Keeping hope alive: Brain activity in vegetative state patients

Thirteen-year-old Jahi McMath went into Oakland Children’s Hospital on December 9 for a tonsillectomy. Three days later she was declared brain-dead; severe complications from the surgery resulted in cardiac arrest and her tragic demise. While neurologists and pediatricians at the hospital have declared Jahi brain-dead, her family refuses to accept the doctors’ diagnosis, fighting to keep her on life support.

This heartrending battle between hospital and family is sadly not a new one, and there is often little that can be done to compromise the two sides. However, neuroscientific research in recent years has made substantial developments in empirically determining if there are still signs of consciousness in vegetative state patients. These revelations can either bring hope to a desperate family or provide stronger footing for doctors trying to do the more difficult but often more humane thing.

In 2010, researchers at the University of Cambridge published a groundbreaking study in the New England Journal of Medicine that looked at brain activity in minimally conscious or vegetative state patients using fMRI. These patients were placed in the scanner and asked to imagine themselves in two different scenarios: in the first, they were instructed to envision themselves playing tennis and swinging a racket, which would activate a motor region of the brain called the supplementary motor cortex. In the second, they were told to think of a familiar place and mentally map or walk around the room. This mental map lights up the parahippocampal gyrus, an area of the brain involved in spatial organization and navigation.

Five of the patients (out of 54) were able to consistently respond to the researchers’ requests, reliably activating either the supplementary motor cortex or parahippocampal gyrus upon each instruction. Even more amazing, one of the patients was able to turn this brain activation into responses to yes or no questions. The patient was asked a series of autobiographical questions like “Do you have any siblings?” If the response to the question was yes, she was instructed to “play tennis,” while if the answer was no, she should take a mental stroll around the room. Remarkably, this individual was able to accurately respond to the researchers’ questions using just these two symbolic thought patterns.

Building on this research, a new study by the same scientists published in November of this year in NeuroImage used EEG to measure electrical activity in the brain in an attempt to better assess consciousness in the same group of vegetative state patients.

A certain type of EEG brain wave, the P300, is generated when we are paying attention; and just as there are different kinds of attention (i.e. concentration, alertness, surprise), there are different P300 responses associated with each type. An “early” P300 burst in activity in the parietal lobe (P3a) is externally triggered, such as when something surprising or unexpected grabs our attention. Conversely, delayed P300 waves in the frontal cortex (P3b) are more internally generated and are activated when we are deliberately paying attention to something.

To test this, the Cambridge researchers hooked up the same group of minimally conscious patients to an EEG machine and made them listen to a string of random words (gown, mop, pear, ox). Sprinkled throughout these distractor stimuli were also the words “yes” and “no,” and patients were instructed to only pay attention to the word “yes.” Typically, when someone performing this task hears the target word (yes), they experience a burst in delayed P300 activity, signifying that they were concentrating on that word. However, upon hearing the word “no,” participants often show early P300 activity, its association with the target word attracting their attention even though they were not explicitly listening for it.

Similar to the first study, four of the participants exhibited brain activity that indicated they were able to successfully distinguish the target from the distractor words. This result suggests that these patients are aware and able to process instructions. Three of the four individuals also demonstrated the appropriate activation during the tennis test listed above. However, it’s important to remember that in both of these studies only a very small minority of the patients were able to respond; the vast majority showed no evidence of consciousness during either task.

For the McMath family, studies such as these provide hope that their daughter is still somewhere inside herself, still able to interact with the outside world. But doctors fear this research may be misleading as these results are by far the exception. Additionally, there is no evidence that this type of activity will result in any change in the patient’s prognosis. Finally, and most relevant to the current controversy, complete brain death–as in the case of young Jahi–is very different from vegetative state or minimal consciousness; there is never any recovery from brain death. Advancements in neuroscience have grown more and more incredible in the last decade, and our knowledge of the brain has increased exponentially, but there is still more that we do not know than what we do, and we are a long way off from being able to bring back the dead.

Also posted on Scitable: Mind Read

Is this a new tool to diagnose ADHD, or is it just another neuro-scam?

When I was in elementary school, there were two kids in my class who always got “special medicine” at lunchtime. I didn’t understand this at the time, as they never looked sick to me, so I couldn’t comprehend why they would need to take a pill. One day I got up the courage (as only an impertinent seven year-old can) to ask my friend why she needed to take medicine every day, but her answer just confused me even more. She said that without the pill she would get too energetic and be unable to concentrate in class. But this didn’t make sense, as I knew that I often got quite excited and would sometimes talk out of turn, but I certainly didn’t need to take any medicine for this!

Flash forward twelve years, and in college nearly all of my friends were regularly taking Adderall to help them study for exams, whether they were prescribed it or not.

Diagnoses of ADHD have skyrocketed over the last decade, rising 66% in the U.S. since 2000. As with the majority of psychiatric disorders, a diagnosis cannot be determined by a physical exam or empirical test, but is instead made using subjective self-reports provided by the parents, teachers and child himself. The doctor or psychiatrist then matches these descriptions to the clinical symptoms listed in the DSM – the Diagnostic and Statistical Manual of Mental Disorders – comparing them to her own observations and makes a decision accordingly. This means that diagnoses of ADHD can be highly subjective and, unfortunately, potentially easy to fake.

However, a new development is attempting to change this by using a physical test to look for signs of ADHD in an individual’s brain patterns.

The Food and Drug Administration recently approved a device that uses electroencephalogram, or EEG, to help diagnose ADHD. EEG measures electrical activity in the brain from the firing of neuronal cells. Different voltages, or different magnitudes of this signal, designate different types of brain waves, which can provide insight into the brain’s current activity. Researchers believe that the ratio between two types of these signals – beta and theta waves – may help better predict the presence of ADHD when combined with standard subjective assessments.

Both of these rhythms are involved in arousal, but in different capacities. Theta waves are most commonly seen during voluntary movements and are associated with an active readiness state. In fact, some studies have shown the presence of theta waves before a movement has even begun, suggesting that they play a role in initiating action. Conversely, beta waves are more associated with alertness and concentration, as well as with the inhibition of movements. They are the most common type of electrical signal present while we are awake.

Children with ADHD have been shown to have a higher ratio of theta-to-beta waves, potentially implicated in their hyper-active and hypo-attentive state. By measuring the ratio of theta and beta rhythms, researchers hope to provide a more empirical test of abnormal brain function in children suspected to have ADHD. Sensitivity using this tool – the percentage of children who are diagnosed with ADHD and show these abnormal brain patterns – has been estimated at 95%, while specificity – the percentage of children without ADHD who don’t shows these patterns – is around 90%.

However, others have refuted this claim, saying that EEGs provide no better assessment of ADHD than the current subjective symptom reports already used. Instead, they argue, selling high-tech machines to measure brain waves is just an easy way to make money off of concerned clinicians and parents, but without providing any more valuable information.

Additionally, as is always the case in psychiatry, there are some children with a subtype of ADHD who markedly differ from the expected patterns. Some show increased beta waves, while others have increased alpha waves or some different ratio of these three rhythms.

However, just because this method isn’t perfect doesn’t necessarily mean we should disregard the data supporting the use of EEG for ADHD and reject this option just yet. EEG may be a useful tool to assist in diagnosing, granted that it’s used in combination with the other currently standard methods, which it must be acknowledged are far from perfect themselves. Instead, a combination of these two imperfect methods may help bring us a little bit closer to a more perfect option.

(Originally posted on Mind Read)