What Is a Vegetative State?

The victim is in an irreversible deep coma and loses consciousness, but the subcortical center can maintain spontaneous breathing movement and heartbeat. This state is called "vegetative state".

Plant state

One. Overview

The vegetative state is an awake but unconscious state after severe brain damage caused by various causes. Prior to 1972, there was no uniformity for such patients

Vegetative state (4 photos)

The most common diseases are named apallic syndrome, and there are also akinetic mutism, post-traumatic dementia or coma vigil. In 1972, Jennett and Plum used the term vegetative state to name such patients. "Plant" means that these patients have basic physiological functions such as breathing, heartbeat, blood pressure, body temperature maintenance, and digestive function, but they are not aware of themselves and the external environment. Persistent vegetative state refers to the vegetative state holding for more than one month, and consciousness is not impossible to recover. Permanent vegetative state means that the traumatic plant state lasts for 1 year or the non-traumatic plant state lasts for more than 3 months. However, cases of vegetative patients who have regained consciousness decades later have also been reported. In 2010, unresponsive wakefulness syndrome was recommended to replace the word vegetative state to avoid negative impressions of "plants". The pathogenesis, diagnosis and treatment of these patients are still difficult, and more and more in-depth clinical and basic research are needed.

two. Etiology and pathogenesis

1. Causes Epidemiological surveys abroad show that the cause of the disease is 1/3 traumatic and 2/3 is non-traumatic. Non-traumatic causes include infection, stroke, poisoning, ischemia and hypoxia, electric shock, tumors, and brain degenerative diseases.

2. Pathogenesis The pathogenesis of plant states is unclear. Patients in the vegetative state are mainly awakened and unconscious.

Vegetative state (3 photos)

Awakening is mainly supported by the brainstem reticular ascending activation system. Some nerve nucleus fibers of the brainstem reticular structure are projected to the thalamus and cerebral cortex via ascending conduction. Therefore, damage to either the brainstem or the cerebral hemisphere will cause arousal decline. If the cephalic pontine cover and midbrain are not damaged, the patient can remain awake. Perception involves the functional integration of the cerebral cortex and multiple brain regions below the cortex. The central circuit model (The mesocircuit model) believes that the loss of central thalamic neurons or the transmission of nerve impulses to the cerebral cortex and striatum will hinder striatum-medium spiny neurons (MSNs). Reduced activation of the striatum reduces the inhibition of the globus pallidus interna (GPi) by the striatum, while the original pallidus inhibits the thalamic and foot bridge nuclei further. This circulation makes the thalamus The excitatory effect of the striatum decreases, eventually leading to a disturbance of consciousness in the patient. Other techniques, such as neuroimaging and electrophysiology, have shown that decreased frontal-parietal network connectivity is associated with loss of consciousness [2, 3].

3. 71% of pathologically traumatic patients had diffuse axonal injury, 80% had abnormal thalamus, and 96% of thalamic abnormalities had a survival time of more than 3 months. Other injuries included neocortical ischemic damage and intracranial hematoma. Non-traumatic patients have diffuse ischemic neocortical lesions in 64% and focal injuries in 29%; thalamic injuries are present in all non-traumatic patients. However, there are also patients with normal cerebral cortex, cerebellum, and brainstem structures in both groups. The two types of patients most severely damaged are the subcortical white matter and / or the main relay nucleus of the thalamus [4].

three. Clinical manifestation

The main clinical manifestations of patients with vegetative state are spontaneous or stimulus-opening eyes, but no awareness of self and surrounding environment. Peripheral sensory stimuli such as auditory, visual, and tactile stimuli cannot induce a patient's casual, purposeful behavioral response; no language expression and understanding ability; retention of breathing, heartbeat, blood pressure, body temperature, digestive function, and sleep-wake cycles; incontinence ; Reserve some brain stem and spinal reflexes, such as visual and auditory startle response, withdrawal flexion, chewing, sucking reflex, etc. Some behavioral fragments such as grimacing, crying, occasional vocalizations, and stereotyped limb movements can also remain [5, 6].

four. Auxiliary inspection

1. Awareness scale Currently used internationally is the Coma Recovery Scale-Revised (CRS-R). The vegetative state patients' hearing, vision, movement, language, and communication subscale scores were less than or equal to 2, 1, 2, 2, and 0 respectively [7].

2. EEG patients with vegetative state of EEG manifest as focal or diffuse persistent or slow waves, intermittent rhythms; amplitude decreases, sometimes it can fall to the isoelectric line; epilepsy discharges such as focal sharp waves can also occur, There may also be alpha-theta coma waves. Sleep EEG is a diffuse low-voltage slow wave [8, 9].

3. fMRI may have activation of the primary sensory cortex as well as activation of the higher cortex, but the connection between the higher and lower cortex is lost, especially the loss of frontal and parietal neural network is the most important [10].

4. The total brain metabolic rate of patients with PET plant state decreased to 40% -50% of normal people, while the metabolism of brain stem and other structures such as foot bridge network, hypothalamus and basal forebrain were preserved. Structures related to advanced cognitive functions, such as bilateral prefrontal cortex, temporal parietal cortex, posterior parietal lobe, and anterior wedge, are metabolically impaired [11].

Other tests include ERPs, TMS-EEG, etc.

Fives. Diagnosis and differential diagnosis

1. Diagnosing typical behavioral manifestations such as awakening and unconsciousness; PET showed reduced bilateral frontal and parietal cortex metabolism, and no voxel activation showing metabolism; TMS-EEG PCI was less than 0.31.

2. Differential diagnosis

The minimal state of consciousness has little but clear evidence of conscious behavior about the self and the surrounding environment. PET showed incomplete inferiority of bilateral frontal and parietal cortex generation, and partially activated voxels were retained. TMS-EEG has a PCI of 0.32-0.49.

