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 Monday > September 11 > 2006 
  
Finding life in an injured brain
  
 
The Gazette 


Monday, September 11, 2006


It's one patient, one study and one team of doctors - far too early to get all
excited and rip up the neurology textbooks. As noted in the editorial under this
one, startling studies need to be examined carefully.

But last week's news report about a a case of brain trauma permits us, while we
wait for confirmation, to hope.

If the study stands up to scrutiny and becomes medical fact, it will
fundamentally alter our view - and treatment - of serious brain trauma.

It will also have widespread implications - ethical, moral, philosophical,
medical, religious and political - about what doctors blandly term PVS, or
persistent vegetative state. We commonly call it a coma.

A team of physicians led by neurologist Adrian Owen of Britain published the
groundbreaking report in the journal Science: Simply put, a 23-year-old woman in
a deep vegetative state following a 2005 car accident has been shown to have
brain activity, despite severe injury to that organ. That runs counter to all
previous conclusions of such cases.

The woman was asked to imagine various activities, like playing tennis and
roaming around her old house. Owen and his team were staggered by her response,
measured as brain blood-flow by a magnetic resonance imaging scanner.

"Her decision to work with us by imagining particular tasks ... represents a
clear act of intent," Owen said. It was proof she was "consciously aware of
herself and her surroundings," he added.

If it's true that someone in an apparent coma can imagine situations - and is,
therefore, capable of thinking - the news would sweep away long-held medical
opinion.

It also opens a Pandora's box. The debate about the sanctity of life - is it
absolute, or relative to a patient's quality of life? - raged in the 2003-05
Terri Schiavo case in the U.S.

But neither side - against terminating life under any circumstance or for
terminating artificially-supported life in extreme cases - can claim the medical
findings as ammunition in their ideological battle. For one thing, the study
will have to be peer-tested for years, with an uncertain outcome.

And as Owen and others noted, there are many different levels of vegetative
states. Schiavo, in fact, was among the worst.

On a human level, it might bring some comfort to people with loved ones in
hospital beds who have slid into unconsciousness. "Can they hear me? Can they
feel?" The answer, for now, would seem to be yes. So playing Vivaldi or Bach -
or Dylan, for that matter - might, indeed, give them pleasure.

Still, this study doesn't bring closure to the topic: It's the start of a new
chapter, not the end, of research on brain injuries and consciousness.

But what a start.

C The Gazette (Montreal) 2006
 
Copyright C 2006 CanWest Interactive, a division of CanWest MediaWorks
Publications, Inc.. All rights reserved.

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'Vegetative' Woman's Brain Shows Surprising Activity
Tests Indicate Awareness, Imagination

By Rob Stein
Washington Post Staff Writer
Friday, September 8, 2006; A01



According to all the tests, the young woman was deep in a "vegetative state" --
completely unresponsive and unaware of her surroundings. But then a team of
scientists decided to do an unprecedented experiment, employing sophisticated
technology to try to peer behind the veil of her brain injury for any signs of
conscious awareness.

Without any hint that she might have a sense of what was happening, the
researchers put the woman in a scanner that detects brain activity and told her
that in a few minutes they would say the word "tennis," signaling her to imagine
she was serving, volleying and chasing down balls. When they did, the
neurologists were shocked to see her brain "light up" exactly as an uninjured
person's would. It happened again and again. And the doctors got the same result
when they repeatedly cued her to picture herself wandering, room to room,
through her own home.

"I was absolutely stunned," said Adrian M. Owen, a British neurologist who led
the team reporting the case in today's issue of the journal Science. "We had no
idea whether she would understand our instructions. But this showed that she is
aware."

While cautioning that the study involved just one patient who had been in a
vegetative state for a relatively short time, the researchers said it could
force a rethinking of how medicine evaluates brain-damaged patients.

"We have found a method for determining if a patient is aware," Owen said. "It
provides us with a tool that may be able to help make difficult decisions about
these patients."

Other researchers were cautious but praised the research as groundbreaking with
potentially profound implications. The work could lead to crucial new insights
into human consciousness, one of the most daunting scientific mysteries, and to
new ways to improve the diagnosis and treatment of tens of thousands of brain
injury patients.

