Generality
The vegetative state is a possible evolution of the coma, corresponding to a waking condition, in which the person who falls is completely unaware of himself and the surrounding environment.
At the origin of a vegetative state there may be: a severe head trauma, a serious episode of stroke or diffuse cerebral hypoxia, a severe metabolic disease, a neurodegenerative disease, a brain tumor or abscess, a meningitis, etc.
For a correct diagnosis of the vegetative state, the following are fundamental: the physical examination, the magnetic resonance of the brain, the encephalic CT, the cerebral PET and the electroencephalogram (EEG).
Due to the lack of specific treatments and the severity of the condition itself, the vegetative state generally has a poor prognosis.
What is the vegetative state?
The vegetative state is a waking condition that can follow the coma, characterized by unawareness of itself and the surrounding environment.
Unfortunately, people in a vegetative state have little, if any, chance to return to a normal life. In most cases, in fact, patients do not improve or show minimal improvements and they constantly need assistance.
A quick definition of a vegetative state could have been unconscious waking .
VEGETATIVE STATE AND MINIMAL CONSCIENCE STATE
The vegetative state represents an alternative to the so-called minimum consciousness state .
Briefly, the state of least consciousness is a waking condition that can happen to the coma, in which the person concerned has a certain degree of awareness of himself and the surrounding environment.
Epidemiology
In Italy, according to some presumed estimates, the number of patients in a vegetative state and state of minimum consciousness would be around 3, 000-3, 500. Data are somewhat vague for at least a couple of reasons, which are: the lack of a reliable epidemiological study and the large number of misdiagnoses.
In the United States, it appears that the number of people in a vegetative state is between 15, 000 and 40, 000 individuals. However, even in this case, these are fairly rough estimates.
ORIGIN OF THE NAME
The Scottish neurosurgeon Bryan Jannett and the American neurologist Fred Plum proposed the term "vegetative state" in 1972 .
OTHER NAMES OF THE VEGETATIVE STATE
In medicine, the terms " apallic syndrome " and " watchful coma " are synonyms of vegetative state.
Specifically, the term "apallica syndrome" represents the original name of the condition that then B. Jannett and F. Plum called "vegetative state". It was coined by a German psychiatrist named Ernst Kretschmer in 1940. Kretschmer is known in the medical field because he has the merit of having first described the characteristics of the condition corresponding to the vegetative state.
Causes
To understand the transition from a coma to a vegetative state, it is necessary to summarize what determines the entry into a coma.
Coming into a coma occurs when the cerebral cortex and / or a structure of the brainstem called the reticular activation system (RAS) suffer damage.
The cerebral cortex and RAS, in fact, are the two nerve components (for the precision of the central nervous system) deputed to the maintenance of the state of consciousness .
Numerous neurological studies have shown that the transition from coma to vegetative state occurs in all those circumstances in which there is a functional recovery from the brainstem (specifically the reticular activation system), but not from the cerebral cortex.
EVENTS AT THE ORIGIN OF THE VEGETATIVE STATE
The vegetative state can derive from episodes of coma following:
- Acute traumatic head injuries;
- Widespread cerebral hypoxia;
- Neurodegenerative diseases;
- Serious congenital anomalies of the central nervous system;
- Serious metabolic diseases;
- Intoxication due to abuse / overdose of drugs, hard drugs, harmful substances or alcohol;
- Meningitis;
- Stroke;
- Brain hernia;
- Brain tumors or abscesses;
- Hepatic encephalopathy at an advanced stage;
- Severe epilepsy;
- Acute disseminated encephalomyelitis (ADEM).
TYPES
The neurologist community and the Royal College of Physicians believe it is correct to distinguish the vegetative state based on the time duration. From this result two main types of vegetative state: the continuous vegetative state and the permanent vegetative state .
- The vegetative state that has been in progress for more than 4 weeks but less than 6 months is defined as continuous.
- The vegetative state in place for more than 6 months is defined as permanent, if the cause is non-traumatic, and for more than 12 months, if the cause is traumatic.
Symptoms, signs and complications
The characteristic symptom of the vegetative state is the lack of awareness of self and the surrounding environment .
Added to this are the inability to respond to visual stimuli or voice commands, the inability to perform voluntary movements, the inability to interact with other people, fecal incontinence, urinary incontinence and the absence of a behavioral response.
