Tap­ping into the con­scious­ness of veg­e­ta­tive pa­tients

Western Univer­sity re­searcher ap­plies aware­ness-de­tect­ing tech­nol­ogy to brain-in­jured pa­tients

The Hamilton Spectator - - HEALTH - SH­ERYL UBELACKER

TORONTO — Imag­ine be­ing fully con­scious, fully aware, but trapped in­side your body with no abil­ity to move at will or com­mu­ni­cate with loved ones or health-care providers — with no way to say “I’m in here.”

For the last 20 years, neu­ro­sci­en­tist Adrian Owen has ded­i­cated him­self to try­ing to “make con­tact” with such pa­tients, di­ag­nosed as be­ing in a per­sis­tent veg­e­ta­tive state or min­i­mally con­scious fol­low­ing a dev­as­tat­ing brain in­jury that has robbed them of their au­ton­omy.

The case of U.S. stu­dent Otto Warm­bier, who was re­turned home to his fam­ily in a state of “un­re­spon­sive wake­ful­ness” from a se­vere neu­ro­log­i­cal in­jury of un­known cause fol­low­ing im­pris­on­ment in North Korea, is a timely ex­am­ple. Doc­tors said the 22-year-old had opened and blinked his eyes, but seemed un­aware of his sur­round­ings and did not re­spond to ver­bal com­mands. He died last month.

In his new book, “Into the Gray Zone” (Scrib­ner), Owen traces how he and his re­search team be­gan har­ness­ing the power of pro­gres­sively so­phis­ti­cated brain scan­ners to tap into the es­sen­tial be­ing of such pa­tients caught in what’s de­scribed as a twi­light ex­is­tence be­tween life and death.

It was the no­tion of brain-da­m­aged but con­sciously aware pa­tients im­pris­oned within their bod­ies that has driven Owen — first at Cam­bridge in the U.K. and for the last seven years at Western Univer­sity in Lon­don, Ont. — to search for ways to give these peo­ple a voice and bring them back to their fam­i­lies.

“If a pa­tient was ly­ing, some­times for decades, fully aware of ev­ery­thing go­ing on around them, wit­ness­ing ev­ery con­ver­sa­tion, hear­ing ev­ery de­ci­sion be­ing made about their health — and we didn’t know it — that’s a pretty hor­rific idea,” he says.

Us­ing what’s known as func­tional magnetic res­o­nance imag­ing, or fMRI, Owen and his team have scanned hun­dreds of such pa­tients over the years, and in al­most one in five cases, they were able to make a con­nec­tion and prove the per­son was con­sciously aware.

An fMRI mea­sures brain ac­tiv­ity by de­tect­ing changes in oxy­gen levels in neu­ral blood flow. Dif­fer­ent men­tal ac­tiv­i­ties will “light up” var­i­ous parts of the brain, al­low­ing the neu­ro­sci­en­tists to pose yes-or-no ques­tions to a pa­tient by tar­get­ing a spe­cific re­gion.

In ground­break­ing re­search, Owen and his col­leagues dis­cov­ered that ask­ing a veg­e­ta­tive pa­tient ly­ing in the scan­ner to imag­ine play­ing ten­nis would ac­ti­vate one part of the brain, while hav­ing the per­son men­tally move from room to room in their home would fire up an­other.

For a “yes” an­swer, the pa­tient would imag­ine swing­ing a racket to send a ten­nis ball over the net; for “no,” they would pic­ture them­selves nav­i­gat­ing the in­te­rior of their home.

“So ask­ing ques­tions like ‘Are you in pain?’ is an ob­vi­ous one, be­cause if the pa­tient is in pain we can do some­thing about it, we can ad­min­is­ter an anal­gesic,” he says.

It also al­lows the sci­en­tists to key into pa­tient pref­er­ences with the goal of im­prov­ing qual­ity of life.

For in­stance, a pa­tient’s fam­ily may keep ex­pos­ing their loved one to ac­tiv­i­ties they en­joyed prior to their in­jury that left them un­able to com­mu­ni­cate.

“So if you liked watch­ing a lot of hockey when you were 20, if you’re still in a veg­e­ta­tive state when you’re 40, you’re go­ing to get sat down in front of a lot of hockey games,” sug­gests Owen. “And you may not want to watch hockey any­more or you may not like to lis­ten to heavy metal mu­sic any­more.

