After a coma, knowing whether a patient has been plunged into a vegetative or minimally conscious state is essential: prognosis and treatment depend on it. Nevertheless a study carried out in Belgium on 103 patients has confirmed that doctors get their diagnosis wrong in numerous cases.

In fairy tales a Prince’s kiss is enough to wake up a Beauty condemned to long years of deep sleep. Reality is clearly less romantic for those who, following a physiological problem or a traumatism, find themselves in an altered state of consciousness. ‘Can he hear us? Does he understand us? Is he trying to communicate? Is he still thinking? Is he suffering? Will he one day rejoin reality and, if that is the case, in how long a time?’ ask those close to the patient. Replying to their questions – in as far as knowledge permits – depends on an evaluation of the sufferer’s state of consciousness. But at the moment too many poor diagnoses are given: they exceed 40% in certain categories of sufferer, which is not without determining repercussions on their prognoses and treatment. This realisation has just been revealed in a study published on the 21st of July in BMC Neurology (1). It has been signed by, amongst others, the neuropsychologist and FNRS candidate Caroline Schnakers (of the Coma Science Group) and by Professor Steven Laureys (Coma Science Group, Cyclotron Research Centre and the Liège University Hospital Centre Department of Neurology, and FNRS Maître de Recherches).

How can this situation be changed and the rate of errors diminished? ‘It would suffice to add, systematically, to the results of medical imaging and to clinical examinations, which remain essential, an established and standardised behavioural assessment scale, such as for example the Coma Recovery Scale-Revised (CRS-R). Developed by Joseph Giacino, of the New Jersey Neurosciences Institute (USA), it has been used in this study in order to be able to establish adequate diagnoses,’ comments Professor Laureys.

The coma, a point of departure

These painful stories of patients deprived of their consciousness to various degrees generally start with a coma. Contrary to what is often believed, this state rarely persists beyond four weeks. The comatose patient experiences no arousal, he keeps his eyes shut, and he shows no interaction with his environment, even if he can sometimes respond to painful stimuli. The coma can conclude with a total recovery, or by brain death, and thus the raising of discussions concerning organ donation (Read Organ transplants like no other and the article Organ donation after physician-assisted death). In addition, beyond certain intermediary situations such as locked-in syndrome (communication is possible for the sufferer, but only through eye movements) (Read: Walled up consciousness), certain patients do not regain consciousness on coming out of a coma: they move towards a neuro-vegetative state.

(1) Diagnostic accuracy of the vegetative and minimally conscious state: Clinical consensus versus standardized behavioral assessment. Schnakers C, Vanhaudenhuyse A, Giacino J, Ventura; Boly M, Majerus S, Moonen G, Laureys S, BMC Neurology, 9 (2009) 35