Application of an Intensive Rehabilitation Program After Very Late Recovery of Consciousness: A Single-Case Neurorehabilitation and Neuroimaging Study

Abstract

Late recovery of consciousness in vegetative state is considered as an exceptional outcome and has been reported prevalently in patients who suffered a traumatic brain injury. In these patients, the benefits of prolonging the rehabilitation, aimed at the recovery of autonomy in basic everyday activities, has been demonstrated. Here, we describe the application of an intensive multi-professional rehabilitation program carried out on a young female patient, with exceptionally late recovery of consciousness, specifically, after 7 years of vegetative state due to severe brain hemorrhage. Neuropsychological and functional assessment was conducted before and after the end of the rehabilitation program. In addition, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI)-based probabilistic tractography were performed. Two follow-up neuropsychological and functional assessments were also conducted 6 and 29 months after the conclusion of the program. Functional results showed an improvement, maintained over time, in walking with assistance, cognitive efficiency, visual acuity and visual field, dysarthria, and execution of activities of daily living. Moreover, functional and structural magnetic resonance imaging (MRI) data documented the existence of preserved neural networks involved in sensory, motor, and linguistic tasks, which in all likelihood support the recovery process. This report suggests the possibility of undertaking an intensive rehabilitation program in patients who remain for long periods in altered states of consciousness, in spite of early negative prognosis.

Neuropsychological rehabilitation, neuroimaging and neuroplasticity: A clinical commentary

“…Another intriguing case example has been reported by Errante et al (2019) . They described a prolonged course of rehabilitation for a young woman who suffered a severe traumatic brain injury (TBI).…”

Proceedings of the First Pediatric Coma and Disorders of Consciousness Symposium by the Curing Coma Campaign, Pediatric Neurocritical Care Research Group, and NINDS: Gearing for Success in Coma Advancements for Children and Neonates

“…However, nonionizing neuroimaging is increasingly employed during the post-acute and chronic phases of disease to assess children with DoC. This includes the surveillance of hydrocephalus and atrophy through structural imaging; the observation of white matter inflammation, degeneration or change in microstructure, and tract disruption, typically through diffusion weighted MRI [104]; and the assessment of anatomical plasticity occurring in correspondence with treatment [105]. In this last case, however, cautious interpretation should be applied, not to infer causality beyond the study design.…”

Towards modern post-coma care based on neuroscientific evidence

“…The variability between individuals is another key element preventing healthcare professionals to accurately estimate a patient's likelihood to recover. Patients who recover consciousness early after brain injury have better chances to recover satisfactory cognitive abilities, but rare reports of spectacular late improvements among chronic UWS patients complicate the task when prognosticating a clinically unresponsive patient ( Dhamapurkar, Rose, Florschutz, & Wilson, 2016 ; Errante et al, 2019 ; Estraneo, Moretta, Loreto, Santoro, & Trojano, 2014 ; Sancisi et al, 2009 ).…”