Clinical and Neuropsychological Long-Term Outcomes After Late Recovery of Responsiveness: A Case Series

doi:10.1016/j.apmr.2013.11.004

Archives of Physical Medicine and Rehabilitation

Volume 95, Issue 4, April 2014, Pages 711-716

https://doi.org/10.1016/j.apmr.2013.11.004 Get rights and content

Abstract

Objective

To report clinical conditions and neuropsychological functioning of patients with late recovery of responsiveness at least 5 years after injury.

Design

Patient series.

Setting

Patients discharged from an inpatient rehabilitation unit.

Participants

Patients (N=13) who recovered from a vegetative state 1 year after severe traumatic brain injury or 6 months after nontraumatic brain injury.

Interventions

Not applicable.

Main Outcome Measures

Coma Recovery Scale-Revised, Disability Rating Scale, and FIM. For patients who recovered full consciousness, neuropsychological tests specifically adapted for patients with very severe disabilities were used.

Results

After regaining responsiveness, 2 patients died because of severe clinical complications. Among the remaining 11 patients, 5 were still in a minimally conscious state at their last assessment, but 4 of them had recovered some complex behavioral responses to the environment (eg, they could follow simple commands, albeit inconsistently). Six patients had emerged from a minimally conscious state at the last evaluation. Severe functional disability was present in both patients who were conscious and patients who were minimally conscious. No patient was autonomous in common daily life activities or in transfers. All patients who were conscious showed variable cognitive impairments, and some of them also developed behavioral and psychological symptoms. However, such disturbances did not impede the patients' interaction with relatives and caregivers.

Conclusions

This study provides systematic data about the course of the disease in a cohort of patients that was previously considered as exceptional. Patients with late recovery show a variable degree of functional recovery, although they experience marked residual motor and cognitive disabilities. The present findings contribute to enhance the understanding of the course of the disease in patients with late recovery and might help clinicians optimize the levels of care and provide the patients' families with correct information.

Section snippets

Participants

For the present study, we followed up the 13 previously reported patients with late recovery of responsiveness6, 7 for at least 5 years postonset. Late recovery of responsiveness was defined by the appearance of any recognizable and reproducible, although inconsistent, nonreflexive response to environmental stimuli (ie, diagnosis of MCS according to current clinical criteria⁹) beyond 12 months after onset in patients with TBI and beyond 6 months postonset in patients with non-TBI.³ Late

Clinical evolution after late recovery of responsiveness

After regaining responsiveness, 2 patients died at 56 and 58 months postonset because of severe clinical complications (hepatic coma and brain hemorrhage, respectively).

The remaining 11 patients were followed for a mean period of 73.6 months postonset (range, 60–89mo). Five patients were still in an MCS at their last assessment, but 4 of them had recovered some complex behavioral responses to the environment (eg, they could follow simple commands, albeit inconsistently). The remaining 6

Discussion

In the present study, we described long-term (at least 5y postonset) clinical and neuropsychological outcomes in a small sample of patients who presented the so-called late recovery of responsiveness, that is, recovery of responsiveness beyond classical temporal limits. This sample of patients was characterized by relatively young age and, only in anoxic patients, by the preserved N20 cortical component of somatosensory evoked potentials at least on 1 side recorded at study entry, which is in

Conclusions

The present study showed that, notwithstanding persistence of some brain plasticity allowing late recovery of responsiveness and late recovery of consciousness, long-term outcome in such patients is often characterized by severe functional impairments. As a consequence, patients' and their families' quality of life is very poor. The severe motor (and cognitive) disabilities and musculoskeletal complications (eg, heterotopic ossifications, contractures) suggest that unresponsive patients with

Acknowledgments

We thank Lucia Abbamonte for her revision of the English text.

