Locked-in: don't judge a book by its cover

From armchair to wheelchair: how patients with a locked-in syndrome integrate bodily changes in experienced identity

Different sort of people are interested in personal identity. Philosophers frequently ask what it takes to remain oneself. Caregivers imagine their patients' experience. But both philosophers and caregivers think from the armchair: they can only make assumptions about what it would be like to wake up with massive bodily changes. Patients with a locked-in syndrome (LIS) suffer a full body paralysis without cognitive impairment. They can tell us what it is like. Forty-four chronic LIS patients and 20 age-matched healthy medical professionals answered a 15-items questionnaire targeting: (A) global evaluation of identity, (B) body representation and (C) experienced meaning in life. In patients, self-reported identity was correlated with B and C. Patients differed with controls in C. These results suggest that the paralyzed body remains a strong component of patients' experienced identity, that patients can adjust to objectives changes perceived as meaningful and that caregivers fail in predicting patients' experience.

End-of-life decision-making in individuals with locked-in syndrome in the acute period after brainstem stroke

Locked-in syndrome (LIS) is commonly associated with a poor prognosis, particularly if the aetiology is stroke. Dealing with individuals with LIS and a poor prognosis raises the issue of introducing end-of-life discussions with the patient and/or family in the acute period of the illness. Existing literature regarding LIS provides little guidance about end-of-life decision-making in the acute management phase. We aim to provide some guidance for clinicians holding end-of-life discussions in the acute management period. We report two cases of relatively young individuals with LIS secondary to brainstem stroke. Both cases had a very poor prognosis and end-of-life discussions were commenced by the treating team in the acute phase. Despite the severity of their conditions, in neither case were end-of-life discussions well tolerated by the family in the weeks following admission. We suggest that LIS patients and their families, who have chosen to persist with full medical management after diagnosis of LIS, should be provided with sufficient time to adjust to the catastrophic changes that have occurred before further end-of-life discussions are pursued. Education and support are likely to be highly beneficial in the acute period post stroke as they allow the patient and family to develop a realistic understanding of the likely outcomes of their decisions.

Survival and quality of life after tracheostomy for acute respiratory failure in patients with amyotrophic lateral sclerosis

BACKGROUND

Acute respiratory failure (ARF) is a common event in the advanced stage of amyotrophic lateral sclerosis (ALS) and may be rarely a presenting symptom. Frequently, such patients require intubation and mechanical ventilation (MV) and, in a large proportion, receive tracheostomy, as a consequence of weaning failure. In our study, we investigated postdischarge survival and quality of life (QoL) after tracheostomy for ARF in patients with ALS.

METHODS

DESIGN

This study is a retrospective chart review combined with prospective evaluation of QoL and degree of depression.

SETTING

The study was conducted in an adult, respiratory intensive care unit in a university hospital.

PATIENTS

Amyotrophic lateral sclerosis patients with tracheostomy for ARF between January 1, 1995 and April 30, 2008 were investigated.

INTERVENTION AND MEASUREMENTS

(a) A retrospective chart review was used and (b) prospective administration of the 11-item short-form Life Satisfaction Index (LSI-11) and Beck Depression Inventory (BDI) questionnaires to survivors, at least 1 month after discharge from hospital, was performed.

RESULTS

Sixty patients were studied retrospectively. None of the patients died in the hospital after tracheostomy. Forty-two patients (70%) were discharged completely MV dependent, and 17 patients (28.3%) were partially MV dependent. One patient (1.6%) was liberated from MV. The median survival after tracheostomy was 21 months (range, 0-155 months). The survival rate was 65% by 1 year and 45% by 2 years after tracheostomy. Survival was significantly shorter in patients older than 60 years at tracheostomy, with a hazard ratio of dying of 2.1 (95% confidence interval, 1.1-3.9). All 13 survivors completed the LSI-11 and BDI. The mean (SD) cumulative score on the LSI-11 was 9.3 (3.6; range, 0-22; higher values indicating better QoL), similar to that obtained from a control group consisting of individuals with ALS who had not received tracheostomy (9.3 ± 4.3) and to that reported for persons in the general population. Only 15% of the tracheostomized patients (2/13) were severely depressed, according to BDI; 11 of 13 patients reported a positive view of tracheostomy and said that they would want to undergo this procedure if they could make the decision again.

