The vegetative state is a special kind of disorder of consciousness in which the patient appears to be awake but is actually unaware of anything and has no conscious response to external stimuli. The vegetative state is mostly caused by severe brain injury such as traumatic brain injury, cerebral hypoxia and stroke. The pathogenesis is due to functional inhibition, necrosis or deficits of a large number of cortical cells, and functional inhibition or damage of the brainstem. A vegetative state of more than one month is called persistent vegetative state (commonly known as vegetative state), and a vegetative state of more than one year due to traumatic brain injury or more than three months due to other causes can be considered a permanent vegetative state, which means that the patient’s chance of awakening is very slim. Hyperbaric oxygen-based comprehensive treatment can significantly increase the rate of waking up in the vegetative state, better restore the patient’s neurological function and improve the patient’s quality of life, and patients who wake up early are expected to regain partial or even complete self-care and working ability. The implantation of high level cervical medullary electrical stimulator (commonly known as brain pacemaker) and the exploration of new therapies such as stem cell mobilization and transplantation can provide new hope for the recovery of vegetative state which is difficult to be promoted by conventional treatment in the past. Symptoms】 1. Can open eyes automatically or under stimulation, eyes can be turned, there can be purposeless eye tracking; 2. Sleep-wake cycle exists in whole or in part; 3. No any conscious activity, lack of perception, thinking, emotion, volition and other activities; 4. Cannot understand and express language; 5. Maintain autonomic breathing and blood pressure, no need for devices and blood pressure raising drugs to maintain life; 6. Subthalamic and brainstem functions Basically preserved. Neurological physical examination: consciousness, cranial nerves, sensorimotor system, reflexes, autonomic function, etc.
2. Scale assessment: PVS scale, GCS score, CRS-R Coma Recovery Scale, DOCS Disorders of Consciousness Scale, etc. can be used to assess the condition.
3. Routine examination: blood routine, urine routine, liver and kidney function, nutritional index, coagulation function, immune function, etc. 4. Neuroimaging: cranial CT or MRI, etc.
5. Neurophysiology: EEG and evoked potentials can assess the condition and roughly determine the prognosis. 6. Functional neuroimaging: cranial SPECT/PET, etc. to check the functional status of brain nerve cells. Common treatment methods】 1. Hyperbaric oxygen therapy: (1)
Treatment plan: treatment pressure 0.18～0.20Mpa, treatment time 70～80min/time, 1 time/day, can be treated 20～30 times continuously, after 5～7 days of rest, the course can be repeated; (2)
Number of treatments: If consciousness is not restored or there is obvious neurological deficit, treatment should be adhered to for at least 60 times.
2. Chinese and Western drug therapy: use western drugs that activate brain cells, promote consciousness recovery, improve cerebral blood supply, and Chinese herbal medicines or proprietary drugs that activate blood circulation and open the brain, as appropriate, and drug therapy helps promote wakefulness and recovery of neurological function. 3. Neurostimulation therapy.
(1) Peripheral nerve electrical stimulation: low-frequency electrical stimulation of the peripheral nerve trunk is used. (2) Acupuncture stimulation: Body and head acupuncture can be applied. (3)
High cervical medullary electrical stimulation: the stimulation electrode is placed in the middle of the epidural at the level of C2 to C4 of the neck by means of surgery or X-ray guided puncture to give electrical stimulation, which brings new hope for waking up in the vegetative state that is difficult to be promoted by conventional treatment. (4)
Deep brain electrical stimulation: Electrodes are implanted in the thalamus, brainstem, midbrain, cerebellum and other deep brain tissues to give electrical stimulation, providing a new wake-up technique for the vegetative state that is difficult to be promoted by conventional treatment.
4. Integrated sensory stimulation therapy: Through sound, light, stimulating odor, passive body movement, massage and physical therapy, the five senses stimulation, postural stimulation, limb sensory and motor stimulation, conditioned reflex stimulation and other integrated stimulation can promote patients’ awakening.
5. Stem cell mobilization and transplantation therapy: Basic and clinical research on self-stem cell mobilization and transplantation as well as exogenous stem cell transplantation can provide new means to promote awakening in the vegetative state which is difficult to be promoted by conventional treatment.
6. Nutritional support therapy: comprehensive and adequate nutrition should be given, and the feeding method can be intravenous nutrition in the early stage, nasal feeding in the short term, gastrostomy in the middle and long term, and strengthening swallowing function training for transoral feeding. The use of hyperbaric oxygen therapy, medication, acupuncture, rehabilitation measures, electrical nerve stimulation, stem cell transplantation, careful nursing care, nutritional security and family care can significantly improve the rate of waking up in a persistent vegetative state. Hyperbaric oxygen therapy should be started as early as possible. As long as the function of the patient’s circulatory system is stable, conditions should be created to start hyperbaric oxygen therapy as soon as possible after the contraindication of hyperbaric oxygen therapy is excluded.
2. The course of hyperbaric oxygen therapy should be sufficient and not be given up lightly, and it is recommended that at least 60 sessions should be adhered to.
3. For patients with central hyperthermia, traumatic epilepsy, artificially assisted breathing, tracheal intubation or incision, lateral ventricular drainage, chest drainage, etc., hyperbaric oxygen therapy can still be continued as long as they are properly treated.
4. Long-term recipients of hyperbaric oxygen therapy should strengthen anti-free radical therapy to prevent the occurrence of adverse reactions to hyperbaric oxygen.
5. It must be emphasized that the treatment of vegetative state is not enough to rely on hyperbaric oxygen therapy alone, but should be carried out simultaneously and complementarily with other therapeutic measures to improve the efficacy.
6. Since the duration of traumatic vegetative state is less than 1 year, and the duration of non-traumatic vegetative state is less than 3 months, there is still hope to promote awakening, so treatment should not be abandoned. 7. Continuing hyperbaric oxygen therapy after the recovery of consciousness can further restore the neurological function.
8. The efficacy of traumatic vegetative state is better than that of non-traumatic vegetative state; among non-traumatic vegetative state, the efficacy of cerebrovascular disease and carbon monoxide poisoning is better than that of cardiac and respiratory arrest, and the efficacy of children’s vegetative state is better than that of adults. 9. For “permanent” vegetative state, treatment with stem cell transplantation and/ or spinal cord electrical stimulator may increase the hope of waking up.