Care protocol for persistent vegetative states (PVS) and minimally conscious state (MSC) in Lorraine: retrospective study over an 18-year period

OBJECTIVES

Retrospective analysis of the efficiency of a protocol for care of chronic vegetative states (CVS) and minimally conscious state (MCS) in Lorraine.

MATERIAL AND METHOD

Two indicators are used: protocol activity (number of patients hospitalized between 1988 and 2006, number of admissions per year, of requests per year, origin of requests, waiting time) and the epidemiological data (age, sex ratio, etiology, length of stay, geographic origin, number of deaths, number of hospital discharges). The number of CVS and MCS and patients having progressed towards arousal is specified as well as the technical procedures (orthopedic surgery, number of tracheotomies).

RESULTS

Forty-seven patients (30 males and 17 females) were hospitalized in a 12-bed unit. The number of admissions per year was 2.4, and the annual number of requests varied between five and 15. Hospitalization times ranged from six to 18 months. The average length of hospitalization was 41 months. Eighty-eight percent of the cases were residents of Lorraine. The etiology was traumatic (53%), vascular (38% including 12% anoxia), miscellaneous (9%). Fifteen percent rate of return to arousal (average time period: 28.41 months, traumatic etiology) with hospital discharge in four cases.

CONCLUSION

The protocol is managed as part of a local scheme and enables an appropriate response to a specific clinical profile by providing up-to-date multidiscipline follow-up care and a rapid solution should intercurrent events occur (signs of arousal, orthopedic deterioration, change of environment). Typical limitations are geographical remoteness and difficulties with family support care.

Eye movements and visuoverbal descriptions exhibit heterogeneous and dissociated patterns before and after prismatic adaptation in unilateral spatial neglect

This prospective study examined the effects of prismatic adaptation on visual exploration strategies in patients with left unilateral spatial neglect (USN). Photo-oculographic gaze recordings were obtained, as the subjects (28 brain-damaged; 15 control) performed a free visual exploration task before and after a session of prismatic adaptation. (i) Before prismatic adaptation, the pattern of visual exploration described two subgroups of patients (symmetrical exploration of hemispaces - similar to the control subjects, deficient exploration of left hemispace). Twelve of 20 patients failed to describe significant elements in the left part of the displayed image. Several visuoverbal patterns were observed, some dissociating visual exploration and verbal description. (ii) Immediately after prismatic adaptation, patients with asymmetrical visual exploration presented a significant increase in the number of point fixations and saccades in the left hemispace. Patients with symmetrical exploration presented the opposite pattern. Improved pattern of visual exploration contrasted with an absence of improved verbal description. Eye movements and visuoverbal descriptions exhibit heterogeneous and dissociated patterns before and after prismatic adaptation. This results demonstrate that prismatic adaptation has no effect in certain patients, suggesting that therapeutic indications and evaluation of prismatic test results should take into consideration the heterogeneous nature of USN.

Right spatial neglect after left hemisphere stroke: qualitative and quantitative study

OBJECTIVES

Comparatively little research has been conducted on right neglect after left brain damage. The authors sought to assess contralateral neglect in subacute left hemisphere stroke patients using a comprehensive test battery validated in a large control group after right hemisphere stroke.

METHODS

Seventy-eight left hemisphere stroke patients were assessed. The test battery included a preliminary assessment of anosognosia and visual extinction, a clinical assessment of gaze orientation and personal neglect, and paper-and-pencil tests of spatial neglect in the peripersonal space. Only nonverbal tests were used.

RESULTS

Drawing and cancellation tasks revealed neglect in 10 to 13% of patients. The combined battery was more sensitive than any single test alone. A total of 43.5% of patients showed some degree of neglect on at least one measure. Anatomic analyses showed that neglect was more common and severe when the posterior association cortex was damaged.

CONCLUSIONS

The frequency of occurrence of right neglect was, as expected, much lower than that reported in a study using the same assessment battery in right brain damage stroke patients. Nevertheless, neglect was found in a substantial proportion of patients at a subacute stage, suggesting that it should be considered in the rehabilitation planning of left brain damage stroke patients.