CONCLUSIONS

Patients with ALS have a high chance of long-term survival after tracheostomy for ARF. Although administered at the time of a respiratory crisis without being discussed in advance, tracheostomy shows good acceptance and results in acceptable QoL.

Locked-in syndrome in children: report of five cases and review of the literature

The locked-in syndrome is a rare neurologic disorder defined by (1) the presence of sustained eye opening; (2) preserved awareness; (3) aphonia or hypophonia; (4) quadriplegia or quadriparesis; and (5) a primary mode of communication that uses vertical or lateral eye movement or blinking. Five cases are reported here, and previous literature is reviewed. According to the literature, the most common etiology of locked-in syndrome in children is ventral pontine stroke, most frequently caused by a vertebrobasilar artery thrombosis or occlusion. In terms of prognosis, 35% of pediatric locked-in syndrome patients experienced some motor recovery, 26% had good recovery, 23% died, and 16% remained quadriplegic and anarthric. These findings raise important ethical considerations in terms of quality of life and end-of-life decisions in such challenging cases.

Is there anybody in there? Detecting awareness in disorders of consciousness

The bedside detection of awareness in disorders of consciousness (DOC) caused by acquired brain injury is not an easy task. For this reason, differential diagnosis using neuroimaging and electrophysiological tools in search for objective markers of consciousness is being employed. However, such tools cannot be considered as diagnostic per se, but as assistants to the clinical evaluation, which, at present, remains the gold standard. Regarding therapeutic management in DOC, no evidence-based recommendations can be made in favor of a specific treatment. The present review summarizes clinical and paraclinical studies that have been conducted with neuroimaging and electrophysiological techniques in search of residual awareness in DOC. We discuss the medical, scientific and ethical implications that derive from these studies and we argue that, in the future, the role of neuroimaging and electrophysiology will be important not only for the diagnosis and prognosis of DOC but also in establishing communication with these challenging patients.

Another kind of 'BOLD Response': answering multiple-choice questions via online decoded single-trial brain signals

The term 'locked-in'syndrome (LIS) describes a medical condition in which persons concerned are severely paralyzed and at the same time fully conscious and awake. The resulting anarthria makes it impossible for these patients to naturally communicate, which results in diagnostic as well as serious practical and ethical problems. Therefore, developing alternative, muscle-independent communication means is of prime importance. Such communication means can be realized via brain-computer interfaces (BCIs) circumventing the muscular system by using brain signals associated with preserved cognitive, sensory, and emotional brain functions. Primarily, BCIs based on electrophysiological measures have been developed and applied with remarkable success. Recently, also blood flow-based neuroimaging methods, such as functional magnetic resonance imaging (fMRI) and functional near-infrared spectroscopy (fNIRS), have been explored in this context. After reviewing recent literature on the development of especially hemodynamically based BCIs, we introduce a highly reliable and easy-to-apply communication procedure that enables untrained participants to motor-independently and relatively effortlessly answer multiple-choice questions based on intentionally generated single-trial fMRI signals that can be decoded online. Our technique takes advantage of the participants' capability to voluntarily influence certain spatio-temporal aspects of the blood oxygenation level-dependent (BOLD) signal: source location (by using different mental tasks), signal onset and offset. We show that healthy participants are capable of hemodynamically encoding at least four distinct information units on a single-trial level without extensive pretraining and with little effort. Moreover, real-time data analysis based on simple multi-filter correlations allows for automated answer decoding with a high accuracy (94.9%) demonstrating the robustness of the presented method. Following our 'proof of concept', the next step will involve clinical trials with LIS patients, undertaken in close collaboration with their relatives and caretakers in order to elaborate individually tailored communication protocols. As our procedure can be easily transferred to MRI-equipped clinical sites, it may constitute a simple and effective possibility for online detection of residual consciousness and for LIS patients to communicate basic thoughts and needs in case no other alternative communication means are available (yet)--especially in the acute phase of the LIS. Future research may focus on further increasing the efficiency and accuracy of fMRI-based BCIs by implementing sophisticated data analysis methods (e.g., multivariate and independent component analysis) and neurofeedback training techniques. Finally, the presented BCI approach could be transferred to portable fNIRS systems as only this would enable hemodynamically based communication in daily life situations.