[Paleopsych] NYT: Signs of Awareness Seen in Brain-Injured Patients

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The New York Times > Science > Signs of Awareness Seen in Brain-Injured Patients
http://www.nytimes.com/2005/02/08/science/08coma.html
5.2.8

    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
    suggests.

    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
    possible.

    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
    recover.

    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.
    Hirsch said.

    "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
    people.

    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
    therapeutic techniques."