Mirror asomatognosia in right lesions stroke victims

The objectives of this prospective study were: to search for mirror-induced disorders of the body image in right hemisphere stroke victims using a description task of the contralateral upper limb, to analyze their clinical features, and to discuss possible mechanisms. Sixteen consecutive patients with documented unilateral right hemisphere stroke were examined for asomatognosia at the acute phase of stroke, then at least 2 months after stroke under three test conditions: without a mirror, with a conventional mirror, with an inverted mirror. Video recordings of the tests were analyzed to assess performance. The diagnosis of asomatognosia was retained if the subject reported at least one of three sensations: limb transformation, limb strangeness, and/or limb alienation. During the acute phase, 14/16 patients presented manifestations of asomatognosia. All of these spontaneous manifestations had disappeared 2 months later, but were reactivated in 12 patients when exposed to mirror images. The mirror tests revealed four situations: no disorder (n = 4), asomatognosia with both mirrors (n = 5), asomatognosia with the conventional or inverted mirrors (n = 1 and 5), and asomatognosia with the inverted mirror (n = 1). These manifestations were designated as mirror-asomatognosia, a disorder resulting from adaptations of the procedures leading to reorganization of the internal representations of the body image. These findings suggest there are several such internal representations of the body image and that direct body image and mirror body image would be two specific ones. These clinical manifestations and their evolution over time are an expression of the progressive nature of the underlying compensatory mechanisms made possible by brain plasticity.

[Disorders of the processing of spatial information in patients with right cerebral lesions and left hemi-neglect]

The aim of this research was to identify, analyze and classify disorders in behavior which occur in the use of mirrors in patients with right cerebral damage presenting left visual spatial hemiplegia. This work was based on models of visual information processing. Seven controls and eleven patients with right cerebral damage performed a test involving grasping of an object using only specular information from a conventional mirror and then from an inverted mirror. The controls grasped up all the cubes straight away. They only experienced minor difficulty with the inverted mirror, mainly in relation to lateral displacement. The patients revealed a variety of behaviors: 1) searching for and trying to seize the object in the conventional and/or inverted mirror, 2) inversion of the paralysed side (left versus right) in the inverted mirror or the appearance of a visual spatial hemiplegia, 3) modifications in the order of grasped (from right to left, from left to right, or at random), 4) directional anomalies in the horizontal plane linked (or not) with disorders in the use of the anteroposterior space. The results of this study confirm that the patients have abnormal behavior in mirror spaces. While the characteristics of this behavior shows analogies with those described in the non-recognition of objects and/or defects in the processing of visual information for localising objects in space, they can be disassociated from them, and constitute separate syndromes. Specific terminology and taxonomy for the clinical forms of mirror agnosia and specular agnosia, of mirror paralysis and specular paralysis, and of specular ataxia are proposed.

Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke

OBJECTIVES

The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of spatial neglect after stroke. The aim of this study was to assess the sensitivity of different tests of neglect after right hemisphere stroke.

METHODS

Two hundred and six subacute right hemisphere stroke patients were given a test battery including a preliminary assessment of anosognosia and of visual extinction, a clinical assessment of gaze orientation and of personal neglect, and paper and pencil tests of spatial neglect in the peripersonal space. Patients were compared with a previously reported control group. A subgroup of patients (n=69) received a behavioural assessment of neglect in daily life situations.

RESULTS

The most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. About 85% of patients presented some degree of neglect on at least one measure. An important finding was that behavioural assessment of neglect in daily life was more sensitive than any other single measure of neglect. Behavioural neglect was considered as moderate to severe in 36% of cases. A factorial analysis revealed that paper and pencil tests were related to two underlying factors. Dissociations were found between extrapersonal neglect, personal neglect, anosognosia, and extinction. Anatomical analyses showed that neglect was more common and severe when the posterior association cortex was damaged.

CONCLUSIONS

The automatic rightward orientation bias is the most sensitive clinical measure of neglect. Behavioural assessment is more sensitive than any single paper and pencil test. The results also support the assumption that neglect is a heterogeneous disorder.

Mirror images and unilateral spatial neglect

Responding correctly to a mirror image requires the creation of a rather peculiar form of dual representation. Mirror agnosia and mirror ataxia, i.e. a deficit in reaching an object reflected in a mirror, have been reported to be associated with parietal lobe lesions. This prospective study was conducted to investigate the capacity of subjects with neglect to identify the mirror image nature of visual information. Four consecutive brain-damaged patients with neglect, selected on the basis of specific criteria, and four control subjects performed grasping and object displacement tests under two response conditions (normal mirror and inverted mirror). Video recordings of the tests were analyzed to assess performance using the following criteria: (i) direction of the arm movement during the initial phase of movement, (ii) number of corrections of the hand position before grasping. The control subjects successfully grasped the objects in both experimental conditions. The patients (1) neglected the contralesional space, grasping objects correctly in the ipsilesional space (normal mirror condition) and (2) neglected the ipsilesional space, grasping correctly objects in the contralesional space (inverted mirror). Controls used real object-centered correction clues to modify the position and direction of their hand movement. The patients only produced horizontal displacements of the upper limb in the "healthy" and neglected space. These results suggest that patients with neglect do not use the same clues and do not modify their procedures as they cannot recalibrate their spatial representations. These differences concerned non-mirror-image clues and directional and positional as well as attentional vectors. Theoretical and rehabilitative implications are discussed.