Atresia syndrome limb paralysis, may have vertical movement of the eyeball or blink, consciousness is completely present. PET shows similar or identical to normal people. The TMS-EEG PCI is 0.44 [11, 12].

six. treatment

1. General rehabilitation and care

2. Drug treatment

Amantadine [13]

Zolpidem [14, 15]

3. Deep brain stimulation [16]

Others include transcranial direct current stimulation, peripheral sensory stimulation stimulation therapy, spinal cord electrical stimulation, median nerve stimulation, epidural stimulation, hyperbaric oxygen, etc. [17].

Seven. Prognosis

Traumatic vegetative state patients have a mortality rate of 30-50% after one year, and non-traumatic is higher than traumatic, which is 50-70%. After one year, the consciousness recovery rate is about 40-60% traumatic and less than 20% non-traumatic. Most of them remain severely disabled after consciousness is restored, and few people can take care of themselves [18].

references

1. Fernandez-Espejo D, Owen AM. Detecting awareness after severe brain injury [J]. Nat Rev Neurosci. 2013, 14 (11): 801-809.

2. Giacino JT, Fins JJ, Laureys S , et al . Disorders of consciousness after acquired brain injury: the state of the science [J]. Nat Rev Neurol. 2014, 10 (2): 99-114.

3. Schiff ND. Recovery of consciousness after brain injury: a mesocircuit hypothesis [J]. Trends Neurosci. 2010, 33 (1): 1-9.

4. Adams JH, Graham DI, Jennett B. The neuropathology of the vegetative state after an acute brain insult [J]. Brain. 2000, 123 (Pt 7): 1327-1338.

5. Monti MM. Cognition in the vegetative state [J]. Annu Rev Clin Psychol. 2012, 8: 431-454.

6. Monti MM, Laureys S, Owen AM. The vegetative state [J]. BMJ. 2010, 341: c3765.

7. Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility [J]. Arch Phys Med Rehabil. 2004, 85 (12): 2020-2029.

8. Kobylarz EJ, Schiff ND. Neurophysiological correlates of persistent vegetative and minimally conscious states [J]. Neuropsychol Rehabil. 2005, 15 (3-4): 323-332.

9. Lehembre R, Gosseries O, Lugo Z , et al . Electrophysiological investigations of brain function in coma, vegetative and minimally conscious patients [J]. Arch Ital Biol. 2012, 150 (2-3): 122-139.

10. Di Perri C, Stender J, Laureys S , et al . Functional neuroanatomy of disorders of consciousness [J]. Epilepsy Behav. 2013.

11. Stender J, Gosseries O, Bruno MA , et al . Diagnostic precision of PET imaging and functional MRI in disorders of consciousness: a clinical validation study [J]. Lancet. 2014.

12.Casali AG, Gosseries O, Rosanova M , et al . A theoretically based index of consciousness independent of sensory processing and behavior [J]. Sci Transl Med. 2013, 5 (198): 198ra105.

13. Giacino JT, Whyte J, Bagiella E , et al . Placebo-controlled trial of amantadine for severe traumatic brain injury [J]. N Engl J Med. 2012, 366 (9): 819-826.

14.Thonnard M, Gosseries O, Demertzi A , et al . Effect of zolpidem in chronic disorders of consciousness: a prospective open-label study [J]. Funct Neurol. 2014, 28 (4): 259-264.

15. Williams ST, Conte MM, Goldfine AM , et al . Common resting brain dynamics indicate a possible mechanism underlying zolpidem response in severe brain injury [J]. Elife. 2013, 2: e01157.

16. Schiff ND, Giacino JT, Kalmar K , et al . Behavioural improvements with thalamic stimulation after severe traumatic brain injury [J]. Nature. 2007, 448 (7153): 600-U610.

17.Georgiopoulos M, Katsakiori P, Kefalopoulou Z , et al . Vegetative state and minimally conscious state: a review of the therapeutic interventions [J]. Stereotact Funct Neurosurg. 2010, 88 (4): 199-207.

18.Schnakers, C. & Laureys, S. (2012) Coma and Disorders of Consciousness. Springer, 2014 edition

Plant state summary

Persistent vegetative state (PVS) is a state first proposed by Jennett and Plum in 1972, which means that after a period of severe brain injury, humans still lack conscious activity and lose language, but retain only unconscious posture adjustment and motor function.

Plant condition diagnostic criteria

First, China's Nanjing Standard 2001

The Chinese Society of Emergency Medicine of the Chinese Medical Association held a special conference in Nanjing in April 1996, with 17 experts from neurosurgery, surgery and basic theoretical research from Beijing, Shanghai, Nanjing, etc .; Differential diagnosis, concise, easy to operate "and other principles, drafted. It was revised in November 2001 to establish the Nanjing Standard 2001.

(I) Diagnostic criteria for plant status

1. Loss of cognitive function, unconscious activity, unable to execute instructions.

2. It can open eyes automatically or under stimulation.

3. Have a sleep-wake cycle.

4. Whether there is purposeful eye tracking movement.

5. Can't understand and express language.

6. Maintain spontaneous breathing and blood pressure.

7. The lower thalamus and brainstem functions are basically preserved.

(2) Diagnostic criteria for persistent plant status

A plant state that lasts for more than a month can be determined as a persistent plant state.

(3) Curative effect scale for persistent vegetative state

1. Whether to leave the plant state

. Vegetative state-completely unable to execute instructions or speechless (except for aphasia).

. Preliminary detached from the plant state-can execute simple instructions or simple answer.

, Out of the plant state-can execute more complex instructions or can answer.