“Giv­ing them back some au­ton­omy, some choice about what time they’re put to bed, what they get to watch, what they get to lis­ten to, are things that we can ad­dress with this tech­nique,” he says.

“But I think more broadly, it does change the dy­namic be­tween pa­tients and their fam­i­lies. Ob­vi­ously know­ing that your rel­a­tive is in there and is aware is go­ing to change the way you be­have around them. It changes the way the nurs­ing staff be­haves around them.”

The fMRI scan­ning, as well as por­ta­ble EEG and in­frared tech­nolo­gies de­vel­oped to make con­tact with pa­tients, also al­lows the sci­en­tists to ask more deeply meta­phys­i­cal ques­tions, among them “Are you happy?” and “Do you want to live?” Per­haps sur­pris­ingly, most an­swer yes. “A lot of these pa­tients are able to live their lives ... and find pur­pose in their lives, and in some cases to find sat­is­fac­tion, where I think those of us are not in that sit­u­a­tion might think ‘I would never want to live like that.’”

In the first case de­scribed in the book, Owen and his Cam­bridge col­leagues in 1997 tried to con­nect with a woman named Kate, who had suf­fered brain dam­age as a re­sult of in­flam­ma­tion caused by a virus. Her eyes opened and closed and she ap­peared to look around her hospi­tal room, but showed no re­sponse when prompted by her fam­ily or doc­tors.

The team showed her pho­tos of loved ones while she was in a PET scan­ner — which pre­dated fMRI — and the part of the brain that pro­cesses that kind of vis­ual in­for­ma­tion “crack­led with ac­tiv­ity,” show­ing she was con­scious and aware.

“She be­came a per­son again,” says Owen, who writes that Kate later told him she had hated be­ing treated by staff as just “a body,” but that the scan had “found her.”

Months later, Kate be­gan to re­cover, even­tu­ally learn­ing to speak again, al­though to­day she re­mains phys­i­cally dis­abled.

Most veg­e­ta­tive pa­tients found to be aware through scan­ning tend to re­cover lit­tle or no phys­i­cal func­tion, but a young On­tario man named Juan ex­ceeded all ex­pec­ta­tions.

In 2013, the then 19-year-old suf­fered se­vere brain dam­age when he as­phyx­i­ated on his own vomit. De­spite try­ing to reach Juan with ev­ery fMRI aware­ness-prov­ing test the team had de­vised, there was no re­sponse.

But months later, Juan be­gan to make a re­mark­able re­cov­ery. With his speech re­cov­ered, he told Owen that he had in fact been aware — he de­scribed be­ing frightened in­side the dark, tube­like scan­ner — but had been un­able to re­spond to re­quests that he men­tally play ten­nis or move through his home.

“This has never been re­ported to my knowl­edge that a pa­tient could go from ap­pear­ing to be en­tirely veg­e­ta­tive to be­ing well on the road to liv­ing a nor­mal life — and re­port what it was like when peo­ple thought you were veg­e­ta­tive,” says Owen, who re­mains mys­ti­fied by Juan’s re­cov­ery.

In the case of Warm­bier, he says it’s the­o­ret­i­cally pos­si­ble the young Amer­i­can had some level of resid­ual aware­ness, but the dif­fuse na­ture of the brain in­jury de­scribed by doc­tors sug­gests that would be un­likely.

Go­ing for­ward, Owen hopes to ap­ply aware­ness-de­tect­ing tech­nol­ogy to newly brain-in­jured pa­tients while they are in the ICU, “be­cause these are peo­ple whose lives or fu­tures are be­ing de­cided on a minute-byminute, hour-by-hour ba­sis.”

“These are pa­tients who are on life-sup­port ma­chines and are in a sit­u­a­tion where de­ci­sions are be­ing made to ‘pull the plug,’ and it would be very im­por­tant to es­tab­lish whether tech­niques like MRI or EEG can help both with di­ag­no­sis or per­haps find­ing out if pa­tients might not be what they ap­pear to be,” he says.

“Maybe some of these pa­tients are also aware.”

PAUL MAYNE, THE CANA­DIAN PRESS

Adrian Owen: find­ing a way to let seem­ingly veg­e­ta­tive pa­tients say “I’m in here.”

“Into the Gray Zone,” by Adrian Owen, Scrib­ner

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