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Persistent Vegetative State

Published byRafe Goodman Modified over 8 years ago

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Presentation on theme: "Persistent Vegetative State"— Presentation transcript:

1 Persistent Vegetative State
SECRETS OF EVALUATION

2 CEREBRAL CATACLYSM

3 “Coma in the ICU” Persistent Vegetative State “Locked In” Syndrome
AKINETIC MUTISM SEVERE ENCEPHALOPATHY “LOCKED OUT” SYNDROME Apallic State

4 THE BRAIN IS THE INSTRUMENT
OF AWARENESS

5 DECARTES’ BRAIN CONSCIOUSNESS BRAIN OUTSIDE WORLD

6 MODERN VIEW CONSCIOUSNESS IS IN THE BRAIN OUTSIDE WORLD

7 A MODULAR VIEW OF BRAIN FUNCTION

8 Consciousness Arousal Content

9 AROUSAL BRAINSTEM ARAS

10 BRAINSTEM STRUCTURES OF AROUSAL

11 MIDBRAIN

12 RETICULAR ACTIVATING SYSTEM
WAKES UP THE CORTEX

13 CONTENT CEREBRAL CORTEX LIMBIC SYSTEM MEDIAL FRONTAL LOBE

14 TO LOSE CONSCIOUSNESS Brainstem Bilateral Cortices

15 ANATOMY OF AWARENESS Reticular Activating system Thalamus Cortex

16 CORTEX ARAS MODULAR VIEW OF CORTICAL ACTIVATORS MEDIAL LIMBIC FRONTAL
THALAMUS THALAMUS SYSTEM LOBE ARAS LOCUS PERIAQU CERULEUS GRAY

17 CEREBRAL CORTEX

18

19 COMA “CEREBRAL SHUTDOWN” RENAL SHUTDOWN MODEL
E.G. SPINAL SHOCK, CONCUSSION

20 RECOVERY COMA PVS DEATH

21 COMA + TIME PVS

22 PVS Awake but not aware Jennett & Plum 1972

23 CONCEPT OF PERSISTENT VEGETATIVE STATE
Arousal but no content to consciousness Brain cut off from environment Awareness?? Return of sleep wake cycle Preservation of primitive reflexes Learned complex behavior incompatible with PVS Expectation: No return of Sapience

24 PVS (DEF’N-1) No Awareness of Self or Environment
Intact Sleep-Wake Cycles (awake) Preservation of Hypoth. and Autonomic Function No Sustained Purposeful or Voluntary Behavioral Response

25 PVS (DEF’N cont’d) No Language Comprehension or Expression
Bowel and Bladder Incontinence Full Chew and Swallow not Present

26 PERSISTENT VEGETATIVE STATE
Severe Bilateral Cortical injury “apallic state” traumatic Vascular Permanent Damage to brainstem arousal structures

27 INCOMPATIBLE WITH PVS COORDINATED CHEWING SWALLOWING VERBAL OUTPUT
SUSTAINED VISUAL FOLLOWING FOLLOWING COMMANDS PURPOSIVE MOVEMENTS NORMAL EEG

28 PVS (AAN Pos’n Statement)
No pain or suffering (sapience gone) Artificial nutrition and hydration may be d/c’d Withdrawing treatment is equivalent to withholding it

29 PVS (AAN Pos’n Statement cont’d)
Dx of permanent Unconsc can be made with high certainty Once dx’d Medical Care is of no value to the patient Pt’s & Family Wishes (not Caregiver) are paramount

30 PVS “Lights are on but no one home.”

31 RECOVERY PVS DEATH

32 RECOVERY IN PVS: NONTRAUMATIC TRAUMATIC VERY RARE AFTER 3 MOS.
VERY RARE AFTER 1 YEAR

33 “COMA VIGIL” RETURN OF SLEEP WAKE CYCLES “AWAKE BUT UNAWARE” EYES OPEN
NO EVIDENCE OF COGNITION MINIMAL VISUAL FOLLOWING AND REACTION TO THREAT NO OR MINIMAL SPONT. MOTOR MOV’T NOW CALLED PVS

34 “APALLIC STATE” NO CLOAK OR MANTLE (No Cortex) Kretchmer 1941
Eyes Open Primitive Visual Following Uncommunicative and Unresponsive

35 ENCEPHALOPATHY REVERSIBLE PROCESS AFFECTING BRAIN FUNCTION METABOLIC
INFECTIOUS

36 ASSOCIATIVE NEUROWELTANSCHUUNG AFFERENT EFFERENT OUTSIDE WORLD

37 ARTIST ASSOCIATIVE AFFERENT EFFERENT OUTSIDE WORLD

38 ATHLETE, ENTREPRENEUR ASSOCIATIVE EFFERENT AFFERENT OUTSIDE WORLD

39 PHILOSOPHER, MATHEMATICIAN
ASSOCIATIVE EFFERENT AFFERENT WORLD

40 ASSOCIATIVE OUTSIDE WORLD LOCKED-IN SYNDROM: “DE-EFFERENTED STATE”
AMPUTATED EFFERENT LIMB ASSOCIATIVE AFFERENT OUTSIDE WORLD

41 PONS

42

43 LOCKED-IN De-efferented state No motor output

44 LOCKED-IN Bilateral basal pontine stroke Severe Guillian-Barre
Severe Myasthenia Myopathy

45 LOCKED-IN SYNDROME “De-Efferented State Consciousness Maintained
vertical willful eye movements Altered REM sleep Absent horizontal eye movements Lesion in Ventral Pons

46 PSEUDO-COMA “Locked in” Syndrome “Locked out” Syndrome

47 QUINLAN’S BRAIN: DEAFFERENTED
“LOCKED-OUT” ASOCIATIVE BRAIN EFFERENT OUTSIDE WORLD

48 LOCKED-OUT De-afferented state Cutting off Sensory Input to Brain

49 THALAMUS “NO ONE…BUT THRU ME” AFFERENT WAYSTATION TO CORTEX

50 THALAMUS

51

52 LOCKED-OUT Bilateral Thalamic lesions Disconnection from Environment
amputation of sensory function

53

54 MEDIAL FRONTAL LOBE MOTIVATION “PUSH”

55 “AKINETIC MUTISM” Cairns 1941 patient w/ craniopharyngioma
Eyes open “giving promise of Speech” Bilateral CINGULATE Gyrus Destruction Or lesion in anterior third ventricle

56 AKINETIC MUTISM (Vigilant Type)
Bouts of Excitement or Agitation Intermittent aimless aggressivity Restless More alert and ready to be Aroused Lesion: subfrontal or Cintulate, orbitomedial frontal lobes

57 AKINETIC MUTISM (somnolent type)
Inertia, somnolence, lethargy, “abulia” paralysis of vertical gaze and other eye movements Primitive Visual Following Diencephalo-mesencephalic Jxn at post. extent of iiird Ventr. Bifurc. or Basilar Mesenceph. Brrs.

58 AKINETIC MUTISM Circumscribed Vascular Lesions
Patients may not be entirely mute

59 LIMBIC SYSTEM EMOTIONAL COLOR

60 LOCUS CERULEUS PERIAQUEDUCTAL GRAY DREAM AND SLOW WAVE SLEEP

61

62 PROGNOSIS HOW MUCH VISIBLE DAMAGE??

63 CEREBRAL HEMORRHAGE

64 HUGE FATAL STROKE

65 LARGE EMBOLISM

66 HYPERTENSIVE ENCEPHALOPATHY

67 MODULAR VIEW OF AWARENESS
HOW TO EVALUATE STATES OF AWARENESS WHAT ACTUALLY HAPPENS PROGNOSIS

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