Feb. 3, 2010 - A few patients who appear to be in a persistent vegetative state may in fact be aware of themselves and their surroundings.
Remarkably, such patients may be able to learn to "speak" using only their brains, suggest findings by Martin M. Monti, PhD, of the UK Medical Research Council, and colleagues.
"If someone can produce a mental state on command, it is like having a language," Monti tells WebMD. "We had 23 apparently vegetative patients, and four were really aware -- as we could tell by MRI [brain scans]."
The findings do not mean that all patients in a vegetative state really are conscious beings trapped in an immovable body, Monti is quick to point out. Only a small minority of patients seem capable of activating their brains at will.
Even patients capable of this limited form of communication may not be fully conscious.
"It is not fair to say these patients are just like you and I who are stuck in their bodies," Monti says. "We don't know what is the mental life of these patients. We don't know if they have the same stream of thoughts we have. But these are very important questions."
Talking With the Brain
Monti and colleagues studied 23 patients diagnosed as being in a vegetative state and 31 patients diagnosed as being in a minimally conscious state. Vegetative patients may be able to open their eyes when awake and may have some muscle reflexes, but cannot respond intentionally. Patients in a minimally conscious state are able to make minimal, inconsistent responses to commands but cannot communicate interactively.
All 54 of these patients with severe brain injury underwent functional magnetic resonance imaging (fMRI), a type of real-time brain scan that shows which parts of the brain are active.
The patients were asked to imagine standing on a tennis court and swinging a racquet to hit a ball back and forth with an instructor. Then they were asked to imagine navigating through a familiar room or driving through a familiar neighborhood. Studies of normal people show that each of these mental tasks activates a different brain region.
Only five of the 54 patients were able to do at least one of these tasks; four were able to do both. Extensive tests showed that three of these five patients were indeed able to make some physical motion when tested at their bedside; two were able to signal researchers only via fMRI.
Importantly, only patients who suffered physical head injuries responded via MRI. Those whose brains were damaged by lack of oxygen (via stroke or drowning, for example) remained unresponsive.
One patient, who was tested five years after lapsing into a vegetative state, actually was able to communicate via MRI. He was asked to imagine playing tennis for a "yes" answer, and to imagine navigating to say "no."
When asked six autobiographical questions (e.g., "Do you have any brothers?" or "Is your father's name Thomas?") he was able to signal the correct answer to all but the final question. He didn't get the final question wrong, he just stopped responding by the time it was asked.
Vegetative State: Is Anybody in There?
The question families most want answered by a loved one in a vegetative or minimally responsive state is, "Are you there?"
The study does not provide an answer, notes an editorial by Allan H. Ropper, MD, executive vice chair of neurology at Brigham and Women's Hospital and professor of neurology at Harvard University.
"Is there someone in there? There's no way to know," Ropper tells WebMD. "There may have to be a new way of thinking of consciousness. Not whether someone is in or not in, but maybe whether they are in some of the time -- or maybe in there but not able to take their own mental temperature and so not suffering. We just don't know who we are talking to. The current studies do not answer that question."
The ability to respond to questions via brain activity doesn't necessarily imply that a person is aware, says Mark A. Brooks, PhD, consulting neuropsychologist at Glancy Rehabilitation Center in Duluth, Ga.
"Awareness is the functional totality of all cognitive skills - the sum of arousal, orientation, attention, perception, memory, and reasoning," Brooks tells WebMD. "The Monti paper leaves me feeling like there are complete, thoughtful people trapped in these bodies, pining for a means of communication. This is clearly not the case."
Monti, Ropper, and Brooks all worry that the study results will be taken to mean that everyone in a vegetative state is conscious. The results simply show that in rare cases, a vegetative patient may have more consciousness than is at first apparent.
What this means -- and whether these extraordinary patients will be able to communicate such things as whether they are in pain or distress -- will be the subject of future research.
The Monti study, and the Ropper editorial, appear in the early online edition of the New England Journal of Medicine.