BackgroundSome 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).DiscussionMany 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.ConclusionSince 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).

SummaryGuidelines for the management of severe head injury in adults as evolved by the European Brain Injury Consortium are presented and discussed. The importance of preventing and treating secondary insults is emphasized and the principles on which treatment is based are reviewed. Guidelines presented are of a pragmatic nature, based on consensus and expert opinion, covering the treatment from accident site to intensive care unit. Specific aspects pertaining to the conduct of clinical trials in head injury are highlighted. The adopted approach is further discussed in relation to other approaches to the development of guidelines, such as evidence based analysis.

cally signi®cant when variations in the initial severity of injury were taken into account.The ®ndings in the present survey are compared with newly analysed information for three previous large series: the International Data Bank involving the UK, the Netherlands and the USA, the North American Traumatic Coma Data Bank, and data from four centres in the UK. The comparisons showed substantial similarities and also di¨erences that may re¯ect variations in policy for admission of the head injury to`neuro' units, and evolution in methods of assessment, investigation and management. The e¨ects of these differences on outcome requires further, rigorous prospective study.

In Europe there are great differences between centres in the frequency of CPP monitoring and ventilatory support applied to head-injured patients. ICP measurement disclosed a high rate of intracranial hypertension, which was not suspected in patients evaluated on a clinical basis alone. ICP monitoring was associated with a low rate of complications. Cases with severe neurological impairment, and with the worse outcome, were treated and monitored more intensively.

I was asked to give my opinion on a young boy who came from Berry to see me in Paris. During the short time he spent in my consulting room, he was taken with attacks of vertigo characterized by abrupt outbursts of laughter; these attacks lasted hardly a few seconds, and when the patient regained consciousness he seemed astonished when I asked him why he had laughed; he was unaware of having done so. The major seizures from which he suffered nearly always started with these vertiginous attacks".A. TROUSSEAU, De I'Epilepsie, Vol. 2, p. 17Trousseau's seems to be the first description of epileptic laughter. Although reports on this subject have been few until recently, more than a dozen have appeared since 1957, when Daly and Mulder proposed the name gelastic epilepsy for epileptic laughter (gelas = joy). Since electroencephalography, neuroradiology and neurophysiology can now contribute to clarifying the mechanism, we propose to review the literature and report 5 cases. I. SYMPTOMATOLOGY OF GELASTIC EPILEPSIESCan the gelastic epilepsy be described? The published cases and our own suggest that it cannot: the laughter seems to be a symptom in certain clinical forms of seizure disorder but the EEG features and the seizures are not uniform. A. Clinical Features of Epileptic Laughter are Variable(1) The laughter itself is pathological and inappropriate. Daly and Mulder (1957) considered it a seizure involving affective behaviour such as may be produced by epileptic discharge in temporal structures. The laughter seems inappropriate because bystanders do not understand the reason for it, and the patient cannot explain since he has amnesia for the attack. This interpretation is valid for certain cases but not for