Unresponsive wakefulness syndrome: a new name for the vegetative state or apallic syndrome

BACKGROUND: Some patients awaken from coma (that is, open the eyes) but remain unresponsive (that is, only showing reflex movements without response to command). This syndrome has been coined vegetative state. We here present a new name for this challenging neurological condition: unresponsive wakefulness syndrome (abbreviated UWS). DISCUSSION: Many clinicians feel uncomfortable when referring to patients as vegetative. Indeed, to most of the lay public and media vegetative state has a pejorative connotation and seems inappropriately to refer to these patients as being vegetable-like. Some political and religious groups have hence felt the need to emphasize these vulnerable patients' rights as human beings. Moreover, since its first description over 35 years ago, an increasing number of functional neuroimaging and cognitive evoked potential studies have shown that physicians should be cautious to make strong claims about awareness in some patients without behavioral responses to command. Given these concerns regarding the negative associations intrinsic to the term vegetative state as well as the diagnostic errors and their potential effect on the treatment and care for these patients (who sometimes never recover behavioral signs of consciousness but often recover to what was recently coined a minimally conscious state) we here propose to replace the name. CONCLUSION: Since after 35 years the medical community has been unsuccessful in changing the pejorative image associated with the words vegetative state, we think it would be better to change the term itself. We here offer physicians the possibility to refer to this condition as unresponsive wakefulness syndrome or UWS. As this neutral descriptive term indicates, it refers to patients showing a number of clinical signs (hence syndrome) of unresponsiveness (that is, without response to commands) in the presence of wakefulness (that is, eye opening)

Prognosis in disorders of consciousness

In patients with prolonged disorders of consciousness (DOC), clinical evolution is determined by several factors closely interacting with each other: etiology, patient's age (likely influencing the physiological process of recovery, e.g., brain plasticity), the duration of DOC (likely related to the severity of brain damage), the structural and functional integrity of neuronal populations (as assessed by neurophysiological and neuroimaging methods), and the presence of clinical complications that could impact care strategies. In the present chapter, we will offer a brief review of the most recent studies on clinical evolution of patients with prolonged DOC and of the longitudinal studies searching for robust prognostic markers in such patients. We will argue that some prognostic indicators for patients in vegetative state can be gathered in the rehabilitative phase, whereas reliable markers to characterize DOC patients who will present late recovery of responsiveness and consciousness have not been identified. Moreover, long-term evolution of patients in minimally conscious state has not been clearly established, and definite prognostic information is not available for these patients. For these reasons, prospective longitudinal systematic investigations of outcome in large groups of individual with prolonged DOC are needed to better clarify the natural recovery of DOC and to define prognostic markers useful to update current positions on medical, ethical, and legal issues connected with management and care of these patients