Enhancing the understanding and treatment of patients with vegetative state Neurosurgery Department of Shandong Qianfoshan Hospital Wei Lin The concept of “persistent vegetative state” (PVS) was first proposed by Jennett and Plum in 1972, which was translated as “vegetative man” in China. “The causes of PVS can be categorized as acute brain injury, degenerative and metabolic diseases, and developmental malformations. The most common are traumatic brain injury and ischemic-hypoxic encephalopathy, degenerative diseases such as Parkinson’s disease, Alzheimer’s disease can also occur in the end stage, or occur in anencephaly and other developmental malformations.PVS in the United States there are about 1 to 25,000 adults and 0.4 to 10,000 children patients, and in our country a rough estimate may be between 50,000 to 70,000 people. Wei Lin, Department of Neurosurgery, Thousand Buddha Mountain Hospital, Shandong Province, China The new concept of “vegetative state” (VS) put forward by the American multidisciplinary PVS research group in 1994 is: “The patient completely loses cognition of himself and his surroundings, has a sleep-wake cycle, and the lower thalamus and brainstem have a sleep-wake cycle”. The VS is characterized by “a complete loss of awareness of oneself and one’s surroundings, with a sleep-wake cycle, and complete or partial preservation of autonomic functions of the subthalamus and brainstem”. This state can be transient, a stage in the recovery process from acute or chronic severe brain injury, or permanent.VS can also be the result of the ongoing progression of certain degenerative or metabolic disorders of the nervous system or congenital malformations. PVS can be diagnosed in VS 1 month after acute traumatic or nontraumatic brain injury, whereas a vegetative state due to degenerative or metabolic diseases or developmental malformations must last more than 1 month to be diagnosed as PVS.However, most Japanese scholars advocate a 3-month cutoff. Most scholars believe that the diagnosis of VS is mainly based on clinical manifestations, and objective tests such as EEG, SEP, BAEP, CT, MRI and SPECT can only be used as auxiliary references.The Nanjing PVS Conference in 1996 and 2001 clarified the diagnostic criteria in China: (1) Loss of cognitive function, unconscious activity and inability to accept instructions; (2) Maintenance of voluntary respiration and blood pressure; (3) Sleep-wake cycle; (4) Inability to accept instructions -wake cycle; (4) unable to understand and express language; (5) able to open eyes automatically or under stimulation; (6) may have purposeless eye-tracking movements; (7) the function of the lower thalamus and the brainstem is basically preserved. If the above state lasts for more than one month, it is PVS. Differential diagnosis is required (1) coma: coma is neither arousal nor cognition, and the majority of patients, including those with prolonged coma, are unable to open their eyes; VS is arousal without cognition, and is able to open their eyes. (2) Brain death: irreversible loss of brain function, including brainstem function, and inability to maintain voluntary respiration and blood pressure, which must be maintained by ventilator and drugs. In the vegetative state, the brainstem function is basically preserved, and autonomous respiration and blood pressure can be maintained. (3) Atresia syndrome: the patient’s injury to the base of the pontine brain causes damage to both sides of the pyramidal fasciculus below it, with the exception of the eyes being able to move, there is a loss of random movement, but the patient is fully conscious and can use vertical eye movements or open and close the eyes to show signs. (4) Minimal Consciousness: a severely altered condition of consciousness with minimal but clear behavioral evidence of self- and environmental arousal. Confusion and Disagreement in Treatment It should be said that arousal and resuscitation of brain function for vegetative patients is difficult. Brain tissue and nerve cells are the most sensitive to ischemia in the entire body, and brain damage occurs after 4 to 5 minutes of suffering complete ischemia, with the cerebral cortex being the least tolerant, with the frontal lobe being the earliest and most severely affected, followed by the parietal, occipital, and temporal lobes; and the cerebellum, medulla oblongata, and spinal cord becoming more tolerant to ischemia and hypoxia in that order. In the past, it was believed that nerve cells could not reproduce or regenerate after development and maturation. However, the reality is that in recent years there are some new discoveries: brain tissue can ① regenerate through DNA repair. ② Inactivation of neural axon growth inhibitors. ③ Other