Download PDF
Aktuelle Neurologie 2013; 40(08): 424-432
DOI: 10.1055/s-0033-1351297
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Gibt es bewusste Wahrnehmung beim apallischen Syndrom?[*]

Does Conscious Awareness Exist in the Apallic Syndrome?
F. Erbguth
1   Klinik für Neurologie, Klinikum Nürnberg
,
W. Dietrich
1   Klinik für Neurologie, Klinikum Nürnberg
› Author Affiliations
Further Information

Publication History

Publication Date:
02 September 2013 (online)

Also available at
    Permissions and Reprints

See also:

LeserbriefAktuelle Neurologie 2014; 41(05): 303
DOI: 10.1055/s-0034-1370121

See also:

AntwortAktuelle Neurologie 2014; 41(05): 303
DOI: 10.1055/s-0034-1370122

Zusammenfassung

Die Annahme fehlenden Bewusstseins bei den Diagnosen „apallisches Syndrom“ bzw. „vegetativer Status“ ist in den letzten Jahren durch klinische Untersuchungen und Erkenntnisse der funktionellen Bildgebung relativiert worden. Durch standardisierte an Skalen orientierte detaillierte klinische Untersuchungen bei schweren bedingten Hirnschädigungen konnten bei bis zu 40% der für „apallisch“ gehaltenen posttraumatischen Patienten Anzeichen für bewusst gesteuerte Reaktionen auf externe Stimuli nachgewiesen werden. Mit bildgebenden Verfahren konnten selbst bei klinisch nicht feststellbarer gezielter Reaktivität stimulus-korrelierte mental prozessierte Hirnaktivierungen detektiert werden, die belastbare Hinweise auf vorhandenes Bewusstsein geben. Allerdings besteht auch die Gefahr der methodischen und inhaltlichen Überinterpretation von detektierten Hirnaktivitätsänderungen als sichtbar gemachte Bewusstseinsfähigkeiten. Die deskriptive Bezeichnung „Syndrom reaktionsloser Wachheit“ soll die Termini „apallisches Syndrom“ und „vegetativer Status“ ablösen.

Abstract

In recent years, the assumption of lacking awareness and consciousness in the so-called “apallic syndrome” or “vegetative state” has been challenged by clinical evaluations and results of neuroimaging. The use of standardised scales for the clinical examination of patients with severe – especially posttraumatic – brain injury detected hints for willful reactions after external stimuli in up to 40%. Neuroimaging methods detected stimulus-correlated cortical brain activation, which reliably could be attributed to conscious awareness. For substantial and methodical reasons detected patterns of brain activation may be over-interpreted in terms of visible awareness. The descriptive term “unresponsive wakefulness syndrome” should replace the names “apallic syndrome” and “vegetative state”.

Schlüsselwörter

Bewusstsein - apallisches Syndrom - vegetativer Status - reaktionslose Wachheit - Bewusstseinsfähigkeiten

Keywords

awareness - apallic syndrome - vegetative state - unresponsive wakefulness - consciousness

* Gewidmet den Patienten und Angehörigen sowie den Pflegekräften und Ärzten, die mit kritischen Diskussionen unseren Blick auf die Probleme des apallischen Syndroms während der letzten 30 Jahre des Engagements in der neurologischen Intensivmedizin geschärft haben.


 

