Does a regular Wessex Head Injury Matrix assessment identify early signs of infections in people with Prolonged Disorders of Consciousness?

BACKGROUND & OBJECTIVE: Patients with brain injury are at high risk for infections. Although infection and cognitive deterioration are established for people with dementia, this has not been shown for patients with a prolonged disorder of consciousness (PDOC). This study determines whether regular Wessex Head Injury Matrix (WHIM) assessments can identify early signs of infections in patients with PDOC. METHOD: Retrospective and prospective approaches were used to assess the WHIM scores of patients with a PDOC (N = 21 in the retrospective study and 22 in the prospective study). RESULTS: The WHIM total scores decreased due to infections in 17 of the 21 cases of infection (p < 0.001) in the retrospective study and 15 (p = 0.001) of the 22 prospective cases of infection. Patients in a minimally conscious state (MCS) showed a bigger proportion of change between their baseline score and the scores taken in the pre-infection stage in both the retrospective and prospective studies when compared to patients in a vegetative state (VS). CONCLUSION: The findings suggest the importance of serial WHIM assessments throughout the period of recovery, not only to measure cognitive changes but also to highlight underlying physical changes such as infections that will impact the response to rehabilitation and recovery.

Brugada syndrome and the story of Dave.

Brugada syndrome (BrS) is a little known genetic condition that causes severe disturbances in cardiac rhythm and may result in sudden unexpected cardiac death in an apparently healthy person. The heart structure is typically normal but there are problems with electrical activity. The syndrome is named after Spanish brothers who are cardiologists, Pedro and Josep Brugada. BrS is the major cause of sudden unexplained death syndrome (SUDS), also known as sudden arrhythmic death syndrome (SADS). Following a description of the syndrome, including its prevalence and incidence, how it is diagnosed and how it can be treated, we consider those who survive a cardiac arrest and what problems they may face. Most publications focus on the medical aspects of BrS but, of course, cardiac arrest can result in hypoxic brain damage. We conclude with the story of Dave, a 25-year-old man diagnosed with BrS following a nose bleed and subsequent cardiac arrest. He was left with a visual impairment, dystonia, hypersensitivity, and language and cognitive dysfunction. We look at Dave's strengths and weaknesses, his response to offered treatment, and his consequent improvement. We stress the contributions from members of the multidisciplinary team and offer suggestions for the rehabilitation of other survivors of BrS.

Does Modafinil improve the level of consciousness for people with a prolonged disorder of consciousness? a retrospective pilot study.

BACKGROUND AND AIM: Modafinil is best known as a sleep regulator among healthy individuals, but studies suggest that it reduces excessive daytime sleepiness in patients with brain injury. This retrospective pilot study evaluated the effectiveness of Modafinil for people with a prolonged disorder of consciousness and whether those with a traumatic brain injury did better than those with a non-traumatic brain injury. METHOD: Twenty four prolonged disorder of consciousness patients who were prescribed Modafinil, were assessed at least four times both before and during treatment. The Coma Recovery Scale-Revised was used to determine if patients had a disorder of consciousness and the Wessex Head Injury Matrix was used to monitor behavior during baseline and treatment periods. Patients with a traumatic brain injury (N = 12) were compared with those with non-traumatic brain injury (N = 12). A chi-square test with significance at 0.05 was used and when frequencies were below 5 a Fisher's Exact Test was used. RESULTS: Cognitive improvements were noted in domains of wakefulness, awareness, concentration, tracking and following commands. Significant differences were found for the whole group between baseline and Modafinil (x2 = 9.80; p = 0.002). Eleven of the 12 traumatic brain injury patients had higher Wessex Head Injury Matrix scores when on Modafinil (x2 = 8.33, p < 0.004). Six non-traumatic brain injury patients had higher scores with Modafinil, two had lower scores and four showed no change. There was no significant difference in the number of patients showing an increase compared to those showing a decrease (Fisher's exact test p = 0.29). CONCLUSION: Modafinil appears to be beneficial for enhancing cognition in prolonged disorder of consciousness patients. Traumatic brain injury patients benefited more than non-traumatic brain injury patients. Implications for Rehabilitation People with prolonged disorders of consciousness are those in coma, a vegetative state or a minimally conscious state. Sensorimotor and neuromodulations (pharmacological and brain stimulation) are the available treatment strategies to this group. Modafinil promotes attention, concentration and maintains wakefulness in a patient with narcolepsy, obstructive sleep apnea and shift work sleep disorders. In a relatively small sample, this retrospective pilot study shows the effectiveness of Modafinil in conjunction with good care, suitable medications and multidisciplinary rehabilitation in enhancing arousal in prolonged disorders of consciousness patients.

The natural history of continuing improvement in an individual after a long period of impaired consciousness: The story of I.J.

AIM: Recovery of consciousness and recovery of function among patients with prolonged disorders of consciousness rarely occur. Those patients who do regain consciousness typically remain with severe disability. The aim of this retrospective study is to suggest that continuing improvement is possible in a survivor of catastrophic brain injury after being in a prolonged state of disordered consciousness. CASE STUDY: This retrospective single case study follows the progress of a 29 year old man, I.J, who sustained a severe traumatic brain injury following an assault in October 2011. He was in a vegetative state for 15 months and in a minimally conscious state for a further 4 months. This was followed by a slow and steady recovery of motor and cognitive functions. At 3 years post-injury I.J is considered to be moderately disabled. He is now living in the community with continuing outpatient support. On the disability rating scale his level of functioning is rated as mildly dependent. CONCLUSION: This study shows that continuing recovery to a level of moderate disability is possible, even after a prolonged disorder of consciousness. Intense multi-disciplinary long-term rehabilitation and cranioplasty may be contributing factors for such an unexpected recovery.