Full or partial recovery after 3 mos in Vegetative state

[Mac3]

A friend recently suffered a cardiac arrest suspected to be caused by septicemia after a ruptured apendix. He was down for 14 minutes. Apparently the appendix was inflamed and began leaking onto the liver.  A very large abscess developed on the liver which ruptured just before the arrest.  The patient is a 54 yr old male with no prior health issues.  Went to walk-in clinic complaining of pain in side 3 weeks prior to arrest. Was told he was developing a hernia.  Pain subsided but patient developed flu like symptoms, low grade fever, nausea and diahrrea.  Visited different Dr. two weeks after first visit and was diagnosed with septicemia and admitted to hospital.  Had lost 20 pounds in 2 weeks and was severly dehydrated.  Suffered cardiac arrest the following day after showing some signs of improvement with hydration therapy, IV antibiotics and Oxygen.



Has not recovered consciousness since arrest 3 mos ago.  GCS rating of 6.  EEG was nearly flat line and VQ scan showed little blood flow to brain.  Eyes respond to light but do not focus.  Does not respond to verbal commands or pain stimulus.



Doctors have told me there is little chance of recovery but some family want to believe facial grimaces and other movement is a conscious response to their voice and statements.  My question is if he can make a face over things he hears them say, why can't he respond to verbal command to blink eyes or squeeze hand.



What is the general thought of recovery or even partial recovery at this point.  If the brain is not getting blood,is it possible for it to recover at all?

[CCF-Neuro-M.D.-PW]

I cannot give you a formal clinical opinion over the internet unfortunately, as this site is purely educational. Also, you do not give me enough information ie the specific test result to make an accurate opinion as well. Sorry!



In general, the longer a patient goes without responding, the less likely they will recover in a functional way. GCS contains 3 components which are important to know to interpret this score. EEG 'nearly flat line' does not mean very much - 'electrocerebral inactivity' is a specific EEG diagnosis which supports brain death but is not necessary for diagnosis, there can also be false positives in teh setting of certain medications and hypothermia. Brain flow studies are like angiography, SPECT (which I presume you are referring to), and transcranial ultrasound) are also supportive to the clinical diagnosis but not diagnostic in themselves.



There are three main parts of the examination that seem to have the most prognostic significance based on an important neurology paper by a Dr. Levy. These are 1) pupillary response to light 2) vestibulocochlear reflex (eye movement in response to cold water in the ear) and 3) movement in response to a stimulus. If all three are absent on several exams over time, then the prognosis is extrememly poor.



Perhaps they need a neurology opinion to evaluate for a diagnosis of brain death? A common test that is done in this scenario is the apnea test - the ventilator is turned off in a controlled and specific way, and the stimulus to breath assessed by watching for spontaneous breathing and measuring carbon dioxide levels in the blood. Absence of spontaneous breathing is a very poor sign.



I hope this information give you some insight into these difficult questions

[Mac3]

Thank you very much for your response.  Unfortunately (and fortunately depending on the case) physicians have usually presented complicated test results in laymans terms.  In reference to the EEG, this they defined as minimal brain activity reflecting only what they infer is that which controls basic body functions.  The other study was referred to as a "VQ" scan, I don't know any other term for this but was told blood flow to the brain was impaired.

Of the 3 main parts of the examination you referred to, he does show some pupil response to light but does not focus or follow objects placed in front of him.  He sometimes appears to be looking at objects but when moved, he does not follow the object.  I don't know if the cold water test was ever done.  At first we only had a babinski reflex to foot stimulation.  Now we get irregular response or none.  

He is not on a ventilator.  He has a trachotomy with some oxygen assistance.  His oxygen saturation rates stay at 90+. He is either in a Persistant Vegitative state or minimally conscious state depending who you talk to.