EVALUATION OF PROLONGED COMA AND ITS TREATMENT

植物状态给出了无肩症的定义，美国神经病学协会于1989年建议对植物状态患者进行生命支持治疗。但仅有3%-7%的患者自发地从这种绝望状态中恢复过来，并进行了递质治疗和感觉刺激治疗，取得了一定的效果。在这种情况下，最重要的是(1)建立植物状态的严重程度分级，(2)了解治疗的有效机制，以了解其发生机制，预测治疗效果。本研究通过认知测试对植物状态患者的神经行为评分，将其分为完全型、不完全型和过渡型三个等级。在评估为过渡型或不完全型的病例中，频谱脑电表现为…的改变更常见的模式是，体感诱发电位的N20波是可记录的，听觉脑干反应的第五波也可以记录到。对于完全型患者，这些神经生理反应总是不完整的。不完全型与过渡型认知痛相关潜伏期波幅(P250)存在差异。但通过测量脑脊液中的递质来了解植物状态的严重程度，难以检测局部脑血流量和代谢，而某些治疗后局部脑血流量和代谢明显增加。刺激靶点选择在丘脑中央正中核或脑干网状结构，近期根据本研究对乙酰胆碱的研究选择Meynert核作为第二靶点。根据我们临床深部脑刺激治疗的随访结果分析，35%的接受治疗的植物患者可以从绝望状态中恢复，72%的治疗过渡型和45%的不完全型患者有机会恢复。恢复良好的患者P250波幅>10-V，提示慢性脑深部电刺激治疗有部分可治疗的植物状态，如不完全型或过渡型EEG改变，N20，听觉脑干诱发电位第五波，P250波幅>10-V。较少

Vegetative state has given a definition of hopless condition and American Neurological Association recommenmded to take out life-surporting treatments for the treatment of vegetative state patients in 1989. But on only 3-7% of them, spontaneously recovery from such hopeless state has been observed and some treatments like a transmitters administration and sensory stimulation therapy have been applied with some effects.At this situation, the most important thing to make clear is (1) setting up the severity grade of vegetative state and (2) getting some informations about mechanisms of the effectiveness of treatments, in order to know phathogenesis and to predict the effect of the treatment.In this study, the severity grade of the vegetative state patients is classified three grade ; complete type, incomplate type and transitional type, by neurobehavioral score which is evaluated by cognitive tests. On the cases evaluated transitional type or incomplate type, spectral EEG shows a changea … More ble pattern, N20 wave of somatosensory evoked potential is recordable and fifth wave of auditory brainstem responses is also able to record. On complete type patients, these neurophysiological responses are always incomplete. And there is a difference of an amplitude of cognitive pain related late potenial (P250) between incomplate and transitional type. But it is difficult to know severity of vegetative state by measuring of the transmitters in CSF,to check regional cerebral blood flow and metabolism which are remakably increased following some treatments.As a treatment for vegetative state patients, chronic deep brain stimulation has been applied in this study. Stimulation target is selected the center median nucleus of the thalamus or brainstem reticular formation and recently the Meynert nucleus is selected as second target according to this study on acetylcholine.According to analysis of the follow up results of our clinical deep brain stimulation therapy, 35% of treated vegetative patients could recover from the hopeless state, and 72% of the treated transitional type and 45% of incomplate type had a chance to recover. The good recovered patients showed more than 10muV amplitude of P250.It is concluded that there are some treatable vegetative state treated by using of chronic deep brain stimulation therapy, if they are incomplate or transitional type who have changeable EEG pattern, N20, and the fifth wave of auditory brainstem evoked potential and more than 10muV of amplitude of P250. Less