A 38-year-old severely brain-injured man who has been unable to communicate or eat by mouth for 6 years now performs both tasks daily, after surgeons – in an investigational study – used deep brain stimulation (DBS) to try and improve function within residual brain networks that they knew were still there.
The DBS surgery targets deep-brain structures with millimeter-precision using computer-generated maps, image-guided navigation, and physiological brain mapping. Tiny electrodes are implanted into these deep-brain structures and connected to programmable pacemaker batteries in the chest. The operation was complicated by the extensive damage to the patient's brain from the traumatic injury. The procedure was performed in two stages and lasted 10 hours. DBS surgery is FDA-approved and routinely performed for patients with Parkinson's disease. Various clinical trials using DBS for the treatment of epilepsy, obsessive-compulsive disorder, and depression are also underway.
"Prior to the use of DBS, the patient's communication ability was inconsistent, including only slight eye or finger movements. Now, he regularly uses words and gestures and responds to questions quickly," says Dr. Joseph T. Giacino, the study's co-lead author and Associate Director of Neuropsychology at JFK Johnson Rehabilitation Institue and the New Jersey Neuroscience Institute. "In addition, he now chews and swallows his food and no longer requires a feeding tube. Before, he could not use his limbs for functional movement, but he can now perform some complex movements, including those required for drinking from a cup or brushing hair. Years of severe immobility and tendon contracture, however, do greatly limit him from carrying out these tasks."
The patient's family has requested that he not be identified at this time. But the patient's mother notes: "My son, as well as the entire family, had little hope of further recovery. If it were not for the DBS surgery and rehabilitation, we would be no further along than we were in 1999. Now, my son can eat, express himself and let us know if he is in pain. He enjoys a quality of life we never thought possible."
"The changes in the man's functional abilities were statistically linked to the use of DBS, and those changes have been remarkable and sustained," says Dr. Ali R. Rezai, the paper's senior author, Director of the Cleveland Clinic's Center for Neurological Restoration, and Professor of Neurosurgery. "We hope that the first use of DBS to treat patients in a minimally conscious state (MCS) marks the beginning of a significant period of innovation in our approach to traumatic brain injury."
Experts estimate that from 100,000 to 300,000 patients with traumatic brain injury are now diagnosed as MCS. Under the current standard of care, most do not receive active rehabilitation and are cared for in long-term nursing facilities. However, based on prior brain-imaging studies, the researchers speculated that DBS – the electrical stimulation of key parts of the brain – might help.
Dr. Ross Zafonte of the University of Pittsburgh, who also was familiar with the study results, agreed that "we need to know more" and said the approach is "very interesting and holds great promise."
Illustration: Here is the x-ray image of a patient undergoing deep brain stimulation. Deep brain stimulation is routinely used to treat Parkinson's disease and other illnesses. --Cleveland Clinic/AP Photo
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