ways, it is not impossible to recover to some extent. A large number of clinical observations have proved that a considerable portion of PVS patients recovered consciousness in 1 to 2 years, we believe that in many comatose and vegetative survival of the patient brain tissue and nerve cells in the ischemia and hypoxia blow, some nerve cells apoptosis is also dead, this part is like what we see in life has been withered trees, how much we try to care for, treatment, watering, fertilizer, are not helpful; and there are more than a few patients who have withered trees in their lives. It does not help; and there are more nerve cells and brain tissues that are dysfunctional under ischemia and hypoxia, this part is like the trees we see in life that have already withered but not yet died, how to make them recover their functions as soon as possible through reasonable treatments, that is, there is still a possibility of recovery and turnaround through our care, treatments, watering, fertilizing, and it will also accelerate their deaths if they are not handled correctly. Japan’s Osaka University Hospital in 1 month after the injury into the “vegetable” state of the treatment of patient statistics found that the beginning of the medical staff had thought that only 20% of the “vegetable” can regain consciousness, but up to seven years of follow-up results show that this proportion is as high as 60%, indicating that the majority of comatose patients. 60%, indicating that the majority of comatose patients have hope of awakening. The United States is not very active in the treatment of these patients, and at most only adopts some life-sustaining measures and frequent bedside calls from family members. Japan is relatively more active, with detailed daily and hourly care, deep brain stimulation and other methods. In our country, there are various means, such as electrical stimulation of the parietal nucleus of the cerebellum, electrical stimulation of the high cervical medulla, electrical stimulation of the peripheral nerves; acoustic, optical, electrical and magnetic stimulation; hyperbaric oxygen, Chinese and Western medicines, acupuncture, massage, etc. However, each method has its own indications. However, each method has its own indications, according to the patient’s affordability, i.e., either general treatment and care at home, or high-level wake-up and rehabilitation treatment in the hospital. At present, China’s long-term coma or vegetative state patients wake-up treatment and rehabilitation is still insufficient understanding, but also insufficient investment, the domestic treatment of persistent vegetative state is actively used in the following methods: the use of drugs that have a nutritive effect on the cerebral nerves, acupuncture in traditional Chinese medicine, and aromatic qi medication, electrical stimulation, hyperbaric oxygen, music therapy, and so on. The main rationale is that the brain has a previously unrecognized capacity for repair. High-intensity multi-sensory stimulation is advocated for comatose patients, and it is believed that such measures will stimulate the reticular activating system of the brain. The reticular activating system is primarily associated with arousal and wakefulness and typically responds to all sensory stimuli including pain, pressure, touch, temperature, proprioception, vision and hearing. It is hoped that this strong stimulation will help the patient to awaken, and that the repetitive stimulation will help to train parts of the brain that were previously “dormant”. The puzzle in treating vegetative patients is the ability to make a relatively accurate assessment of the prognosis for coma and vegetative survival, which is critical for the patient, the patient’s family, and society. Usually, we assess the patient’s response to treatment through direct patient observation and objective assessment. Our treatment ideas and methods Recently, based on our many years of experience in treating comatose and vegetative patients, and on the basis of the original treatment in China, we propose to “try our best to save brain tissues and neural cells that have not yet apoptosed (died) and have lost their normal functions, and to provide them with physiological support”. and nerve cells, and create a favorable environment and conditions for their physiological repair and functional recovery.” According to this idea, we carefully analyze the reason why the vegetative person doesn’t wake up for each patient, and gradually find and think that: those who are combined with hydrocephalus and cerebral edema; those who have increased intracranial pressure; those who have poor cerebrospinal fluid circulation; those who have cerebral atrophy and reduced compliance of