Change of Ascending Reticular Activating System Following Shunt Operation for Hydrocephalus in a Subarachnoid Hemorrhage Patient.

OBJECTIVE: To demonstrate the change of the ascending reticular activating system (ARAS) concurrent with the recovery of impaired consciousness following a shunt operation in a stroke patient. METHODS: A 65-year-old female patient underwent coiling of a ruptured right posterior communicating artery and, subsequently, underwent right external ventricular drain (EVD) placement, left EVD placement, and lumbar drain placement for management of intraventricular hemorrhage. After 6 months from onset, she began rehabilitation, and brain magnetic resonance imaging showed dilatation of the ventricular system. The patient exhibited impaired alertness, with a Glasgow Coma Scale (GCS) score of 7. At ∼ 20 days after starting rehabilitation, the patient underwent a ventriculoperitoneal shunt operation for hydrocephalus. At 10 days postsurgery, her GCS improved to 15. RESULTS: Regarding the change of neural connectivity of the thalamic intralaminar nuclei, compared with preoperative diffusion tensor tractography (DTT), postoperative DTT showed that neural connectivity to the prefrontal cortex was increased in both hemispheres. In terms of configuration of DTT, the lower portion of the ARAS between the reticular formation and the intralaminar thalamic nuclei did not show a significant change. CONCLUSIONS: A patient with subarachnoid and intraventricular hemorrhage showed recovery of an injured ARAS and consciousness after a shunt operation for hydrocephalus.

Recovery From Vegetative State to Minimally Conscious State: A Case Report.

In this study, we attempted to demonstrate the change of the ascending reticular activating system (ARAS) concurrent with the recovery from a vegetative state (VS) to a minimally conscious state (MCS) in a patient with brain injury. A 54-year-old male patient had suffered from head trauma and underwent cardiopulmonary resuscitation immediately after head trauma. At 10 months after onset, the patient exhibited impaired consciousness, with a Coma Recovery Scale-Revised (CRS-R) score of 7 (auditory function: 1, visual function: 2, motor function: 1, verbal function: 1, communication: 0, and arousal: 2) and underwent the ventriculoperitoneal shunt operation for hydrocephalus. After the operation, he began comprehensive rehabilitative therapy. At post-op 2 and 8 weeks, his CRS-R score had recovered to 15 (3/3/4/1/1/3) and 17 (3/3/4/2/2/3), respectively. In terms of configuration on diffusion tensor tractography (DTT), there was no significant change in the lower portion of the ARAS. Regarding the change of neural connectivity of the thalamic intralaminar nucleus, increased neural connectivities to the hypothalamus, basal forebrain, prefrontal cortex, anterior cingulate cortex, and parietal cortex were observed in both hemispheres on post-op DTTs compared with pre-op DTT. We report on a patient with brain injury who showed change of the ARAS concurrent with the recovery from a VS and a MCS.