2. Other functional efficacy scores (see Table 1)

Table 1 Scoring criteria for persistent plant status

Response Scoring Date

1, limb movement

None 0

Is there a purposeful exercise 1

Have random movement 2

2. Emotional response

None 0

Mild reaction 1

Normal response 2

3. Eye movement

None 0

Eye Tracking 1

Intentional Gaze 2

4. Eat

Gastric tube nutrition 0

Can swallow 1

Automatic feeding 2

5.EEG

Flat wave 0

or rhythm 2

Alpha or beta rhythm 2

6.SEP

N20 disappears (both sides) 0

N20 latency extended by 1

N20 latency is normal 2

Total score

Note: The sum of the above 4 clinical scores and 2 objective examination scores is calculated as 0-12 points. Overall efficacy score: Ineffective: 0-1 points; Minimal effect: 2-3 points; Effective: 4-7 points; Significant effect: 8 points.

Note: Each score must include the above two aspects; The curative effect scale should be checked and registered at least once a month.

The American Society for Ethics and Neurology (1993) diagnostic criteria

1. Lack of awareness of yourself or surroundings, and reflexive or spontaneous eye opening may occur.

2. Can not perform meaningful and coherent listening and writing and communication. Eyeballs usually cannot track target stimuli and occasionally visual tracking can occur.

Vegetative state (8 photos)

Lack of emotional response to spoken language.

3. Lack of understandable words or words.

4. Occasionally, smiles, frowns, or tears may appear, but they are irrelevant to surrounding stimuli.

5. There is a sleep-wake cycle.

6. The brain stem and spinal reflex activity varies. Raw reflections such as sucking, pouting, chewing, and swallowing can be preserved, and pupil reflections on light, head-eye reflection, strong grip reflection, and tendon reflection can exist.

7. No random movement or behavior. No acquired sexual activity or mimicry. For harmful or unpleasant stimuli there may be weak movements (such as withdrawing or taking a certain posture).

8. Normal blood pressure and heart function, incontinence.

Third, Zeman is based on British diagnostic criteria

1. Diagnosis basis:

Respiratory, cardiovascular, digestive and renal functions are usually maintained without machinery.

There is a sleep cycle, which is manifested as closed eyes, but may wake up with eyes open. Eyes can be awakened by pain and obvious irritation, shortness of breath, occasional movement of limbs.

Have a certain degree of spontaneous exercise such as chewing, bruising and swallowing.

Unexplained smiles, tears, and groans may appear. Sometimes the eyes look at moving objects and high sound directions.

Nervous system examination usually includes brainstem reflexes, such as pupils, eyes, cornea, and knee tendon reflexes. Changeable limb reflexes. Pain irritation can cause flexion or extension reactions. Grip reflections can exist.

2. Exclusion basis: there is any clear perception, communication, purposeful conscious activity, etc.

Plant state differential diagnosis

It should be distinguished from the following three situations:

I. Coma

Coma is a more serious pathological conscious disorder. It is distinguished from the plant state by closed eyes, no eyes open, no sleep-wake cycle, severe cases without any cognitive and motor functions, and sometimes vital signs are difficult to maintain. Systems such as mechanical ventilation, booster medications, etc. Various low-perceived disturbances of consciousness are shown in Table 2.

Table 2 Comparison of various states of reduced perception

State-aware sleep-wake cycle brainstem function brain metabolism

No change in coma

No change in plant status

There may be changes in the minimum response state

Atresia syndrome is complete

Brain Death No No No

Brain death

Refers to the irreversible loss of all brain functions, including brainstem functions. There is no self-breathing clinically, and it must be maintained by artificial respirator. All brain reflexes disappear. Laboratory examination of the SEP above P waveform disappeared, TCD blood flow direction was retrograde, cerebral angiography intracranial arteries did not enter the contrast agent. The identification of the two is shown in Table 17-7-2.

Table 17-7-2 Differences between brain death and plant status

Item Brain Death Plant Status

Cognitive loss of function

Necrosis of the entire brain seen in anatomy Extensive necrosis of the cerebral cortex

Spontaneous breathing

Level of consciousness deep consciousness but unconsciousness

Brain stem reflex

No chance of recovery

Short survival time

Third, atresia syndrome

Nordgren reported in 1971 that due to bilateral pontine basal lesions, the cortex of the brainstem ventral cortex and the cortical spinal cord were damaged, resulting in loss of all motor functions. It looks like a coma, but in fact the consciousness is completely clear, the patient Be able to answer questions with closed eyes. The physician must check carefully to make the identification.

Fourth, mixed aphasia

If the tectum of the left inferior frontal gyrus and the motor cortex of the triangular cortex and the sensory language center in the posterior superior temporal gyrus are damaged, symptoms similar to the vegetative state appear, but patients with mixed aphasia often have no coma. Plant behavior is often transferred from a coma. Sometimes when it is difficult to distinguish between the two, it is necessary to repeatedly observe carefully to distinguish.

Phytopathogenic

The etiology of persistent vegetative states can be roughly divided into 3 categories.

1. Acute injury: This is the most common cause of PVS. Trauma is most common, including nontraumatic injuries such as gunshot wounds and childbirth in traffic accidents, including hypoxic-ischemic encephalopathy caused by various causes such as cardiac arrest and asphyxia, hanged drowning, etc .; severe persistent hypotension, cerebrovascular accident Such as cerebral hemorrhage, cerebral infarction, subarachnoid space hemorrhage, etc .; In addition, there are infectious tumors and poisoning of the central nervous system.

2. Degenerative and metabolic diseases: Alzheimer's disease, multiple cerebral infarction, dementia, Pick's disease, Creutzfeldt-Jakob disease, Parkinson's disease, Huntington's disease are common causes in adults. In children, ganglion lipid deposition disease and adrenal white matter nutrition are common. Bad mitochondrial encephalopathy, gray matter degeneration and other diseases.