ventricular enlargement; those who have cerebral cortical atrophy; those who are combined with epileptic persistent state; those who have a large range of brain injuries; those who have high limb muscular tension or even spasticity; those who have not been treated by hyperbaric oxygen chamber and who have not mastered the treatment of hyperbaric oxygen chamber during the early period of coma. The use of hyperbaric oxygen chamber treatment, did not grasp the indications of hyperbaric oxygen chamber treatment; combined with brain stem contusion and central hyperthermia, etc., these are the obstacles affecting the recovery of the patient’s brain tissue function, the patient’s wakefulness, we need to use different treatment programs and measures for different patients, which also includes effective surgical treatment measures. The general idea of treatment is to use the combination of central and peripheral, internal medicine and surgery to increase the blood and oxygen supply to the intracranial brain tissues, improve the microenvironment of the patient’s cerebral cortex, and promote the repair and functional recovery of nerve cells, and to relieve the muscle tension of the limbs, correct the cerebral edema and hydrocephalus, and adjust the intracerebral pressure, to prevent and control epilepsy and the emergence of complications, so as to create a good condition for the patient’s sobriety. At the same time, combining with other treatment means commonly used in China, we formulate an overall comprehensive treatment plan to gradually complete the restoration of consciousness, language, swallowing, consciousness, walking and memory and other functions of the vegetative patients. This kind of treatment idea is fundamentally different from the traditional treatment idea, and the effective rate and cure rate are obviously improved. It is found that the key to treatment lies in whether a good internal microenvironment can be created for the recovery of brain tissues and nerve cells; whether the metabolic function of brain tissues and nerve cells can be improved by increasing the blood supply and oxygenation to the brain, providing more nutrients to the brain tissues and taking away more metabolic wastes. It can be seen that it is not helpful to treat vegetative patients by simply using one or two treatment methods. The vegetative patients can be firstly categorized according to the nature of brain damage: such as traumatic brain injury type, cerebrovascular disease type, ischemic-hypoxic encephalopathy type, poisoned type, cerebral cortex injury type, brain stem injury type, and extensive axonal injury type. Then basic treatment is carried out: surgery, drugs, hyperbaric oxygen, extracorporeal counterpulsation to increase the supply of oxygen and blood to the brain. Individualized programs are implemented in the treatment, such as increasing electromagnetic stimulation of nerves for traumatic brain injury and neural axonal injury types. For brainstem injury, hyperbaric oxygen is given to increase stimulation therapy. For extensive cerebral cortex injury, the early use of hyperbaric oxygen will cause cortical vasoconstriction and reduce the blood supply to the cerebral cortex, so the use of sympathetic network stripping, drugs, external counterpulsation, electrical stimulation and other measures. The principle of combining Chinese and Western medicine with Western medicine as the mainstay and Chinese medicine as a supplement is practiced. We believe that there is no need to be pessimistic about PVS, nor should we be blindly optimistic because of the high rate of awakening. In addition, we should pay attention to the time window of treatment, the early treatment of all patients after injury, every step of which is related to the patient’s future prognosis, and avoid the long-term use of inappropriate means to promote awakening. At present, it is believed that within one year of traumatic brain injury, ischemic-hypoxic encephalopathy 3 months have the possibility of awakening, there is the value of active treatment, and degenerative or metabolic or neurodevelopmental abnormalities caused by vegetative consciousness recovery possibility is small. Combined with the domestic and foreign research in the past 10 years to determine the standard of rescue treatment, for the vegetative person who has no possibility of awakening and stable condition can reduce the level of treatment, give nutrition and care of basic treatment to maintain the patient’s life. Wei Lin, Department of Neurosurgery, Thousand Buddha Mountain Hospital, Shandong Province, China Tel: 0531-89268598, 89268504, 13905310616 Address: No. 66, Jingshi Road, Jinan City, Shandong Province, China Zip Code: 250014 E-mail: [email protected]