In following the scale of consciousness…
‘In teams it is not always so easy to change habits and to introduce tools which are added to the examinations already made and which we are used to,’ admits Professor Laureys. ‘Nevertheless, those who take these patients into their care know to what extent this task can be difficult and frustrating. The improvements in our knowledge concerning them can only be considered a plus. Moreover, establishing a good diagnosis is essential for the prognosis, a possible decision to halt therapeutics or to put treatments in place…’ At present, for the lack of always determining accurately the patients’ states, we risk stopping the re-education for people we have wrongly labelled as being in a vegetative state. Or we don’t prescribe pain killers when it is necessary. Or we don’t offer them all the therapies that are being developed.
New treatment pathways
‘By chance, a South African team has discovered that a medicine aimed at sleep allows certain patients in a minimally conscious state to recover consciousness and to communicate...during the period the molecule is active,’ states Professor Laureys. This activity, ‘miraculous’ when it occurs, is currently the object of a study being led at Liège in collaboration with a Chinese team led by Dr Haibo Di. Furthermore, another medicine, but this time an antiviral, also activates the brain of certain sufferers: the latter do not communicate whilst they are taking it, apart from possibly pronouncing a few words, but their condition improves. They manage to eat through the mouth, for example. Admittedly this effect is less spectacular than that produced by the first substance used, but it works in a larger number of cases. Here again a study is underway but the Liège team has already demonstrated its effects, using PET scan, on the brain of patients in a state of altered consciousness (2).
Furthermore, in 2000 The Lancet published the work of Professor Laureys concerning the regaining of the connectivity between the cortex and the thalamus in these patients. ‘When a patient recovers in passing from a vegetative state to a minimally conscious one, what changes in the brain is the connection between the thalamus and a section of the grey matter,’ pinpoints Professor Laureys. ‘After these observations, Nicolas Schiff’s New York team, with which we collaborate, developed the idea of placing a stimulator in this area of the thalamus, which is what we do for other pathologies, such as Parkinson’s disease for example.’ This invasive technique, for which the patient’s agreement cannot be obtained, because of the very nature of things, is only considered with the informed consent of his family. It is anticipated that patients in altered states of consciousness will have such brain stimulators implanted at the Liège University Hospital Centre.
An attack on unconsciousness
The routine use of CRS-R is finally inscribed in the global advances concerning progress carried out as much at the patient’s bedside as in our overall understanding of how the brain works. In recent years genuine leaps forward have been accomplished, in a large part due to medical imaging. A battery of more and more sophisticated tests benefits each patient. At Liège the close collaboration between Professor Laurey’s team and the University Hospital Centre’s doctors contributes to these tests being optimized. And the hospital regularly receives patients from abroad for a complete evaluation and to participate in research protocols.
(2) Measuring the effect of amantadine in chronic anoxic minimally conscious state Schnakers C, Hustinx R, Vandewalle G, Majerus S, Moonen G, Vanhaudenhuyse A, Laureys S Journal of Neurology Neurosurgery and Psychiatry 79 (2008) 225-227