  • Literatur

  • 1 Owen AM, Coleman MR, Boly M et al. Detecting awareness in the vegetative state. Science 2006; 313: 1402
    CrossrefPubMedGoogle Scholar
  • 2 James W. The principles of psychology. New York: Macmillan; 1890
    CrossrefGoogle Scholar
  • 3 Zeman A. Consciousness. Brain 2001; 124: 1263-1289
    CrossrefPubMedGoogle Scholar
  • 4 Wijdicks EF, Bamlet WR, Maramattom BV et al. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58: 585-593
    CrossrefPubMedGoogle Scholar
  • 5 Kretschmer E. Das apallische Syndrom. Zschr Ges Neurol Psychiat 1940; 169: 576-579
    PubMedGoogle Scholar
  • 6 Gerstenbrand F. Das traumatische apallische Syndrom. Klinik, Morphologie, Pathophysiologie und Behandlung. Wien: Springer; 1967
    CrossrefGoogle Scholar
  • 7 von Wild K, Laureys S, Dolce G et al. for the European Task Force on Disorders of Consciousness. Syndrom Reaktionsloser Wachheit. Zur Begriffsbestimmung Apallisches Syndrom – Wachkoma – permanenter vegetativer Zustand. Neurol Rehabil 2011; 17: 209-215
    PubMedGoogle Scholar
  • 8 Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1972; 1: 734-737
    PubMedGoogle Scholar
  • 9 The Multi-Society Task Force on PVS . Medical aspects of the persistent vegetative state (Part 1 and 2). N Engl J Med 1994; 330: 1499-1508 und 1572–1579
    CrossrefPubMedGoogle Scholar
  • 10 Laureys S, Faymonville ME, Berre J. Rapid Response: Permanent vegetative state and persistent vegetative state are not interchangeable terms. BMJ 2000; 321: 916.1
    PubMedGoogle Scholar
  • 11 Giacino JT, Ashwal S, Childs N et al. The minimally conscious state: definition and diagnostic criteria. Neurology 2002; 58: 349-353
    CrossrefPubMedGoogle Scholar
  • 12 Laureys S, Celesia G, Cohadon F et al. for the European Task Force on Disorders of Consciousness . Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Medicine 2010; 8: 68 http://www.biomedcentral.com/1741-7015/8/68
    CrossrefPubMedGoogle Scholar
  • 13 Wild K, Laureys S, Dolce G. Apallisches Syndrom, vegetativer Zustand: Unangemessene Begriffe. Dtsch Arztebl 2012; 109: A-143
    PubMedGoogle Scholar
  • 14 American Congress of Rehabilitation Medicine . Recommendations for use of uniform nomenclature pertinent to persons with severe alterations in consciousness. Arch Phys Med Rehabil 2005; 76: 205-209
    PubMedGoogle Scholar
  • 15 Beaumont JG, Kenealy PM. Incidence and prevalence of the vegetative and minimally conscious states. Neuropsychol Rehabil 2005; 15: 184-189
    CrossrefPubMedGoogle Scholar
  • 16 Donis J, Kräftner B. The prevalence of patients in a vegetative state and minimally conscious state in nursing homes in Austria. Brain Inj 2011; 25: 1101-1107
    CrossrefPubMedGoogle Scholar
  • 17 Mateen FJ, Niu JW, Gao S et al. Causes and Outcomes of Persistent Vegetative State in a Chinese Versus American Referral Hospital. Neurocritical Care 2013; 18: 266-270
    CrossrefPubMedGoogle Scholar
  • 18 Kinney HC, Samuels MA. Neuropathology of the persistent vegetative state. A review. J Neuropathol Exp Neurol 1994; 53: 548-558
    CrossrefPubMedGoogle Scholar
  • 19 Adams JH, Graham DI, Jennett B. The Neuropathology of the vegetative state. After an acute brain insult. Brain 2000; 123: 1327-1338
    CrossrefPubMedGoogle Scholar
  • 20 Laureys S, Owen AM, Schiff ND. Brain function in coma, vegetative state, and related disorders. Lancet Neurology 2004; 3: 537-546
    CrossrefPubMedGoogle Scholar
  • 21 Plum F, Posner JB. The diagnosis of stupor and coma. FA Davis; Philadelphia: 1966