[Early surgery management of pelvic region pressure ulcers versus directed cicatrization in a population of spinal cord injured patients]

OBJECTIVE

To estimate the benefit brought by an early surgery management of pelvis region pressure ulcers compared to medical processing in a population of subjects spinal cord disabled.

MATERIAL AND METHOD

The studied population consist of 53 patients (62 pressure ulcers) divided into two groups: the group 1 includes 30 patients (34 pressure ulcers) presenting pressure ulcers stage III or IV (NPUAP scale) with early surgery management, included consecutively during a period of 2 years; the group 2 includes 23 patients (28 escarres) included in a retrospective way, with medical processing by the same team of care. The criteria of judgment are the delay of healing and the delay of delivery of the station sat in the armchair.

RESULTS

In the group 1, the average delay of healing is of 42 days and the average delay of delivery for the armchair of 39 days. In the group 2 healing can be obtained only in 13 cases and in an average delay of 180 days. Differences are significant (p < 0.05).

DISCUSSION - CONCLUSION

The originality of this study results in the comparison of two processing within two groups of patients having close demographic characteristics. It clearly shows the interest of the early surgery of the pelvic pressure ulcers comparing to medical processing and illustrates the requirement for a close cooperation between teams specialized in plastic surgery and teams specialized physical medicine.

[Presenting a battery for assessing spatial neglect. Norms and effects of age, educational level, sex, hand and laterality]

The aim of this study was to build up a battery for assessing spatial neglect, then to analyse the norms and potential effects of age, education level, sex, hand used, and laterality. It was also to contribute evaluating the pseudoneglect phenomenon described by Heilman, which consists in a tendency of normal subjects to neglect the right peripersonal space. Tasks selected were presented to important groups of normal subjects, most often larger than 450. The battery comprised of a bell cancellation test, scene copy, clock drawing, two line bisection tasks, identification of overlapping figures, text reading, writing task, and the representational task of the France map. For each of them, different variables were selected, especially investigating the difference between performance in the right and the left hemispaces. This study allowed defining the threshold values (percentiles 5 and 95) for deciding of the pathological character of a patient performance. It also showed that the pseudoneglect phenomenon is more obvious in some tasks such as line bisection, and probably also in the representational task of the France map and writing. His importance and at times his side were influenced by the factors we studied, with between tasks differences, but also by the nature of the task to be performed, and especially his verbal component.

[Illusions of body normality in amputees and paraplegic patients]

Phantom limbs in amputees, or body illusion in hemiplegics, have been the subject of wide ranging descriptions. The detected abnormalities involve morphological, postural and/or kinetic features. The aim of this prospective study carried out in 25 amputees and 10 adult paraplegics was to describe the typology of these perceptions. Data were collected from free and semi-directive investigations before and after caloric vestibular stimulation. Amputees and paraplegics perceived normal, deformed and painful body phantom segments, reffered perceptions and "normal limbs" which took on the request posture considering the general body position (illusion of body normality). This perception corresponds to an image of the body, such as it should be and not such as it is. In amputees, the limb follows the movements of the prothesis. These perceptions conform quite well reality so that the loss of the paralyzed limb is not perceived as a missing limb. This illusion of body normality should be distinguished from the normal phantom limb, characterized by a stronger perception of the lost limb compared with the other. In both amputees and paraplegics, vestibular stimulation can generate or modify phantoms limbs or body illusion and can abolish painful phantom limbs. The neuromatrix, which rebuilds body representations, could get its information from reorganized cortical areas (instantaneous body image), autobiographical engrams (painful phantoms limbs), or innate engrams (identity body schema) that, via congruence mechanisms, could be identified as a somatic reference, particularly for motor programming. This interpretation is compatible with current knowledge and suggests how amputees can easily use a prothesis.

Temporary phantom limbs evoked by vestibular caloric stimulation in amputees

OBJECTIVE

Relationships between the vestibular system and the body schema have been suggested but never demonstrated in amputees. We studied the effects of vestibular stimulation on body representation in amputees focusing on the phantom limb phenomenon.

