world that has been
neglected by medical inquiry. "This is an extremely important work,
for that reason alone," said Dr. James Bernat, a professor of
neurology at Dartmouth.
Dr. Bernat said findings from studies like these would be relevant to
cases like that of Terri Schiavo, a Florida woman with brain damage
who has been kept alive for years against her husband's wishes. In
that case, which drew the attention of Gov. Jeb Bush and the
Legislature, relatives of Ms. Schiavo disagreed about her condition,
and a brain-imaging test - once it has been standardized - could help
determine whether brain damage has extinguished awareness.
The patients in question have significant brain damage. Three million
to six million Americans live with the consequences of serious brain
injuries, neurologists said. An estimated 100,000 to 300,000 of them
are in what is called a minimally conscious state: they are bedridden,
cannot communicate and are unable to feed or care for themselves, but
they typically breathe on their own.
They may occasionally react to instructions to blink their eyes or
even reach for a glass, although such responses are unpredictable. By
observing behavior in a bedside examination, neurologists can
determine whether a person is minimally conscious or in a "persistent
vegetative state" - without awareness, and almost certain not to
In the study, a team of neuroscientists in New York, New Jersey and
Washington, D.C., used imaging technology to compare brain activity in
two young men determined to be minimally conscious with that of seven
healthy men and women. In a measure of overall brain activity, the two
groups were vastly different: the two minimally conscious men showed
less than half the activity of the others.
But the researchers also recorded an audiotape for each of the nine
subjects in which a relative or loved one reminisced, telling familiar
stories and recalling shared experiences. In each of the brain-damaged
patients, the sound of the voice prompted a pattern of brain activity
similar to that of the healthy participants.
"We assumed we would get some minimal response in these patients, but
nothing like this," said Dr. Nicholas Schiff, an assistant professor
of neurology and neuroscience at Weill Cornell Medical College in
Manhattan and the study's lead author. The two men showed near-normal
patterns in the language-processing areas of their brains, Dr. Schiff
said, suggesting that some neural networks "could be perfectly
preserved under some conditions."
Although the number of patients studied was very small, the
specificity and intricacy of the patterns made it all but impossible
that the results were a fluke, said Dr. Joy Hirsch, director of the
Functional MRI Research Center at Columbia University Medical Center
and the study's senior author.
One of the two minimally conscious men lay still in a brain-imaging
machine while his sister recounted his toast at her wedding and
recalled times playing together as children. Although his eyes were
closed, the researchers found that visual areas of his brain were
active, suggesting that he might have been producing images, Dr.
"We do not know for sure what is happening in this man's head, but if
he were imagining things at the sound of his sister's voice, that
would suggest some connection to emotion," Dr. Hirsch said.
Since the study was completed, Dr. Hirsch said, the team has run the
same kinds of tests on seven similar brain-injury patients, with
similar results: the language processing networks in their brains
display seemingly normal patterns upon their hearing the voice of a
loved one. The government has provided financing for the team to
conduct a larger study of mental activity in minimally conscious
A better understanding of brain patterns in minimally conscious
patients should also help cut down on misdiagnosis by doctors, Dr.
Fins said. He said one study had found that as many as 30 percent of
patients identified as being unaware, in a persistently vegetative
state, were not. They were minimally conscious.
Moreover, mental states can change over time, and some patients have
almost completely recovered function after being thought vegetative.
Brain imaging would be one way to track these changes, and even link
them to efforts at treatment. Doctors have no cure for either a
minimally conscious or persistently vegetative state.
"The most consequential thing about this is that we have opened a
door, we have found an objective voice for these patients, which tells
us they have some cognitive ability in a way they cannot tell us
themselves," Dr. Hirsch said. The patients are, she added, "more human
than we imagined in the past, and it is unconscionable not to
aggressively pursue research efforts to evaluate them and develop
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