3. Developmental malformations: including anencephaly malformations, congenital hydrocephalus, and microcephaly.

Phytopathogenesis

Pathological changes in PVS patients often vary from person to person. The time between brain damage and death can affect the nature and severity of pathological changes. The patient's primary disease can also affect the test results.

In 1994, Kinney reported that pathological examination of patients with persistent vegetative states found that the thalamus is the most important lesion. It is believed that the thalamus is very important to consciousness and perception, but the significance of awakening is secondary.

In 1997, Reinder reported that plant status may be related to damage to the gray matter of the caudate nucleus, and believed that in addition to diffuse damage, certain focal ischemic changes are also important.

However, there are roughly two pathological changes in PVS caused by trauma or non-traumatic brain injury.

1. This type of chronic cortical necrosis is mainly seen in 10 autopsy data reported by Dougherty of ischemic and hypoxic encephalopathy. Neocortical necrosis in 7 cases, multifocal infarction in 2 cases, and 1 in embolic infarction can be seen under the microscope. Yuan loss and glial hyperplasia in one case. Neocortical damage is most obvious in the occipital lobe. In addition, most of the hippocampal striatum, thalamus, and cerebellum have neuronal loss and glial hyperplasia. Nine of the 10 cases had normal brain stems in only 10 cases, and only 1 had a quadrilateral infarction.

2. Diffuse axonal damage This kind of abnormality is seen in acute craniocerebral injury. It is because extensive subcortical axonal damage interrupts the connection between the cerebral cortex and other parts of the brain. Sometimes diffuse axonal damage can be accompanied by primary or secondary Hypothalamus can also be reported severely in primary brain stem injuries.

Phytotherapy

It is difficult to say that there are special effects in the treatment of plant states. The reason is that brain cells are very sensitive to hypoxia and ischemia and are very vulnerable to damage. Once damaged, it is extremely difficult to recover. Traumatic patients can recover about 1/2 of their consciousness after entering the vegetative state, but the vegetative state caused by non-traumatic causes is more difficult to recover. Even if the patient's consciousness has been restored, their functional recovery is worse and slower, which makes the medical and nursing expenses costly. Because of this, countries are conducting research on the treatment of patients with vegetative states. Drug therapy is the easiest and most convenient method. So far, many drugs have been used in patients with vegetative state, including a large number of vitamins, vasodilators, nootropic drugs, calcium antagonists, nerve cell activators, etc. It is difficult to say that the desired result has been achieved. Compare exact and effective hyperbaric oxygen therapy.

First, hyperbaric oxygen therapy (HBO)

Hyperbaric oxygen therapy is a special treatment method highly recommended at home and abroad, showing encouraging prospects.

(I) Mechanism of action.

1. Improve the supply of oxygen to brain cells and promote the recovery of some functional cells in a reversible state: blood flow in normal brain tissue is 0.5 ml · g-1 · min-1, and when the blood flow in the lesion area is reduced to 0.1 ml · g-1 When the temperature is below min-1, the "sodium pump" function that maintains the ion gradient inside and outside the nerve cell membrane fails, causing cell edema and damage. This cerebral blood flow value is called the "cell membrane failure threshold". Below this value, brain cells cannot survive, and irreversible necrosis occurs within 10 to 15 minutes. However, the brain cells in the "ischemic penumbra" between the necrotic foci and normal tissues are in a state equivalent to the "spindle failure threshold" or "electroencephalographic activity failure threshold" proposed by Astrup. In this state, synaptic transmission is blocked, the brain's autogenous potentials and evoked potentials disappear, but the brain cell structure is still intact and still alive, but it is just a dysfunction. Once the cerebral blood flow supply returns to normal or the blood oxygen content is increased accordingly, the oxygen supply to the brain cells returns to normal, and this part of the brain cell function can be restored. HBO can increase blood oxygen tension and tissue oxygen tension. For example, if pure oxygen is absorbed at 0.2 MPa (2 ATA), the oxygen tension of cerebral cortex tissue is increased by 7 times than normal. In addition, HBO can also increase the diffusion radius of oxygen and increase tissue oxygen storage. The partial pressure of oxygen at the arterial end of pure cerebral cerebral cortex capillary can be increased from 7.31 kPa to 22.61 kPa at 0.2 MPa. From 30 m to 100 m. HBO can greatly increase the oxygen tension and diffusion distance of the non-reflowing microvessels, so that the disabled brain cells can regain oxygen supply, so the aerobic metabolism is strong, and ATP is increased, which can promote the function of this part of the brain tissue. restore.

2. New collaterals occur through axons to establish new axonal connections: HBO can promote the regeneration of axons and dendrites. Animal experiments have shown that the length and number of axon regeneration in the HBO group after 4 weeks is equivalent to 2 in the control group. Multiple times. HBO can also accelerate the establishment of collateral circulation, inhibit demyelinating allergies, and restore nerve function through newly established axonal connections.

3. Activate the ascending reticular activation system: Kanai reports that HBO can reduce carotid blood flow, reduce intracranial pressure, and increase vertebral blood flow, thereby increasing blood oxygen tension in the reticular system and the brain stem. The reticulated ascending system is a strong stimulus. Therefore, HBO has the effect of accelerating awakening and promoting consciousness recovery, which is more important for the recovery of PVS patients with diffuse axonal injury (DAI).

4. The damaged brain tissue of patients with PVS can be necrotic due to ischemia and hypoxia in the early stage, and there will still be some necrotic cells in the PVS stage. This may be due to the disturbance of microcirculation caused by cerebrovascular changes, so that this part of the brain cells still do not get sufficient oxygen supply; at the same time, the production of SOD and the like is reduced, the antioxidant capacity of the body is reduced, and excess free radicals are not effectively removed. , Causing damage to brain cells. HBO improves blood oxygen tension, accelerates the establishment of collateral circulation, increases the diffusion distance of oxygen, improves the aerobic metabolism of the brain, increases the antioxidant enzymes such as SOD, and increases the activity of enzymes, timely removes excess free radicals, and protects brain tissue No longer damaged.