METHOD

Prospective study in 31 amputated subjects of one or several limbs before the age of 16 years. The amputees underwent a caloric vestibular stimulation test, ipsilateral (n = 31) and contralateral (n = 8) to the side of amputation. Amputees were asked to report their perceptions spontaneously and to answer open questions. Four types of perceptions were analyzed: normal phantom, deformed phantom, painful phantom, and no phantom, before, during, and after the vestibular stimulation test. Data were compared between the two groups for pre- and post-test perceptions (chi2 test).

RESULTS

Vestibular caloric stimulation provoked temporary perception of a normal phantom limb in 16 of 17 amputees who previously did not experience phantoms. For 12 of 12 amputees who currently experienced deformed or painful phantom limbs, caloric stimulation led to temporary replacement of the abnormal phantom with a non-painful normal phantom.

CONCLUSIONS

The phenomena observed: 1) throw light on assumed mechanisms controlling construction of static and dynamic engrams used to produce the body schema; 2) complete the neuromatrix theory proposed to explain the phantom limb phenomenon; and 3) suggest that the vestibular system triggers the procedure of reconstruction of the global body schema.

[Georges Gilles of Tourette, pioneer of gait analysis in the nervous system diseases]

Georges Gilles de la Tourette's contribution to neurology goes beyond the description of the neurological disorder named after him. On December 28, 1885, he defended his doctoral thesis devoted to "gait in the diseases of the nervous system, studied by the method of imprints". In collaboration with Albert Londe, he worked for two years in Charcot's department on "a simple method applicable to both healthy and unhealthy patients", establishing the scientific and modern basis of functional exploration of human gait. The purpose was to "record the modifications of the gait and to fix them permanently, using suitable devises to guarantee not only rigorous comparison, but also to prevent observers, making use of the same method, from disputing or canceling the results completely independent of the experimenter himself". Georges Gilles de la Tourette defined the various characteristic parameters and provided the normal reference values in males and females, determining the physiological asymmetry of steps. He described spastic gait, shaking palsy, and locomotor ataxia. He distinguished between disorders of nervous control and related joint diseases. He also classified gait disorders occurring during hemiplegia. Modern development of kinetic, kinematic and biomechanical studies is a good illustration of the current relevancy of Gilles de la Tourette's contribution.

Vestibular caloric stimulation evokes phantom limb illusions in patients with paraplegia

STUDY DESIGN

Prospective study.

OBJECTIVES

To determine the mechanisms of body illusions in paraplegia patients as compared with the amputee phantom phenomena.

METHODS

A vestibular caloric stimulation was performed in 10 consecutive patients with complete section of the spinal cord. Perception of body, before and after stimulation, was classed as illusion of a normal body (lower limbs with normal morphological, postural and kinetic characteristics perceived as before spinal injury), normal phantom (overly vivid perception of all or part of the lower limbs), deformed phantom (perception of all or part of the limbs below the injury level as abnormal in shape, posture, movement or even number), or painful phantom.

RESULTS

After vestibular caloric stimulation, nine out of 10 patients stated their perception of body segments below the injury level had changed to normal phantoms or to deformed phantoms (morphological, postural or kinetic changes). Among the four patients who initially had painful limbs, two stated the stimulation greatly relieved their pain.

CONCLUSION

The normal or deformed phantom evoked by vestibular stimulation would result from use of identity data or instantaneous data as is observed in amputees. Cerebral remapping following deafferentation could be the origin of the deformed phantoms. Illusions corresponding to phenomena perceived at the time of the accident corresponding to autobiographical engrammes do not appear to be evoked by vestibular stimulation, as is also the case in amputees.

[Classification and mechanisms of body perceptions in the amputees]

OBJECTIVE

Amputees can experience several types of physical illusions and phantom limb phenomenon. The objective was to establish a synthetic classification of theses perceptions.

METHOD

Prospective study in 75 amputees (group 1: amputation (n = 60), group 2: congenital defect). The subjects were asked first to report their perceptions spontaneously and then to detail the perception, if exist, of the missing limb: form recognition, posture, movement, reminiscence of a lost limb.

RESULTS

Different types of perception were described besides the perception of the real state : normal, deformed or commemorative phantom limb and illusion of a normal body.

DISCUSSION

Whatever the model (i.e.: neuro-matrix) which support the construction of the scheme and the body image, the representations related to identified perceptions, use various innate, autobiographic and identity frames of references as well as instantaneous peripheral information, treated by reorganized cerebral structures. Each type of perception is related to a particular representation pattern.

CONCLUSION

This approach, in accordance with the literature, offers a better understanding of the differences between amelic and amputated subjects and of their perception of any prosthetic equipment.