"This is a very important study," said Nicholas D. Schiff, a neurologist at the
Weill Cornell Medical College in New York. "It's the first time we've ever seen
something like this. It really is kind of shocking."

But Schiff and others stressed that much more work is needed.

"It raises a lot of questions," Schiff said. "At what level is she conscious? Is
she really imagining she is playing tennis? Is it possible to communicate with
this person? At this point, this doesn't allow us to make any inference about
where this patient's consciousness might be."

The research inevitably renewed questions about patients such as Terri Schiavo,
the Florida woman in a persistent vegetative state whose family dispute over
whether to discontinue her care ignited a national debate over the right-to-die
issue. Schiavo's brother, Bobby Schindler, said the study underscores the
uncertainties in diagnosing brain injury patients.

"Things are changing almost every day with what they're finding out about the
brain," he said. "The technology they're creating could help people like my
sister."

But Owen, Schiff and others stressed that the research does not indicate that
many patients in vegetative states are necessarily aware or likely to recover.
Schiavo, in particular, had suffered much more massive brain damage for far
longer than the patient in Britain, making awareness or recovery impossible,
they said.

"I'm quite confident that [Schiavo] would not have responded in this way," said
James L. Bernat, a neurologist at Dartmouth Medical School. But, he said, the
findings indicate that current methods of evaluating awareness are unreliable.

"It's a little disturbing," Bernat said. "This suggests there may be things
going on inside people's minds that we can't assess by interacting with them at
the bedside."

Some experts said the findings are compelling enough that patients should be
routinely assessed this way.

"If it was a relative of mine, I know I'd demand it," said John Connolly, a
University of Montreal neuroscientist.

Others said that is premature.

"We have to be exquisitely cautious. We don't want to raise false hopes. This is
very new technology," said Kenneth W. Goodman, a University of Miami
bioethicist. "We don't really know what parts of your brain lighting up really
mean."

An estimated 25,000 Americans are in a vegetative state, and more than 100,000
are believed to be in a related condition known as "minimally conscious," in
which they exhibit impaired or intermittent awareness.

Owen stressed that the test could never rule out the possibility that patients
have some awareness because even healthy people sometimes show no response on
the scan.

The findings follow recent studies by Schiff and others that suggest some brain
injury patients may be more responsive than anyone realized. And scientists have
long known that patients in a vegetative state sometimes regain at least some
awareness. Those who had a blow to the head generally have better prospects than
those whose brains were oxygen-deprived because their hearts stopped.

The 23-year-old patient in Britain, whose name and other personal details were
withheld, suffered head trauma in a July 2005 traffic accident that left her in
a coma. After about two weeks, she opened her eyes and started going through
cycles of being asleep and awake. But she had no ability to communicate, and
repeated tests over more than five months found no signs of awareness or
consciousness, leading doctors to diagnose her as being in a vegetative state.

But then Owen and his colleagues began a series of tests on the woman at the
University of Cambridge using functional magnetic resonance imaging, which can
detect different types of mental activity by measuring blood flow to various
parts of the brain.

The key tests were experiments in which the researchers asked her 20 times to
envision herself playing tennis and exploring her house. Brain regions involved
in language, movement and navigation, which would be active when someone was
playing tennis, wandering around a building, or imagining doing so, lighted up
in ways that were "indistinguishable" from those in 12 healthy people.

The findings show that the woman "retained the ability to understand spoken
commands and to respond to them through her brain activity, rather than through
speech or movement," the researchers wrote. "Her decision to cooperate . . . by
imagining particular tasks when asked to do so represents a clear act of
intention, which confirmed beyond any doubt that she was consciously aware of
herself and her surroundings."

"It was an absolutely stunning result," Owen added in a telephone interview.

About six months later, during follow-up testing, the woman appeared to follow a
mirror to the right with her eyes. But that was the last hint of awareness, and
her future remains unclear.

"Whether she has a life of the mind is a question that is incredibly provocative
and important," said Joseph J. Fins, a bioethicist at Weill Cornell Medical
School. "What we may be seeing perhaps is a window into the recovery of
consciousness. But we just can't answer that at this point."

C 2006 The Washington Post Company
 
 

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