Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI

W Matsuda; A Matsumura; Y Komatsu; K Yanaka; T Nose

doi:10.1136/jnnp.74.11.1571

Responses

Short report

Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI

Compose a Response to This Article

Compose Response

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

PLEASE NOTE:

A rapid response is a moderated but not peer reviewed online response to a published article in a BMJ journal; it will not receive a DOI and will not be indexed unless it is also republished as a Letter, Correspondence or as other content. Find out more about rapid responses.
We intend to post all responses which are approved by the Editor, within 14 days (BMJ Journals) or 24 hours (The BMJ), however timeframes cannot be guaranteed. Responses must comply with our requirements and should contribute substantially to the topic, but it is at our absolute discretion whether we publish a response, and we reserve the right to edit or remove responses before and after publication and also republish some or all in other BMJ publications, including third party local editions in other countries and languages
Our requirements are stated in our rapid response terms and conditions and must be read. These include ensuring that: i) you do not include any illustrative content including tables and graphs, ii) you do not include any information that includes specifics about any patients,iii) you do not include any original data, unless it has already been published in a peer reviewed journal and you have included a reference, iv) your response is lawful, not defamatory, original and accurate, v) you declare any competing interests, vi) you understand that your name and other personal details set out in our rapid response terms and conditions will be published with any responses we publish and vii) you understand that once a response is published, we may continue to publish your response and/or edit or remove it in the future.
By submitting this rapid response you are agreeing to our terms and conditions for rapid responses and understand that your personal data will be processed in accordance with those terms and our privacy notice.

I agree to and have read the terms and conditions for rapid responses and BMJ Privacy Notice *

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Other responses

Jump to comment:

Persistent vegetative state after severe head injury: we should not generalize
Wakoto Matsuda
Published on: 13 April 2016
Persistent vegetative state: Should we generalize?
Boris Kotchoubey
Published on: 13 April 2016

Published on: 13 April 2016
Persistent vegetative state after severe head injury: we should not generalize
- Wakoto Matsuda
- Other Contributors:
  Yoji Komatsu, Kiyoyuki Yanaka, Akira Matsumura
Dear Editor
We greatly appreciate the considerable and thoughtful comments offered by Boris Kotchoubey and his interest in our report of three cases in a persistent vegetative state (PVS) after severe head injury, who recovered from a prolonged disturbance of consciousness after the administration of levodopa.[1]
As author points it out, PVS patient present a wide range of neurological symptoms and syndro...
Show More

Dear Editor
We greatly appreciate the considerable and thoughtful comments offered by Boris Kotchoubey and his interest in our report of three cases in a persistent vegetative state (PVS) after severe head injury, who recovered from a prolonged disturbance of consciousness after the administration of levodopa.[1]
As author points it out, PVS patient present a wide range of neurological symptoms and syndromes in addition to their main symptoms. According to the description by Jennet and Plum, PVS is the condition of patients with severe brain damage in whom coma has progressed to a state of wakefulness without detectable awareness. In this state, there is the absence of any adaptive response to the external environment, the absence of any evidence of a functioning mind which is either receiving and projecting information.[2,3] The widely accepted criteria of PVS are those in the 1994 report from the US Task Force.[4,5] In this report, PVS was defined in detail and distinguished from the other related conditions such as coma, brain death, locked-in syndrome, akinetic mutism, and dementia. The causes of PVS, however, include various pathogenesis such as trauma, hypoxic ischemic damage, cerebrovascular injury, infection, tumor, toxins or poisoning.[4] After all, the concept of PVS seems to be the entity of "syndrome" that contains some typical symptoms and variable pathogenesis. The advantage of the term "vegetative state" is that it simply describes observed behavior, without implying specific structural pathology.[5] On considering these points, the cases we presented may be a subgroup among a large group of PVS patients.
Some individuals whose dopaminergic systems may have been selectively damaged could be latent among majority of the patients in a PVS after severe head injury and only such individuals may respond to levodopa treatment.[1,6] Similarly, another individuals whose another neural systems may be damaged must be latent among a PVS and such individuals may respond to another treatment such as another specific stimulative agent (including neurotransmitter), deep brain stimulation, or intensive rehabilitation. We should not regard it as unitary entity. Probably, there is no single method to treat all the PVS patients. PVS should be divided to many subgroups according to its pathogenesis. Thus, when we decide the treatment for PVS patients, it should be in line with the anatomical and physiological mechanism of each case. To investigate the pathogenesis like that, newer diagnostic concept of disturbance of consciousness and radiographic tool for prognostic factor of vegetative state would probably be useful and helpful in future.[7,8]
In a point of statement above, the comments that Kotchoubey mentioned are very important. These points were touched upon in our report [1] and our reply to corresponding letter,[6] and we would like to agree with the view of him that it may be a wrong strategy to search for a treatment for the PVS in general. We are very glad that author has brought up these questions and points of view now. To give a definitive answer to this question, we will have to continue to our study and obtain more data and clinical experience. Finally, once again, we should not generalize the PVS as a unitary entity.
References
1. Matsuda W, Matsumura A, Komatsu Y, Yanaka K, and Nose T. Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI. J Neurol Neurosurg Psychiatry 2003; 74:1571-3
2. Jennet B, Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet 1972; 1: 734-7
3. Zeman A. Persistent vegetative state. Lancet 1997; 350: 795-9
4. The Multi-Society Task Force On PVS. Medical aspects of the persistent vegetative state. N Engl J Med 1994; 330: 1499-1508
5. Jennet B. The vegetative state. J Neurol Neurosurg Psychiatry 2002; 73: 355-7
6. Matsuda W, Matsumura A, Komatsu Y, and Yanaka K. Author 's reply to ÒParkinsonism and persistent vegetative state after head injuryÓ by Kurt A. Jellinger. J Neurol Neurosurg Psychiatry (Corresponding letter, in press) 2004
7. Giacino JT, Ashwal S, Childs N, Cranford R, Jennet B, Katz DI, Kelly JP, Rosenberg JH, Whyte J, Zafonte RD, Zasler ND. The minimally conscious state: Definition and diagnostic criteria. Neurology 2002; 58: 349-353
8. Uzan M, Albayram S, Dashti SGR, Aydin S, Hanci M, Kuday C. Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury. J Neurol Nerurosurg Psychiatry 2003; 74: 33-38
Show Less