In short, HBO has indeed received good curative effect in the treatment of PVS, but its mechanism of action is not completely clear at present, and further research is needed.

(Two) methods

Depending on the etiology and the location and degree of damage shown by CT or MRI, large and medium-sized HBO cabins are used with different treatment options. Generally pressurize with air to 0.15 0.25 MPa (1.5 2.5 ATA). Use a face mask or special joint to connect the tracheal tube to absorb pure oxygen, 2 times in 30 minutes, and air in the middle for 10 minutes, 1 or 2 times a day, 10 The days are 1 course. The most patients in this group were treated for 14 courses, while the shortest were treated for 2 courses. During HBO treatment, supplemented with brain cell activators, supportive therapy, symptomatic treatment and functional exercise.

(Three) curative effects

Hyperbaric oxygen therapy (HBOT) is a special treatment that is highly admired at home and abroad, showing encouraging prospects. Wang Chuanmin and others compared the efficacy of 168 cases of PVS (HBO group) treated with HBO as the main treatment and 86 cases (non-HBO control group) of PVS treated with general medicine and the like. Several factors. Results: The total effective rate of the HBO group was 83.3%, and the total effective rate of the non-HBO control group was 54.6%. There was a very significant difference between the two (P <0.01). The therapeutic effect of the HBO group was significantly better.

Neubaner of the Florida Brain Recovery Center in the United States treated 20 patients with vegetative state with hyperbaric oxygen. Pure oxygen was absorbed under the oxygen pressure of 1.5 to 2.5 ATA. 50% of the patients were effective, of which 35% almost recovered. Soon he reported that 5 patients with vegetative status in 1 year, 2 years, 8 years, 11 years, and 14 years had different degrees of recovery, showing promising prospects for patients with persistent vegetative status and even permanent vegetative status. One case was treated with hyperbaric oxygen 8 years after CO poisoning, and 78 times of treatment under 1.5ATA finally woke up. One patient with a course of up to 14 years was hypoxic encephalopathy. He underwent 200 hyperbaric oxygen treatments. After 52 treatments, the patient's language, communication, cooperation, and hand movements improved. After 200 treatments, in addition to residual spasms Can go upstairs with wheelchair and with help. Neubaner recommends that continuous hyperbaric oxygen under 1.5 ATA, 1 to 2 times a day, at least 5 days a week, 40 times a course of treatment. If necessary, increase the pressure to 1.75 to 2.00 ATA, especially for severe and long courses, the treatment can reach 200 times.

Second, conventional basic treatment

Routine basic treatment includes basic medical treatment, nursing and traditional rehabilitation treatment.

(1) Basic drug treatment

It is mainly to increase cerebral blood flow, promote central nervous cell metabolism, and activate nerve cell drugs. In application, the simultaneous application of these three classes of drugs is more effective than a single application. One principle that must be grasped in medical treatment is that the treatment of patients with low-level neurological conditions should first be harmless. That is, in the treatment measures, behaviors that hinder the ongoing nerve recovery must not be present. For example, in the treatment of epilepsy, phenytoin and anticonvulsants should be used with caution or contraindicated.

1. Drugs that increase cerebral blood flow: there are niacins, calcium blockers, angiotensin, ergot alkaloids, etc., by directly relaxing vascular smooth muscle, or exciting and blocking certain receptors, expanding cerebral blood vessels, increasing Cerebral blood flow to improve brain circulation. Commonly used drugs: nicotinic acid, papaverine, cerebrazine, nimodipine, cibilin, hexacocoline, caranine, etc.

2. Drugs that promote metabolism of central nervous cells: adenosine triphosphate, cytochrome C, chloroester, idebenone, coenzyme-A, acetylglutamine, r-aminobutyric acid, brain rehabilitation, brain rehabilitation, nucleotides, etc. .

3. Brain cell activators: Conorexin, ganglioside, citicoline, cerebrolysin, naloxone.

(Two) rehabilitation nursing

Is the key to maintaining patient survival. Mainly to maintain the maintenance of nutrition, toilet care, and promote swallowing function. Generally there is a certain degree of swallowing dysfunction in patients in the plant state and low response state, so swallowing should be taken as much as possible, and simple permanent nasal feeding should be avoided. The rehabilitation of swallowing function should be actively and patiently performed. Regular urinary catheterization should be used for dysuria, and open catheterization should not be used. Maintaining the patient's benign limb position is the focus of rehabilitation care and an important measure to prevent joint contracture and muscle spasm.

(3) Traditional rehabilitation treatment

Refers to exercise therapy (PT), occupational therapy (OT). Passive activities to maintain the range of motion of the limbs and joints are effective measures to prevent joint contracture and venous thrombosis of the limbs.

The above-mentioned conventional basic treatments have positive significance for maintaining and prolonging life, reducing secondary comorbidities, and striving for recovery opportunities. This is often ignored in China, leading to a series of secondary complications for patients and shortening the survival time. Once consciousness is restored, due to severe comorbidities, such as common joint contractures, the quality of life is affected and the meaning of true recovery is lost.

Third, adjuvant special treatment

Adjuvant special treatment is composed of 5 kinds of treatment methods: environmental stimulation method, operation stimulation method, sensory stimulation method, drug stimulation method and nerve stimulation method.

(I) Environmental Stimulation Act

The specific approach is to systematically expose patients to naturally occurring environmental stimuli. For example, let patients receive the stimulation of sunlight, air, and humidity outdoors; listen to the recorded speech of loved ones regularly; let patients watch TV. These methods, although not scientifically proven, are reasonable. Because in the vegetative state, the sensory transmission of hearing, sight, and touch is normal. These naturally-occurring environmental stimuli help to promote the connection between the cortex and the subcortex. Listening to the voices of the loved ones mentioned above can often play an emotional call and play the role of resurrection. Such individual reports are not uncommon, and our experience has proved encouraging.

