Editorials

fMRI for vegetative and minimally conscious states

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8045 (Published 28 November 2012) Cite this as: BMJ 2012;345:e8045
  1. Lynne Turner-Stokes, professor of rehabilitation1,
  2. Jenny Kitzinger, professor of communications research2,
  3. Helen Gill-Thwaites, consultant occupational therapist3,
  4. E Diane Playford, reader in neurological rehabilitation4,
  5. Derick Wade, professor of neurological rehabilitation5,
  6. Judith Allanson, consultant in neurorehabilitation6,
  7. John Pickard, professor of neurosurgery7
  8. On behalf of the Royal College of Physicians’ Prolonged Disorders of Consciousness Guidelines Development Group
  1. 1King’s College London School of Medicine, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London SE5 9PJ, UK
  2. 2Cardiff University, School of Journalism, Media and Cultural Studies, UK
  3. 3Royal Hospital for Neurodisability, London
  4. 4Institute of Neurology, University College London, London
  5. 5Nuffield Orthopaedic Centre, Oxford Centre for Enablement, Oxford, UK
  6. 6Division of Neurosciences (Neurorehabilitation), Addenbrooke’s Hospital, Cambridge, UK
  7. 7Neurosurgery and Wolfson Brain Imaging Centre, University of Cambridge, Addenbrooke’s Hospital
  1. lynne.turner-stokes{at}dial.pipex.com

A more balanced perspective

The BBC’s Panorama programme The Mind Reader: Unlocking My Voice broadcast on 13 November 2012 provided important insights into the devastating experience of patients who live in vegetative or minimally conscious states and the families who support them. It also provided useful information on the use of functional magnetic resonance imaging (fMRI) to explore evidence of localised brain activity that might indicate underlying awareness. However, the programme failed to distinguish clearly between the two states and gave the impression that 20% of patients in a vegetative state show cognitive responses on fMRI. This claim needs to be clarified and put into perspective.

There are important differences between the two states. Patients in a vegetative state have no discernible awareness of self and no cognitive interaction with their environment. Patients in a minimally conscious state show evidence of interaction through localising or discriminating behaviours, although such interactions occur inconsistently. It is clinically important to make this distinction, for prognostic reasons and because some evidence suggests that patients in a minimally conscious state experience symptoms (such as pain) in a manner indistinguishable from non-brain injured patients.1 2

The programme presented two patients said to be in a “vegetative state” who showed evidence of cognitive interaction on assessment using fMRI in Ontario, Canada. The clinical methods used for the original diagnosis …

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