Buccal hemineglect

OBJECTIVES

To determine whether the peripersonal and intrapersonal buccal space can be affected by a hemispheric stroke and to evaluate the clinical signs resulting from buccal neglect.

METHODS

A prospective study comparing 2 groups of patients with hemiplegia, 1 with a right hemispheric lesion and the other with a left hemispheric lesion. Patients were selected consecutively on the basis of specific criteria at least 1 month after stroke.

RESULTS

Buccal hemineglect was usually concomitant with other hemineglect phenomena resulting from lesions of the right hemisphere (10 of 12 in right lesions and 1 of 12 in left lesions). Clinical signs associated with this condition consisted of impaired swallowing (retention, defective insalivation, presence of food debris in the left hemibuccal space, loss of saliva from the left side of the mouth, and choking); loss of the ability to perceive salty, sweet, or acid tastes; and impaired buccal representation. These problems were usually incorrectly diagnosed initially. Outcome was usually favorable, but functional disorders persisted in some patients for more than 18 months. The underlying attention and representation mechanisms are discussed with reference to experimental lesions of the postarcuate (area 6) cortex in rhesus monkeys. The area around the mouth may be considered to be, as in monkeys, a peripersonal space, ie, probably of little functional importance. The lesion may involve area 6 or its projections to the thalamus or posterior parietal cortex.

CONCLUSIONS

Buccal hemineglect, which is likely to cause social embarrassment, should be considered whenever the oral phase of swallowing is impaired in a context of neglect syndromes. Prophylactic measures and rehabilitation can reduce the impact and complications of the condition (food bolus).

Eye patching in unilateral spatial neglect: efficacy of two methods

OBJECTIVES

To determine whether patches obscuring half the visual field affect eye movement in subjects with unilateral spatial neglect and whether there is consequent improvement in the subject's everyday life, and to interpret the potential changes observed with the aid of a theoretical model.

DESIGN

Prospective and randomized study.

SETTING

Rehabilitation medicine department in an urban general hospital.

PATIENTS

Twenty-two subjects with left unilateral neglect.

INTERVENTION

Two eye-patching procedures-right half-field patches (n = 7) and right mononuclar patch (n = 7)-and control group (n = 8).

MAIN OUTCOME MEASURES

Functional tests (FIM) and analytical tests (measurement of right eye movements by photo-oculography) at admission and after 3 months.

RESULTS

Results of the paired comparison tests showed (1) significant differences between the control group and the group with the half-eye patches for total FIM score (p = .01) and the displacements of the right eye in the left field (p = .02), and (2) no significant differences between the control group and the group with the right monocular patch.

CONCLUSION

Patching the right half-field helped subjects initially regain voluntary control over the deficit. The actual interpretation is based on physiologic and psychophysiologic models.

Event-related potentials in the segmental exclusion syndrome of the upper limb

Upper limb segmental exclusion syndromes are frequent after traumatic or infectious affections. They can be defined as an insufficient utilization of a limb segment--fingers or hand--reversible on verbal exhortation and arising in subjects with no other neurologic or psychiatric disorder. Our hypothesis was that the segmental exclusion syndrome could be likened to a neglect behavior. To verify the validity of this hypothesis, we measured digital nerve short-latency SEP and SEP-P300 waves in response to odd-ball task target stimuli in healthy volunteers (n = 11) and patients with digit exclusion syndromes (n = 19). For N20 latency, there was no significant difference (Wilcoxon's test: p = 0.52) between normal and excluded digits. Stimulation of the excluded vs normal digit resulted in a significant lengthening in SEP-P300 latency (p = 0.0003). The implication of these results and means of extending our knowledge of the pathophysiology of exclusion syndromes are discussed.

Detection of visual field deficits and visual neglect with computerized light emitting diodes

A computer test for visual field deficits and visual neglect was developed and evaluated by testing 63 patients with brain damage. This computer test controls the sequence of unilateral or bilateral lights series, and stores the responses. Test results are compared to clinical and ophthalmological tests and neuropsychological assessment. Visual field deficits were present in 17 patients on the computerized test, in 16 patients on ophthalmological test, and in 13 patients on clinical examination. Neglect was present in 12 patients on the computerized test, and in 10 patients on the neuropsychological assessment. Eighteen patients had mixed disorder (hemianopia and neglect). Results of the chi 2 statistic confirm the greatest correlation between the computerized test and the ophthalmological (phi = 0.93; p < 0.001) and neuropsychological (phi = 0.90; p < 0.001) tests. Correlation between the computerized test and the clinical examination was poorer (phi = 0.85; p < 0.001). The computerized test makes it possible to detect mixed disorder with the same tool, during the same examination.