(B) Conditional Operation Therapy

It is a conditional reflex method, which means that systemic enhancement is given to spontaneous or induced responses based on the principle of conditional operation. Boyel and Greer observed 3 vegetative patients and found that during the treatment, 2 patients had upper limb responses approaching or exceeding the mean value of the expected response.

(Three) sensory stimulation

Controlled application of special and intense sensory stimuli. Many scholars think it is effective. However, many scholars believe that sensory stimulation cannot change or promote the recovery process. In this regard, we believe that the basic principle of traditional rehabilitation exercise therapy, such as neuromuscular proprioception, is to promote the central nerve through deep joint sensations. Functional magnetic resonance imaging showed that when the joint was moving, there was a change in the nerve activity of the corresponding cortex, followed by the corresponding part of the opposite side. So it's a good idea to feel stimulating.

(IV) Drug Stimulation

It is a hot spot that has been widely studied in the past 50 years. Many scholars have directly or indirectly monitored the effects of some specific excitatory neurotransmitters and their metabolites in plasma or cerebrospinal fluid. They have done a lot of vegetative or coma model tests on animals and they have been proven.

Some special drugs can inhibit or promote nerve recovery to the injury. Some transmitters have a tendency to really repair nerve defects. Adrenergic and dopaminergic central stimulants are generally considered to have a promoting effect. In contrast, catecholamine antagonists and? R-aminobutyric acid (GABA) stimulants should be avoided in the early stages of injury. After the acute phase, the above Drugs such as acetylcholine antagonists and diazepam should also be avoided. However, there are also reports that the effect of drugs on promoting nerve recovery or preventing the development of nerve damage is minimal in vegetative, persistent vegetative, or coma. According to a few selective studies and general clinical trials, certain drugs have a certain arousal effect on low awake in a low response state. It has also been observed that certain drugs, such as amphetamine, have enhanced efficacy when used concurrently with exercise therapy.

Since the 1980s, Japanese scholars have found that thyroid-stimulating hormone-releasing hormone (TRH) has a wake-up effect on persistent conscious disturbances. Usage is 2 times a day, 1 ~ 2mg each time, intravenous bolus, 14 days as a course of treatment, intermittent treatment can be repeated for 1 week, or intravenous drip. In early treatment, it is effective or improved by 50.5%, if the course of treatment is more than 1 month, the effect is only about 30%.

TRH has a noradrenaline-like effect, antagonizes endorphins, thereby acting as an excitatory center and increasing cortical awakening levels.

Since the 1990s, nerve growth factors have received widespread attention, especially domestically. However, because it cannot pass the blood-brain barrier, the purification activity has not reached effective activity, so it has not been used clinically abroad. In China, the so-called various neural factors extracted from animals such as the subrenal gland of rats have not been scientifically proven to have a regenerating effect on the central nervous system. Because the source is not generated by genetic engineering, but is extracted from a heterogeneous animal, the side effects are large, especially allergic reactions often occur, so it is not suitable for application. But the discovery of nerve growth factor and the research progress of genetically engineered synthetic nerve growth factor will bring encouraging prospects for the treatment of plant states.

Dopaminergic central stimulant: Madopa "250" 1/2 tablet, three times daily, from the second week, one tablet, three times daily. Taishuda (Trastal) 50mg ~ 100mg, 2 to 3 times a day. Bromocriptine: 10mg / time, three times a day.

(5) Nerve stimulation method

Including two aspects, namely deep stimulation and peripheral nerve stimulation.

1. Deep stimulation method: including thalamic electrical stimulation, brainstem electrical stimulation, and cerebellar electrical stimulation. The electrodes are directly buried in the corresponding parts, and then continuous electrical stimulation is given. Because it is difficult to be placed for a long time, it cannot be promoted in the clinic. The more widely used high cervical spinal cord electrical stimulation therapy is to place electrodes at the C2 and C4 levels in the epidural midline under general anesthesia. Similar to pacemaker stimulation, it is only placed under the outer skin of the abdomen. The stimulation condition is 2 ~ 5V, 0.1 ~ 0.5ms, 100 times / second, 15% ~ 25% magnification, daily stimulation lasts 6 ~ 12 hours. If placed under the dura mater, the strength can be reduced by 1/2. The electrical stimulation of the high neck spinal cord reaches the brain stem and is transmitted to the cerebral cortex through the ascending reticular activation system and the lower thalamus activation system. Its mechanism of action is: to promote the metabolism of serotonin in the brain; increase local blood flow; In animal experiments, the amount of acetylcholine can be increased; the brain wave can be improved, and the alpha wave can be increased and the slow wave can be reduced after stimulation. The stimulation can continue for 1 hour after the stimulation is stopped.

Treatment effect: The total effective rate was 44.3%, and the effective rates for head trauma, hypoxic encephalopathy, and cerebrovascular disease were 57.1%, 31.2%, and 29.4%, respectively. The effect is related to the etiology, and also related to age and course of disease. 80.6% of patients under 30 years of age are effective, and 67.7% of patients with disease course within 12 months are effective. However, there are some reports that the disease is highly effective even if the course is as long as 30 months.

2. Peripheral nerve stimulation method: that is, low frequency functional electrical stimulation (FES) is used to continuously stimulate both lower limbs or upper limbs. In normal people, it has the effect of activating EEG, which increases the amplitude in the alpha frequency domain, that is, it promotes the cerebral cortex. Extensive awakening mechanisms exist. However, in the vegetative state, it has not been considered effective, but it is theoretically reasonable, so it can be used as one of the therapeutic measures.

