Leon Sazbon

Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment

Objective: The goal of the study was to look for the response of treatment with increasing doses of dopaminergic medication on the recovery of vegetative state patients post-TBI. Design: A prospective study of eight patients aged 25–50 years in vegetative state (VS) of mean duration of 104 days following traumatic brain injury (TBI) was performed by investigating changes of their state of consciousness while they were treated with levodopa/carbidopa. Results: Initial improvement was observed in all patients within a mean of 13 days after onset of treatment. Seven patients recovered consciousness after a mean time of 31 days of treatment. The remaining patient showed only slight improvement to minimally conscious state. The sequence of symptoms leading to recovery was the same in all patients; the first to appear was moving a limb on a request, which appeared at a mean time of 13 days. Gradual increase of dose leads to the appearance of better-organized responses like reacting to more than one command, than opening the mouth and appearance of a reciprocal contact. The only side effect was visual hallucinations in one patient, which disappeared after decreasing the dosage. Conclusions: Clinical awareness to the structured order of responses and to the effect of dosage can help clinicians in early assessment of response to dopaminergic treatment in VS patients.

Loewenstein communication scale for the minimally responsive patient

Primary objective : Any sign of communicative ability in patients in vegetative state can provide information about regain of consciousness and conservation of cognitive abilities. The aim of this study was to test the reliability and validity of an instrument designed to measure the degree of communication in minimally responsive patients. Materials : The Loewenstein Communication Scale (LCS) measures five hierarchical functions - mobility, respiration, visual responsiveness, auditory comprehension and linguistic skills (verbal or alternative) - which are divided into five parameters and rated in developmental order on a 5-point scale by level of difficulty. Scores for each function are summed to obtain a quantitative communication profile. Methods : Forty-two adult patients in vegetative state, as a result of acquired brain injury, were examined with the proposed LCS for the minimally responsive patients by two speech and language clinicians at admission to the Intensive Care Unit (ICU) for brain injured patients and, thereafter, at least once weekly. At the end of the ICU stay, 27 patients who showed signs of recovery and were referred for continued rehabilitation were compared to a group of 15 patients who were not referred for continued rehabilitation, for functional and general LCS scores. The predictive power of the LCS in differentiating between these groups was tested. Results : The LCS was found to have very good reliability with good inter-rater agreement. Patients who eventually continued rehabilitation had significantly higher total scores as well as in the motor, visual and auditory sub-scales. Logistic regression results indicated that these parameters successfully differentiated between the two groups of patients, even after adjusting for age and for scores on the Glasgow Coma Scale. Conclusion : The LCS for the minimally responsive patients proved to be reliable and predictive of rehabilitation progress of minimally responsive patients. It may be useful for the interdisciplinary rehabilitation team in planning early individually targeted therapeutic programmes.

Time-related sequelae of TBI in patients with prolonged post-comatose unawareness (PC-U) state

Seventy-two patients who were in a post-comatose unawareness state for periods longer than 1 month following traumatic brain injury recovered consciousness thereafter. The incidence of residual sequelae of brain trauma in relation to duration of unawareness was studied. The incidence of motor disability, communication disorders, cognitive disturbances and malbehaviour was studied in the patients recovering consciousness after 1, 2, 3 and 6 months. It was found that no significant differences were found in the incidence of the above-mentioned residual sequelae of brain-damaged patients in relation to duration of post-comatose unawareness. However, 76.1% (51/67) of the patients who recovered consciousness and survived the first year following injury were living at home. Most of these were patients who recovered consciousness within the first 3 months following trauma. None of the patients who were in post-comatose unawareness longer than 6 months did so, Five patients (6.9%) died during the first year. Motor disability, independence in activities of daily living, vocational outcome and place of living were significantly related to duration of prolonged unawareness state whereas the disturbances in high mental functions did not. Although the vocational outcome of patients with post-comatose unawareness is not good, the fact that most of them are still able to live at home, having an acceptable quality of survival, justifies, according to our experience, the comprehensive rehabilitation programme.

Relationship between muscular tone, movement and periarticular new bone formation in postcoma± unaware (PC-U) patients

Forty-eight post-traumatic brain-injured patients in postcoma-unawareness (PC-U) state, are included in this study. All recovered consciousness at least 1 month after the accident. The muscular tone and movement of all limbs was examined. At least two X-rays of the big joints were taken. Periarticular new bone formation appeared in 26 patients. This heterotopic ossification occurs in severely injured patients, primarily in proximal joints of the upper and lower extremities. Their aetiology in brain injury is unknown. Risk factors include prolonged coma, tone and movements in the involved extremity, and associated fractures. We found that the appearance of periarticular new bone formation had a close correlation with pathological movement (paresis or plegia), a borderline correlation with hypertonus, and no correlation with hypotonus or with associated fractures.

The Diagnostic Value of Three Common Primitive Reflexes

Systematic attempts were made to elicit the snout, palmomental and corneomandibular reflexes in 50 young patients with prolonged traumatic coma, 50 elderly hemiplegics soon after their first cerebrovascular accident and in 100 normal age-matched controls. None was found significantly more frequently alone in brain-damaged patients than in age-matched controls. Only combinations of two or three reflexes showed diagnostic value in distinguishing between neurologically damaged patients and normal age-matched controls. Only the combination of all three was completely absent in the normal controls; this combination was found in 13% of the brain-damaged subjects.