    Google Scholar
  • 22 Kuehlmeyer K, Racine E, Palmour N et al. Diagnostic and ethical challenges in disorders of consciousness and locked-in syndrome: a survey of German neurologists. J Neurol 2012; 259: 2076-2089
    CrossrefPubMedGoogle Scholar
  • 23 Gill-Thwaites H, Munday R. The sensory modality assessment and rehabilitation technique (SMART): a valid and reliable assessment for vegetative state and minimally conscious state patients. Brain Injury 2004; 18: 1255-1269
    CrossrefPubMedGoogle Scholar
  • 24 Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehab 2004; 85: 2020-2029
    CrossrefPubMedGoogle Scholar
  • 25 Chatelle C, Majerus S, Whyte J et al. A sensitive scale to assess nociceptive pain in patients with disorders of consciousness. J Neurol Neurosurg Psychiat 2012; 83: 1233-1237
    CrossrefPubMedGoogle Scholar
  • 26 Steppacher I, Eickhoff S, Jordanov T et al. N400 predicts recovery from disorders of consciousness. Ann Neurol 2013; 73: 594-602
    CrossrefPubMedGoogle Scholar
  • 27 Howard RS, Holmes PA, Koutroumanidis MA. Hypoxic-ischaemic brain injury. Pract Neurol 2011; 11: 4-18
    CrossrefPubMedGoogle Scholar
  • 28 Thömke F. Beurteilung der Prognose nach kardiopulmonaler Reanimation und therapeutischer Hypothermie. Dtsch Ärztebl 2013; 110: 137-143
    PubMedGoogle Scholar
  • 29 Katz DI, Polyak M, Coughlan D et al. Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1–4 year follow-up. Prog Brain Res 2009; 177: 73-88
    PubMedGoogle Scholar
  • 30 Jennett B. The vegetative state. J Neurol Neurosurg Psychiatry 2002; 73: 355-357
    CrossrefPubMedGoogle Scholar
  • 31 Childs NL, Mercer WN, Childs HW. Accuracy of diagnosis of persistent vegetative state. Neurology 1993; 43: 1465-1467
    CrossrefPubMedGoogle Scholar
  • 32 Andrews K, Murphy L, Munday R et al. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ 1996; 313: 13-16
    CrossrefPubMedGoogle Scholar
  • 33 Schnakers C, Giacino J, Kalmar K et al. Does the FOUR score correctly diagnose the vegetative and minimally conscious states?. Ann Neurol 2006; 60: 744-745
    CrossrefPubMedGoogle Scholar
  • 34 Schnakers C, Vanhaudenhuyse A, Giacino J et al. Diagnostic accuracy of the vegetative and minimally conscious state: clinical consensus versus standardized neurobehavioral assessment. BMC Neurology 2009; 9: 35
    CrossrefPubMedGoogle Scholar
  • 35 Gill-Thwaites H. Lotteries, loopholes and luck: misdiagnosis in the vegetative state patient. Brain Injury 2006; 20: 1321-1328
    CrossrefPubMedGoogle Scholar
  • 36 Laureys S, Lemaire C, Maquet P et al. Cerebral metabolism during vegetative state and after recovery to consciousness. J Neurol Neurosurg Psychiatry 1999; 67: 121
    CrossrefPubMedGoogle Scholar
  • 37 Vanhaudenhuyse A, Noirhomme Q, Tshibanda LJ et al. Default network connectivity reflects the level of consciousness in non-communicative brain-damaged patients. Brain 2010; 133: 161-171
    CrossrefPubMedGoogle Scholar
  • 38 Fernández-Espejo D, Junqué C, Vendrell P et al. Cerebral response to speech in vegetative and minimally conscious states after traumatic brain injury. Brain Inj 2008; 22: 882-890
    CrossrefPubMedGoogle Scholar
  • 39 Yu T, Lang S, Vogel D et al. Patients with unresponsive wakefulness syndrome respond to the pain cries of other people. Neurology 2013; 80: 345-352
    CrossrefPubMedGoogle Scholar
  • 40 Laureys S, Faymonville ME, Peigneux P et al. Cortical processing of noxious somatosensory stimuli in the persistent vegetative state. Neuroimage 2002; 17: 732-741
