Doctors 'Awaken' Man 6 Years After Severe Brain Injury
WEDNESDAY Aug. 1, 2007 -- In a scene reminiscent of Oliver Sacks' book Awakenings, doctors have managed to partially rekindle the mind of a man who had been in a minimally conscious state for six years.
The 38-year-old patient, who was severely brain-damaged, received deep brain stimulation and can now feed himself and communicate, activities that were unthinkable before the therapy.
This is the first time that deep brain stimulation has been used on a person with a traumatic brain injury in a minimally conscious state, and it offers some hope for others in similar situations, the researchers said.
"Hopefully, this will now begin to open doors that were closed up to this point," said Joseph Giacino, study co-investigator and associate director of neuropsychology at JFK Johnson Rehabilitation Institute and at the New Jersey Neuroscience Institute in Edison, N.J. "There's a very nihilistic view that when a brain is badly damaged there's not much we can do to change that. We have a very tough time getting research funded because of the need to jump higher than most other research. By demonstrating that we did move the bar in this patient this late, we hope that it's going to force people to revisit this somewhat nihilistic view."
Lead study author Dr. Nicholas Schiff, an associate professor of neurology and neuroscience at Weill Cornell Medical College in New York City, said: "We set out with a goal to try to identify a set of patients who might, if this was successful, regain functional communication and we thought that was important because being able to communicate is important, even if you remain disabled, because you can reengage with people in your immediate environment, including family and the people taking care of you and give a better idea of your needs. We were able to do this for this patient. Whether this means we'll be able to do this again, we don't know until we do it again but we do think there will be other patients who can respond to this. It's a first step to building a science to do this."
The patient was the first of 12 patients to try deep brain stimulation in a U.S. Food and Drug Administration-approved trial.
Dr. Ali Rezai, senior author of the paper and director of the Cleveland Clinic's Center for Neurological Restoration, said, "There's a great period of scientific discovery coming with respect to traumatic brain injury. This had been a great big desert of unknowns. There are 1.5 million new cases of TBI [traumatic brain injury] in the U.S. each year and two-thirds of Iraq war veterans have TBI. This is an exciting time to come."
The finding is published in the Aug. 2 issue of Nature.
People in a minimally conscious state can show sporadic evidence that they are aware of themselves or their environment. The state is not the same as a persistent vegetative state or a coma.
An estimated 100,000 to 300,000 traumatic brain injury patients in the United States are currently diagnosed with minimally conscious state. Most do not receive active rehabilitation and are relegated to long-term facilities.
"These patients are devastated and their families are devastated. They are taken to nursing homes and chronic-care facilities and forgotten about," Rezai said.
But some patients in a minimally conscious state, including the man in the new study, do retain brain activity. In one other recent high-profile case, 39-year-old Terry Wallis of Mountain View, Ark. regained speech and movement two decades after a truck accident left him in a minimally conscious state. Some of the same researchers involved with the new study also documented the Wallis "awakening," proposing that the re-growth of neural networks was responsible.
The patient who is the subject of the new study underwent a 10-hour operation during which electrodes were implanted into his brain and used to stimulate the thalamus on both sides of the brain. The procedure has been used before in Parkinson's disease, dystonia, obsessive-compulsive disorder and depression.
According to Rezai, the procedure required much more precision when used for minimally conscious state. "You have to target specific parts of the brain with millimeter precision using various computer-generated brain maps and physiological mapping," he explained.
The patient also received other forms of rehabilitation.
Within 48 hours, the patient turned his head in response to voices and kept his eyes open for prolonged periods of time. After more time, the patient, who previously could not talk, started naming objects and using objects, such as a hair brush, with his hands.
After an initial "titration" period during which the dosage and timing of the stimulation were fine-tuned, the patient began a six-month period during which periods of stimulation were alternated with periods of no stimulation.
Communication, motor control and feeding were the most improved when the brain was receiving electrical impulses, but were still enhanced even when the device was turned off.
"What we did here was facilitate and augment neural networks that were already in place," said Dr. Joseph J. Fins, study co-investigator and a professor of medicine and public health and chief of the division of medical ethics at Weill Cornell Medical College. "This is distinct from permanently vegetative patients like Terri Schiavo. You need an intact set of circuits to work with and he did have an intact set, except he was not able to sustain their activation, as it were."
Giacino added: "We were able to influence this patient's course of recovery very late in the process. No treatment has been proven to accelerate the course of recovery from brain injury or improve outcome at the end of day. At least in one patient, we think we've convincingly shown this is possible."
There are still many unknowns, however, including whether this patient will continue to improve and whether deep brain stimulation will help other brain-injured patients.
"This patient continues to improve outside of the trial with the stimulator in place," Fins said. "But we're in uncharted territory about what kind of degree of recovery he might ultimately achieve."
"It's very dicey stuff, brain injury, because the next patient we enroll in the study, that brain injury will not be the same because no two are alike," Giacino said. "We need to continue to replicate the findings and figure out who would benefit from this."
Dr. Jonathan Friedman, director of the Texas Brain and Spine Institute, agreed. "This could have huge implications but it's all speculative with just one patient," he said. "Every head injury is very different. It's probably naive to think we could stimulate every patient in the same way, although some might benefit even more."
To learn more, visit the Brain Injury Association of America.
Posted: August 2007