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A lot of work has been done on the accurate diagnosis of patients with disorders of consciousness1,2 to establish prognostic indicators3,4 and to understand the neural correlates of consciousness.5
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This novel finding could contribute to explaining the worse outcome in VS patients with respect to MCS patients, as reported in literature.32-34 Moreover, the number of total MCs and the number of severe MCs were higher in anoxic patients, likely in relation to the more diffuse brain damage and worse outcome in such patients, than vascular or traumatic patients.13-15,32-35 Our main findings showed that in our cohort of patients some MCs negatively affected long-term outcome, whereas available studies provided information about impact of MCs on outcome at 1 year of follow-up in DoC patients.3,4
To investigate medical complications (MCs) occurring within 6 months postinjury in brain-injured patients with prolonged disorders of consciousness (DoC) and to evaluate impact of MC on mortality and long-term clinical outcomes.
Prospective observational cohort study.
Rehabilitation unit for acquired DoC.
Patients (N=194) with DoC (142 in vegetative state [VS], 52 in minimally conscious state; traumatic etiology 43, anoxic 69, vascular 82) consecutively admitted to a neurorehabilitation unit within 1-3 months postonset.
Not applicable.
Mortality and improvements in clinical diagnosis and functional disability level (assessed by Coma Recovery Scale-Revised [CRS-R] and Disability Rating Scale) at 12, 24, and 36 months postonset.
Within 6 months postinjury, 188 of 194 patients (>95%) developed at least 1 MC and 142 of them (73%) showed at least 1 severe MC. Respiratory and musculoskeletal-cutaneous MCs were the most frequent, followed by endocrino-metabolic abnormalities. Follow-up, complete in 189 of 194 patients, showed that male sex and endocrine-metabolic MCs were associated with higher risk of mortality at all timepoints. Old age, anoxic etiology, lower CRS-R total scores, and diagnosis of VS at study entry predicted no clinical and functional improvements at most timepoints; however, epilepsy predicted no improvement in diagnosis at 24 months postonset only.
MCs are very frequent in patients with DoC within at least 6 months after brain injury, regardless of clinical diagnosis, etiology, and age. Endocrino-metabolic MCs are independent predictors of mortality at all timepoints; however,epilepsy predicted poor long-term outcome. Occurrence and severity of MCs in patients with DoC call for long-term appropriate levels of care after the postacute phase.
Current validity of diagnosis of permanent vegetative state: A longitudinal study in a sample of patients with altered states of consciousness
2019, Neurologia
Los estados alterados de conciencia han sido considerados tradicionalmente como cuadros clínicos de pronóstico infausto. En la actualidad, sabemos que dichos estados engloban distintas entidades clínicas cuyo perfil diferencial empieza a reconocerse.
Se incluyeron 37 pacientes con el diagnóstico de estado vegetativo o síndrome de vigilia sin respuesta (SVSR) y 43 en estado de mínima conciencia (EMC) de acuerdo con la Coma Recovery Scale-Revised (CRS-R). Todos los pacientes fueron evaluados mensualmente con la CRS-R durante al menos 6 meses. Se evaluó el momento de superar cada estado considerando los puntos de corte de «irreversibilidad» (12 meses para los casos de origen traumático y 3 para los no traumáticos), tradicionalmente establecidos por la Multi-Society-Task-Force. Se empleó un modelo de regresión logística para determinar las variables predictoras de superar el EMC.
Un total de 23 pacientes en SVSR superaron este estado, pero solo 9 superaron el EMC. De los 43 pacientes en EMC al ingreso, 26 lograron superarlo. Ocho de los 23 (34,7%) pacientes que superaron el SVSR y 17 de los 35 (48,6%) que superaron el EMC lo hicieron más allá del punto de «irreversibilidad». La etiología (p < 0,01), la cronicidad (p = 0,01) y la puntuación en la CRS-R (p < 0,001) predijeron la salida de EMC en el modelo multivariante con un 77,5% de acierto.
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Altered states of consciousness have traditionally been associated with poor prognosis. At present, clinical differences between these entities are beginning to be established.
Our study included 37 patients diagnosed with vegetative state/unresponsive wakefulness syndrome (UWS) and 43 in a minimally conscious state (MCS) according to the Coma Recovery Scale–Revised (CRS-R). All patients were followed up each month for at least 6 months using the CRS-R. We recorded the time points when vegetative state progressed from ‘persistent’ to ‘permanent’ based on the cut-off points established by the Multi-Society-Task-Force: 12 months in patients with traumatic injury and 3 months in those with non-traumatic injury. A logistic regression model was used to determine the factors potentially predicting which patients will emerge from MCS.
In the UWS group, 23 patients emerged from UWS but only 9 emerged from MCS. Of the 43 patients in the MCS group, 26 patients emerged from that state during follow-up. Eight of the 23 patients (34.7%) who emerged from UWS and 17 of the 35 (48.6%) who emerged from MCS recovered after the time points proposed by the Multi-Society-Task-Force. According to the multivariate regression analysis, aetiology (P < .01), chronicity (P = .01), and CRS-R scores at admission (P < .001) correctly predicted emergence from MCS in 77.5% of the cases.
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: No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.

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Original articleClinical and Neuropsychological Long-Term Outcomes After Late Recovery of Responsiveness: A Case Series

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Participants

Clinical evolution after late recovery of responsiveness

Discussion

Conclusions

Acknowledgments

Neurol Clin

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Clin Neurophysiol

Arch Phys Med Rehabil

Prog Brain Res

Lancet

Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome

BMC Med

Medical aspects of the persistent vegetative state (1)

N Engl J Med

Late recovery from post-traumatic vegetative state

Brain Inj

The vegetative state: a report of two cases with a long-term follow-up

Brain Inj

Late recovery of responsiveness and consciousness after traumatic, anoxic or hemorrhagic long-lasting vegetative state

Neurology

Predictors of recovery of responsiveness in prolonged anoxic vegetative state

Neurology

Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs

J Neurotrauma

Original article
Clinical and Neuropsychological Long-Term Outcomes After Late Recovery of Responsiveness: A Case Series