Fourth, brain tissue transplantation

(A) surgical methods

Cerebral cortex, brainstem and pituitary gland of stillbirth induced fetus at 12 weeks of gestation were selected and prepared into suspension. According to the patient's condition and CT, BEAM changes to determine the target of brain parenchyma transplantation. The brain tissue suspension was transplanted to the lateral ventricle, lateral cleft cistern, and targets in the brain parenchyma using rapid preoperative positioning and percutaneous cone-cranial needle aspiration.

(Two) curative effect

Wang Rongyang and others used brain tissue transplantation to treat 23 cases of persistent vegetative state, and evaluated the curative effect 2 months after operation. Results: 5 cases were effective (21.7%), 13 cases were significantly effective (56.5%), and the total effective rate was 78.3%. The whole group of patients reviewed EEG, BEAM, and EP at the same time as evaluating the efficacy. A comparison and analysis with the results of preoperative examination showed that among the 18 cases that were effective, 16 were significantly improved (88.9%). , 13 cases (72.2%) and 10 cases (55.6%). The main characteristics of postoperative EEG improvement are: the emergence of medium and short-range wave rhythms, waves are significantly reduced, waves are reduced, and the amplitude is increased. The main characteristics of the improvement of BEAM are: the distribution density of the alpha band is increased, and the power density of the delta and theta bands is reduced. The main characteristics of EP improvement are: the waveform differentiation is clearer than before surgery, the latency period is shortened, and the wave interval is shortened.

(Three) mechanism

Neurotrophic factors play an important role in the survival, differentiation, and growth of neurons. They are necessary for mature neurons to maintain survival and perform their normal functions. Neurotransmitters are indispensable for transmitting information between neurons. Early in the period after transplantation, the implanted fetal brain tissue provides patients with a large number of exogenous neurotrophic factors and neurotransmitters. After implanted fetal brain cells survive, these substances can be secreted and released. The effective mechanism of fetal brain tissue transplantation is related to the fact that the graft provides patients with a large number of exogenous neurotrophic factors and neurotransmitters.

V. Traditional Chinese Medicine Treatment

(1) Prescription

20g, Polygala chinensis 15g, Angelica 12g, Chuanxiong 15g, Salvia miltiorrhiza 30g, Dilong 15g, Tao Ren 12g, Yizhiren 20g, red peony and white peony 10g, chicken blood vine 20g, raw astragalus 40g, huangjing 15g. Add or subtract with symptoms.

Taking: Take 1 dose daily, 2 times a day and night.

Course of treatment: 2 months.

(Two) curative effect

Geng Mingliang and others used this prescription to treat 10 cases of persistent vegetative state. The total effective rate in the treatment group was 70% and the total effective rate in the control group was 20%.

(Three) mechanism

Traditional Chinese medicine believes that coma is caused by blood stasis, heart disturbance, blood stasis by the lungs, but the Qi is blocked, the air is not clear, the turbid air is not generated, and the vital energy cannot be generated. , Lost souls and so on. The above prescriptions are mainly for promoting blood circulation and removing blood stasis, and then they are mixed with spicy incense to open up the consciousness and refreshing, so it has a wake-up effect.

Acupuncture treatment

(1) Method

1. Acupuncture

Select 30-inch 1.5-inch acupuncture needles for Shenting, Primal God, Baihui, Sishen Cong, Shugu, Naoto, and Naokong. Shenting and Benshen points from 0.5 to 1 inch under the cap-shaped aponeurosis along the scalp from front to back; Baihui penetrates 1 inch from front to back; Shikami Sat penetrates 1 inch from front to back and left to right; 1.2 inches forward and backward; 1 inch of thorns in the brain and cavities. The acupuncture method adopts the method of lifting, lowering and pushing slowly, gently inserting and re-lifting, with a lifting width of about 0.5 inches, with a degree of inward adsorption under the needle as the degree, connected to the G-6805 electroacupuncture instrument, frequency 8 ~ 13Hz , Continuous wave, stimulation for 30 minutes, needle retention for 1 hour, during the needle retention process, the needle was inserted and discharged twice. Acupuncture is performed once a day, and 30 times is a course of treatment, with a rest period of 3 to 5 days.

2, body needle

Select Shuigou, Fengfu, Neiguan, Shenmen, Laogong, Shixuan, Sanyinjiao, Yongquan. Shuigou point was inserted 0.3 inches into the nasal septum, using the peck-pecking method, with the patient's eyeball moistened; Fengfu point was inserted 1 inch into the jaw direction, using a small high-frequency twisting method for 1 minute, leaving no needle Xuan puncture 1 to 2 bleeding points each time, alternately puncture; 0.5 to 1 inch straight in Neiguan, 0.3 to 0.5 inch straight in Shenmen and Lao Gong. The G-6805 electrotherapy device was connected to Guan and Lao Gong. The parameters of the electroacupuncture were the same as before; Sanyinjiao was pierced by 1 to 1.5 inches, and Yongquan was pierced by 1 inch. . Acupuncture is performed once a day, and 30 times is a course of treatment. The treatment results were counted after 3 courses.

(Two) curative effect

Wang Shengxu and others applied the above-mentioned acupuncture method of Xinshen Kaiqiao to treat 31 cases of persistent vegetative state after traumatic brain injury. The duration of the vegetative state of the three unconscious patients was more than six months.