Conflict of Interest:
None declared.
- Back to top
Published on: 13 April 2016
Persistent vegetative state: Should we generalize?
- Boris Kotchoubey, Associate professor, Medical psychology
Dear Editor
Matsuda et al.[1] reported three cases of patients with traumatic persistent vegetative state (PVS), in which an active treatment with levodopa, starting after 3, 7, and 12 months, respectively, resulted in fast recovery of consciousness.
All three patients had parkinsonian symptoms and MRI evidence of the damage to the substantia nigra or ventral tegmental area. This is an astonishing r...
Show More

Dear Editor
Matsuda et al.[1] reported three cases of patients with traumatic persistent vegetative state (PVS), in which an active treatment with levodopa, starting after 3, 7, and 12 months, respectively, resulted in fast recovery of consciousness.
All three patients had parkinsonian symptoms and MRI evidence of the damage to the substantia nigra or ventral tegmental area. This is an astonishing report given the well-known inefficiency of most treatment techniques in PVS.[2,3] One can object, however, that both Parkinsonism and the midbrain lesions are not very typical for PVS in general, and that, therefore, the authors' success was due to the selection of a particular, very specific subgroup of PVS patients. This is correct. But let's think this idea one step further. It is based on the implicit assumption that there is such thing as "the" PVS, and that the presence of additional symptoms (like Parkinsonism in Matsuda et al.[1]) always indicates a deviation from some "classical" PVS pattern. This assumption is not self-evident, though. In fact, PVS patients present a wide range of neurological symptoms and syndromes, such as pareses, disorders of vision, or various disturbances of the sleep pattern, in addition to their main symptomatics, i.e. the lack of behavioral responses. Do we need to remove all patients with such additional symptoms from our experimental groups in order to obtain the "pure" PVS? And, if we do this selection scrupulously, how many will remain in the rest?
An alternative may be to regard PVS, like any other neurological disease, as a multi-facet complex consisting of a well-defined "core" and a set of subgroups. Such subgroups may, or may not, possess a pathogenetic specificity like the midbrain lesions in the patients of Matsuda et al.[1] If this view is correct, it may be a wrong strategy to search for a treatment for the PVS in general. Hence, it should not be surprising that this search has been so unsuccessful to date. Another strategy is looking for particular subsets of symptoms characterizing a different subgroups of PVS patients. The treatment is, then, aimed at a specific key mechanisms of pathogenesis in these patients. A unitary view of PVS should not be an obstacle to look for those curative methods which may help in particular cases. At the very least, for a patient who regained consciousness, it does not matter whether he should thank to a generalized or a specific treatment.
References
(1) W Matsuda, A Matsumura, Y Komatsu, K Yanaka, and T Nose. Awakenings from persistent vegetative state: report of three cases with parkinsonism and brain stem lesions on MRI. J Neurol Neurosurg Psychiatry 2003; 74: 1571-1573
(2) Giacino JT. The effects of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review. Journal Head Trauma Rehabilitation 2000; 15: ix-x.
(3) Jennett B. The Vegetative State. Cambridge, UK: University Press, 2002. Matsuda W, Matsumura A, Komatsu Y, Yanaka K, Nose T. Awakenings from persistent vegetative state: Report of three cases with Parkinsonism and brain stem lesions on MRI. Journal of Neurology, Neurosurgery and Psychiatry 2003; 74: 1571-1573.
Show Less

Conflict of Interest:
None declared.
- Back to top

Main menu

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Log in using your username and password

Main menu

Log in using your username and password

You are here

Plain text

PLEASE NOTE:

Vertical Tabs

Other responses

Jump to comment:

Read the full text or download the PDF:

Log in using your username and password