    CrossrefPubMedGoogle Scholar
  • 41 Kassubek J, Juengling FD, Els T et al. Activation of a residual cortical network during painful stimulation in long-term postanoxic vegetative state: a 15O-H2O PET study. J Neurol Sci 2003; 212: 85-91
    CrossrefPubMedGoogle Scholar
  • 42 Monti MM, Vanhaudenhuyse A, Coleman MR et al. Willful modulation of brain activity in disorders of consciousness. N Engl J Med 2010; 362: 579-589
    CrossrefPubMedGoogle Scholar
  • 43 Liu AA, Voss HU, Dyke JP et al. Arterial spin labeling and altered cerebral blood flow patterns in the minimally conscious state. Neurology 2011; 77: 1518-1523
    CrossrefPubMedGoogle Scholar
  • 44 Fernández-Espejo D, Bekinschtein T, Monti MM et al. Diffusion weighted imaging distinguishes the vegetative state from the minimally conscious state. Neuroimage 2011; 54: 103-112
    CrossrefPubMedGoogle Scholar
  • 45 Kotchoubey B, Merz S, Lang S et al. Global functional connectivity reveals highly significant differences between the vegetative and the minimally conscious state. J Neurol 2013; 260: 975-983
    CrossrefPubMedGoogle Scholar
  • 46 Cruse D, Chennu S, Chatelle C et al. Bedside detection of awareness in the vegetative state: a cohort study. Lancet 2011; 378: 2088-2094
    CrossrefPubMedGoogle Scholar
  • 47 Cruse D, Chennu S, Chatelle C et al. Relationship between etiology and covert cognition in the minimally conscious state. Neurology 2012; 78: 816-822
    CrossrefPubMedGoogle Scholar
  • 48 Faugeras F, Rohaut B, Weiss N et al. Probing consciousness with event-related potentials in the vegetative state. Neurology 2011; 77: 264-268
    CrossrefPubMedGoogle Scholar
  • 49 Goldfine AM, Bardin JC, Noirhomme Q et al. Reanalysis of “Bedside detection of awareness in the vegetative state: a cohort study”. Lancet 2013; 381: 289-291
    CrossrefPubMedGoogle Scholar
  • 50 Cruse D, Chennu S, Chatelle C et al. Author’ reply. Lancet 2013; 381: 291-292
    CrossrefPubMedGoogle Scholar
  • 51 Bennett CM, Baird AA, Miller MB et al. Neural correlates of interspecies perspective taking in the post-mortem Atlantic Salmon: An argument for multiple comparisons correction. Poster. Human Brain Mapping Conference; San Francisco: http://prefrontal.org/files/posters/Bennett-Salmon-2009.pdf
    Google Scholar
  • 52 Laureys S, Celesia G, Cohadon F et al. for the European Task Force on Disorders of Consciousness . Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome. BMC Medicine 2010; 8: 68
    CrossrefPubMedGoogle Scholar
  • 53 Giacino JT, Whyte J, Bagiella E et al. Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med 2012; 366: 819-826
    CrossrefPubMedGoogle Scholar
  • 54 Du B, Shan A, Zhang Y et al. Zolpidem Arouses Patients in Vegetative State After Brain Injury: Quantitative Evaluation and Indications. Am J Med Sci 2013; (Epub)
    PubMedGoogle Scholar
  • 55 Mitchell S, Bradley VA, Welch JL et al. Coma arousal procedure: a therapeutic intervention in the treatment of head injury. Brain Inj 1990; 4: 273-279
    CrossrefPubMedGoogle Scholar
  • 56 Schiff ND, Giacino JT, Kalmar K et al. Behavioural improvements with thalamic stimulation after severe traumatic brain injury. Nature 2007; 448: 600-603
    CrossrefPubMedGoogle Scholar
  • 57 Bundesärztekammer . Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Dtsch Ärztebl 2011; 108: 346-348
    PubMedGoogle Scholar
  • 58 Ganzini L, Goy ER, Miller LL et al. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med 2003; 349: 359-365
    CrossrefPubMedGoogle Scholar