(Three) mechanism

Persistent vegetative states belong to the categories of "missing", "unconsciousness", "unconsciousness", and "fainting" in traditional Chinese medicine. They are clinically critical and critical diseases. Take refreshing and enlightening first. Acupuncture and acupuncture at the head of Xingshen Kaiqiao were selected from Shenting, Primal God, Baihui, Sishen Cong, Shugu, Naohu and Naokong. The above-mentioned acupoints are the main points for traditional refreshing and enlightening, treating psychiatric diseases. Acupuncture the above-mentioned acupuncture points, using the method of light insertion and repeated lifting, and the use of electrical stimulation consistent with the frequency of the brain wave wave, help to relieve the brain. The state of inhibition of the cortex plays a role in enlightening the brain. The acupoints are selected from acupoints such as Shuigou, Fengfu, Neiguan, Shenmen, Laogong, Shixuan, Sanyinjiao, and Yongquan. The above-mentioned acupoints are often used for coma, syncope, stroke emergency, and dementia, epilepsy and other psychiatric diseases. treatment. The strong stimulation of the acupuncture points can activate the function of the brainstem reticular awakening system, promote the recovery of consciousness in patients with persistent vegetative state after traumatic brain injury, and play a role of refreshing and enlightening.

It can be seen from the above that the neurological rehabilitation treatment for patients with vegetative state is a comprehensive and multi-dimensional system engineering. Routine basic treatment and adjuvant special treatment must be combined. The former is a maintenance treatment, the latter is a wake-up treatment, and the two complement each other. It must be noted that the importance of the former is often ignored in China. Although it has spent a lot of manpower and material resources to obtain a pleasant awakening effect, due to the neglect of basic treatment, the corresponding functions cannot be restored, such as limb It is regrettable that contracture affects the recovery of motor function and does not fundamentally change the quality of life.

Section IX Prognosis

The prognosis of PVS includes two aspects: the recovery of consciousness and the recovery of function. The prognosis determines the following aspects.

First, the cause

The cause is acute traumatic and non-acute traumatic injury.

1. Traumatic injury: 434 adult PVS patients with severe head trauma reported 33% recovery of consciousness at 3 months after injury, increased to 46% at 6 months, 52% at 12 months, and 12 Only 7 cases recovered after the month. According to the Glasgow Outcome Scale, 434 adults had PVS after one year, 33% died, 15% were still in PVS, 28% were severely disabled, 37% were slightly disabled, only 7% recovered well, and half of them were after injury Those who started to improve after 3 months, the rest recovered after 6 months, and none recovered after 12 months. The functional recovery of PVS in children is similar to that in adults.

2. Non-traumatic injury: Non-traumatic prognosis is worse than traumatic. After 3 months of 169 cases of non-traumatic injury, only 11% recovered consciousness, and only 15% recovered after 1 year. Moreover, the function recovery of these conscious patients was extremely poor, and the prognosis of children was similar to that of adults.

3. PVS caused by degenerative and metabolic diseases and developmental deformities are impossible to recover.

Second, age

Overall, patients with PVS under 40 years of age have relatively good recovery and have a better traumatic prognosis than non-traumatic. According to data from the US PVS research group, 754 of the 754 cases were adults, 151 children, and 251 cases of adult consciousness restored within 12 months, accounting for 41.6%, while 72 cases of children recovered consciousness within 12 months, accounting for 47.7%. Recovery rates are slightly higher than in adults.

Third, the course of disease

Whether it is an adult or a child, 12 months after trauma and 3 months after non-traumatic injury are unlikely to recover, that is, they have become a permanent vegetative state. Of course, there are also reports in the literature of long-term PVS regaining consciousness after several years.

In addition to the above three factors, there are also brain stem evoked potentials, EEG, CT, MRI, etc. also have certain effects on judging the prognosis.

PVS patients survive an average of 2 to 5 years, and those who survive more than 10 years are extremely rare. Of adult PVS patients with traumatic injury, 33% died within 3 years, compared with 53% of nontraumatic injuries within 1 year, compared with 9% and 22% of children, respectively. Another group reported 110 cases with 3-year and 5-year mortality rates of 65% and 73%, 90% of patients died within 10 years, and 71 patients who died had an average survival time of 38.4 months. Infants and children had PVS. The survival time was 4.1 ± 0.7 years. A few reported that the survival time of PVS patients can reach 15 years, and 3 cases survived 17, 37, and 41 years, respectively, and the probability of surviving more than 15 years is 1 / (15,000-75,000).

According to 163 PVS statistics, the causes of death were pulmonary or urinary infections (52%), systemic failure (30%), sudden death of unknown cause (9%), respiratory failure (6%), and other causes including stroke Or tumors (3%).

Ethical thinking of plant state

There is no doubt that successful cases of vegetative rescue are extremely rare, and even if there are very few successful cases, they rely entirely on huge medical expenditures and long treatment paths as the cost. This can be said to be a serious waste of human, material and medical resources. In this case, giving up the treatment of vegetative people has become a very important and practical issue in clinical ethics. Therefore, in today's China's medical legislation is still incomplete, it is necessary to discuss and determine the medical standards to abandon rescue and related legal procedures and ethical issues.

Most people have agreed that consciousness is the prerequisite for life activities, and drugs or instruments cannot be used to permanently maintain the "vegetative" survival. It is also impossible for society and family members to maintain the "live dead" for the emotional and economic costs of PVS patients. It is generally believed that, under the premise permitted by law, the exact diagnosis of persistent vegetative state for more than one year has little chance of recovery, and withdrawal treatment is a more reasonable method. How to be ethically and legally recognized during withdrawal treatment must have the following statutory levels:

One or two doctors discuss the decision together

Be sure to have two or more doctors discuss the decision together, and write down the medical records in detail to answer the reasons for giving up treatment. Whenever possible, the patient's immediate family members (spouse, children or parents, and friends and relatives trusted during life) should participate in the discussion. It is required to include the consent of the patient's family to not treat and sign it, and get the support and approval of all doctors or nurses involved in the rescue. If there is a chance of a turnaround, the decision to abandon treatment must be reversed.

Determine the nature of the disease

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1997R.Hoffenberg