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BB2 > Persistent Vegetative State > Flashcards

Persistent Vegetative State Flashcards

1
Q

What is consciousness?

A

State of full awareness of self and the environment

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2
Q

What are the 2 parts of consciousness?

A

Arousal - sleep and wake up cycle

Content - sum of all our interactions with environment

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3
Q

What is a vegetative state?

A

Complex condition
Spontaneous eye-opening signalling wakefulness but no evidence of purposeful behaviour suggesting awareness of self or environment
No purposeful behaviours when exposed to stimuli and no language comprehension or expression
Patient appears to be awake but shows no sign of awareness of themselves/environment

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4
Q

What are the 2 types of vegetative state?

A
  • persistent (persistent for 1 month)

- permanent (12 months after traumatic brain injury, 3 months after non traumatic causes - anoxia/hypoxia)

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5
Q

What are the anatomical correlations of consciousness?

A

Small region in rostral dorsolateral pontine tegmentum

  • connected to 2 cortical regions: ventral anterior insula and pregenual ACC
  • disconnection = disorders of consciousness
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6
Q

How is vegetative state diagnosed?

A
  • clinical history
  • repeated observation of spontaneous and elicited behaviour
  • imaging (anatomical and functional)
  • electrophysiology
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7
Q

What do you look for on an electrophysiology?

A
  • absent somato-sensory evoked potentials

- EEG: global slowing

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8
Q

Which anatomical tests do you carry out?

A

MRI

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9
Q

Which functional tests do you carry out?

A

PET
MRI - reduction in default mode neurons
Diffusion Tensor Imaging

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10
Q

What do you look for on an observation of spontaneous and elicited behaviour?

A

Sustained reproducible purposeful or voluntary response to visual/olfactory/auditory/tactile or noxious stimuli
- comprehension of language/expression

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11
Q

How do you assess consciousness?

A
  • Auditory Stimulation

- imaging: PET or blood oxygenation level dependent MRI imaging to see central blood flow associated with brain activity

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12
Q

How can a misdiagnosis occur?

A

Assessor Factors: lack of training, limited knowledge

Patient Factors: physical disability, visual impairment

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13
Q

What is a minimally conscious state?

A

wakefulness with inconsistent signs of awareness:

  • non-reflexic response to sensory stimulus
  • language comprehension/expression
  • visual tracking
  • appropriate smiling/crying to visual/linguistic stimuli

Akinetic Mutism

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14
Q

What is akinetic mutism?

A

Awake but diminished drive to respond

  • apparent alertness along with lack of almost all motor functions including speech, gestures and facial expression
  • often misdiagnosed as depression or delirium
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15
Q

What factors affect recovery?

A
  • time spent in vegetative state (inversely proportional)
  • age (younger better)
  • type of brain injury (traumatic better outcome than anoxic)
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16
Q

What pharmacological treatment is there?

A

Amantadine - weak NMDA receptor antagonist and blocks dopaminergic reuptake
Zolpidem - indirect GABAa receptor agonist, ST treatment

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17
Q

What surgical treatment is there?

A

Central thalamic DBS

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18
Q

What other problems would need supportive treatment?

A

Spasticity
UTI
Sleep problems
Agitation/hyperkinesia

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19
Q

What is the ethical perspective?

A
  • only made if patient shown to be unaware of self/environment
  • stopping artificial nutrition/hydration requires approval of high court
  • is continued treatment in patients best interest?
20
Q

What structures of the brain control consciousness?

A

Rostral dorsolateral pontine tegmentum connected to 2 cortical regions: ventral anterior insula and pregenual anterior cingulate cortex

21
Q

What is the function of the pontine tegmentum?

A

Controls sleep states and levels of arousal and vigilance

22
Q

What is the seat consciousness?

A

Lateral prefrontal cortex
Posterior parietal cortex
(responsible for high-level complex thought)

23
Q

What is the global workspace theory?

A

We taken on sights/sounds/taste and combine into global workspace, selects all the ones we want filtering it and merge it into a single person object

24
Q

What can alter consciousness?

A

Traumatic brain injury
Severe stroke
Haemorrhage
Hypoxia

25
Q

How do you assess consciousness?

A

Glasgow Coma Scale - lower it is the worse, lowest is 3, but more for motor assessment

AVPU - alert, verbal stimuli, painful stimuli, unresponsive

26
Q

What are the types of coma?

A

Brain death
Vegetative state
Locked in syndrome
Recover wakefulness (happens at the end)

27
Q

What are the types of vegetative state?

A

Permanent

Minimally conscious state

28
Q

What are the centres for sleep?

A

Preoptic region of hypothalamus

29
Q

What are the 3 main categories of consciousness disorders?

A 
Comatose State (asleep and unconscious)
Vegetative State (awake and unconscious)
Minimally conscious state (awake and some consciousness)
30
Q

What is a comatose state?

A

State of complete unresponsiveness in which patient lies with eyes closed and cannot be aroused to respond to any stimuli

  • transitional state which lasts for a few weeks and rarely longer than 1 month
  • Temporary State
31
Q

What is stupor?

A

Similar to coma but will respond to strong stimuli

32
Q

What is locked in syndrome?

A

State of unresponsiveness in which patient lies within eyes closed and cannot be aroused to respond appropriately to any stimuli

  • However patient retains eye movement only up and down and are fully conscious
  • Profound paralysis of everything
33
Q

What is the mechanism of locked in syndrome?

A

Primarily due to injury to ventral pons = CSP and CTB tract interruption = quadriplegia and anarthria (mute)

  • often misdiagnosed with coma/vegetative state
  • can communicate via e-tran frame/brain computer interface
34
Q

What are the important areas damaged in akinetic mutism?

A

Frontal Lobe
Basal Ganglia
Mesencephalothalamic regions

35
Q

What is akinetic mutism associated with?

A

Alzheimer’s

Pick’s

36
Q

What is minimally conscious state?

A

Severely altered consciousness in which there is definite but often subtle and inconsistent, behavioural evidence of self or environmental awareness

37
Q

How does minimally conscious state present?

A
  • recognise verbal/gestural yes or no responses
  • provide simple verbal
  • follow simple commands
  • provide purposeful movements
  • often after passing through coma and vegetative state
38
Q

How does a confusional state present?

A
  • interactive communication
  • amnesia/confusion
  • hypokinetic or agitated
  • labile behaviour
  • after recover
39
Q

How does post-confusional state present?

A
  • resolution in amnesia/confusion
  • cognitive impairments in higher levels (attention, memory retrieval, executive functioning)
  • deficits in self awareness, social awareness, behavioural and emotional regulation
  • achieve functional independence in daily self care
40
Q

What is the prognosis of vegetative state?

A
  • absent brain stem reflexes is poor prognosis
  • favourable if return of speech, spontaneous eye movements that can track objects, normal resting muscle tone, ability to follow commands
  • even if emerge from state = physical, intellectual and psychological problems for life
41
Q

What does prognosis of vegetative state depend on

A

Cause, severity, site of damage, duration and depth of consciousness

42
Q

Define wakefulness?

A

ability to have basic reflexes such as open eyes, cough, swallow suck

43
Q

What is awareness?

A

ability to carry out complex thought processes

44
Q

What is the function of the ascending reticular activating system?

A
  • alerts/arousal

- involves number of structures in rostral brain stem, tegmentum, diencephalon and projections to cerebral cortex

45
Q

What are some future treatments?

A
  • vagal stimulation (to activate pontine tegmentum/thalamo-cortical network)

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