FUNCTIONS AND CAPACITIES PRESENT IN THE PEOPLE IN THE VEGETATIVE STATE
People in a vegetative state can recover functions and abilities, which in a state of coma are typically absent.
Unlike those who are in a coma, in fact, those who are in a vegetative state:
- It has a regular and correct cardiac function and respiratory function;
- It has complex reflections, which allow it to yawn, chew, swallow etc;
- He is able to open and move his eyes temporarily;
- He can hear louder noises;
- Reacts with involuntary movements, following painful stimuli;
- Presents a sleep-wake cycle. It is important to point out that the sleep-wake cycle of people in a vegetative state is often abnormal;
- He can smile or frown;
- Presents spinal reflexes.
Diagnosis
The vegetative state alters the consciousness in a similar way to other conditions. This could, therefore, make it difficult to identify and require the execution of various diagnostic tests.
Among the exams useful for a correct diagnosis of a vegetative state, a quotation certainly deserves: the physical examination, the magnetic resonance of the brain, the encephalic CT, the cerebral PET and the electroencephalogram (EEG).
EXAMINATION OBJECTIVE AND CLINICAL CRITERIA
The physical examination allows to establish the presence or not of those clinical criteria necessary to affirm if a person is in a vegetative state or not.
According to these clinical criteria, a person is in a vegetative state if:
- When awake, his eyes are open and he has some eye and eyelid mobility; nevertheless, however, with the look does not follow any visual stimulus;
- He has no awareness of himself and the surrounding environment;
- Presents the sleep-wake cycle;
- Shows reflex patterns of involuntary movement, in response to painful stimuli;
- Performs spontaneous stereotyped movements;
- It can present complex reflexes, including chewing and swallowing movements, facial grimaces, yawning and hand grip;
- Breathe independently;
- Presents a normal heart rhythm.
Therapy
Doctors and experts in the field of vegetative state, state of minimum consciousness and coma have not yet identified a medicine or a particular therapeutic instrument capable of restoring a normal state of consciousness in the person concerned.
Having said this, for those in a vegetative state, supportive therapy is provided, which includes:
- All those precautions aimed at preventing immobilization complications .
The main complications of immobilization include: aspiration pneumonia, bedsores and thromboembolic disease;
- The administration of food and water in the correct quantities and modalities (correct and complete feeding). Supplying the body with all the necessary nutrients is essential for the survival and maintenance of good health;
- Physiotherapy exercises, to prevent muscle contractions due to prolonged immobility.
Supportive therapy is essential to keep the patient alive and significantly reduce the risk of complications (eg, the aforementioned bedsores, aspiration pneumonia, etc.).
Prognosis
In general, the vegetative state has an unfavorable prognosis, in the sense that the patients concerned tend never to recover completely, even after the recovery of a certain degree of awareness of oneself and the environment.
The outcome of the vegetative state is usually the permanence in this condition or death .
That being said, there are several factors that influence the prognosis; among the factors in question, they certainly deserve a special mention:
- The triggering causes and the extent of brain damage . It is known that there is greater hope of recovering from a vegetative state, when the latter depends on a reversible condition (for example a metabolic disease) or a contained brain damage, rather than a stroke not treated in time or damage extensive cerebral
- The patient's health conditions before entering a coma . An individual of poor health already before entering a coma (and in a vegetative state) is far less likely to awaken and return to a normal life.
- The patient's age . According to various surveys, patients who recover better from a vegetative state are young patients; the elderly, on the other hand, have little hope of recovery.
CURIOSITY
Statistical studies have shown that a protracted vegetative state coincides with little chance of recovery and a high probability of death. In other words, people in a vegetative state for a long time (months if not years) have little hope of becoming aware of it and of surviving further.
In general, subjects in a vegetative state die due to aspiration pneumonia or multiple organ failure.
According to some surveys, the percentage of individuals in a vegetative state who survive for more than 5 years is equal to 25% of patients.
| Result of the vegetative state according to a 1994 report | |
Sample of patients and origin of the vegetative state | One year after the incident |
Sample of patients who entered the vegetative state one month after a traumatic causal event |
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Sample of patients who entered the vegetative state one month after a non-traumatic causal event (eg stroke) |
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