Bladder tone in patients in post-traumatic vegetative state

The aim of the present study was to examine the bladder tone in vegetative patients using urodynamic tests. The study population consisted of 17 patients, 13 men and four women, in a post-traumatic vegetative state under treatment at the Loewenstein Rehabilitation Centre. Time since injury ranged from 1 to 6 months. Cystometry results indicated that 100% of the patients had neurogenic bladder, hypertonic type, two (12%) with mild spasticity and 15 (88%) with severe spasticity. None showed detrusor-sphincter dyssynergia or unstable bladder. Based on these unequivocal findings, it is suggested that all patients in trauma-induced vegetative state be treated prophylactically from the 2nd week with anticholinergic agents.

Some aspects of the humoral and neutrophil functions in post-comatose unawareness patients

Post-comatose unawareness (PCU) is one of the possible outcomes of severe brain injury. Patients with severe brain injury have an increased susceptibility to severe nosocomial infections for multifactorial reasons, including immune suppression at different levels. We studied different immunological aspects in 11 PCU patients. Impaired humoral immunity was found in 27% of them. Two patients had decreased haemolytic activity of the classical complement pathway, associated with decreased levels of the components C1q, C1r and C4. Another patient had very low levels of IgG2 and IgG4. The neutrophil killing activity was impaired in these three patients, but was completely restored with the addition of a heterologous serum, suggesting a humoral defect. Neutrophils showed normal chemotaxis and random migration, and the superoxide anion release by neutrophils was also found to be normal. Understanding the immunological events in PCU patients contributes to a better and more intensive therapeutic approach, which might accelerate the rehabilitation of these patients.

CT findings in persistent vegetative state following blunt traumatic brain injury.

The use of linear measurements in the analysis of CT scans of TBI patients was found to contribute to the understanding of brain damage and were correlated with outcome in severe traumatic close brain injured patients. The purpose of the present study was to analyse the data obtained by the linear measurements on CT studies of TBI patients who remained in persistent vegetative state following blunt head trauma. All 27 patients included in the study were reported to be neurologically normal prior to injury. Thirteen patients, 11 remaining in persistent vegetative state (responsive but unaware) and two who died, constituted the worst outcome group. Fourteen patients who regained consciousness, underwent multidisciplinary evaluation when their recovery reached a plateau and were ranked according to severity of residual symptoms and outcome. The degree of correlation with the overall vocational outcome parameter with the various radiological indices was calculated as the Spearman rank correlation coefficient, with correction for tied scores. Fishers z transformation was used to combine results with those of our previous analysis. Three radiological parameters showed a statistically significant correlation with clinical outcome. These were the right and left septum-caudate distance and the cerebroventricular index 2; these showed Spearman rank coefficients of 0.52, 0.45 and 0.48; with two-tailed p-values under 0.01, 0.02 and 0.01 respectively. The width of the third ventricle suggested correlation with the clinical scoring. The findings of the present study point to the importance of loss of deep gray matter of the caudate nuclei and widening of the adjacent part of the lateral ventricles in catastrophic brain injury. This finding may highlight the role of localized ischemic changes, in addition to diffuse axonal injury. Values of over 8 mm for the width of the third ventricle and over 11 mm for septum caudate distance are suggestive of catastrophic and poor prognosis for recovery.

Somatosensory evoked potentials in prolonged postcomatose unawareness state following traumatic brain injury

Somatosensory evoked potentials (SEPs) were found by several authors to have a prognostic value in traumatically brain-injured (TBI) patients and can serve for monitoring changes in the state of TBI patients. Most of the studies were performed in the acute phase of trauma and most of reports have dealt with the short-latency components. The present study reports on seven patients (mean age 26.2 years) who suffered severe blunt TBI and were in prolonged post-comatose unawareness (PCU) state, in whom early and late SEP components were recorded at least 5 weeks after sustaining trauma. The SEPs studied could not reveal a uniform pattern apart from prolonged central conduction time (CCT), which was common to all patients. This may be due to individual non-homogeneous patterns of brain damage in our severe TBI patients. Meaningful late recovery of consciousness occurred in one patient and correlated with shortening of CCT. We suggest that the prolonged CCT found in our patients is related to diffuse subcortical axonal injury and that the shortened CCT found during the second examination in this patient actually reflects late partial recovery--either structural or functional--of affected brain regions. This patient is also an example of the possible relationship between reduction of CCT and recovery of consciousness a long time after injury.

Epidemiological findings in traumatic post-comatose unawareness

We have examined the epidemiological background of 134 consecutive patients admitted to our centre who suffered from post-traumatic unconsciousness of over 1 months duration. The incidence of such unconsciousness in Israel is estimated as 4 per 1,000,000, or one case in 410 hospitalizations for head trauma. The cause of trauma was a road accident in 69% of cases. Among victims, pedestrians and cyclists were more likely than four-wheeled vehicle drivers and their passengers to suffer from prolonged unconsciousness, from which they were less likely to recover.