Does the four score correctly diagnose the vegetative and minimally conscious states?
| Abstract | Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests for eye movements or blinking on command. This is welcomed given that misdiagnosis of the locked-in syndrome has been shown to occur in more than half of the cases (see Laureys and colleagues3 for review). As for the diagnosis of the vegetative state, the scale explicitly tests for visual pursuit, and hence can disentangle the vegetative state from the minimally conscious state (MCS). The diagnostic criteria for MCS have been proposed4 only recently, but Wijdicks and colleagues1 do not mention the existence of this clinical entity in their article. As for the vegetative state, MCS can be encountered in the acute or subacute setting as a transitional state on the way to further recovery, or it can be a more chronic or even permanent condition. The MCS refers to patients showing inconsistent, albeit clearly discernible, minimal behavioral evidence of consciousness (eg, localization of noxious stimuli, eye fixation or tracking, reproducible movement to command, or nonfunctional verbalization).4 The FOUR scale does not test for all of the behavioral criteria required to diagnose MCS.4 It is known from the literature (see Majerus and colleagues5 for review) that about a third of patients diagnosed with vegetative state are actually in MCS, and this misdiagnosis can lead to major clinical, therapeutic, and ethical consequences. We tested the ability of the newly proposed FOUR scale to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting.. | |||||||||
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Guy Kahane & Julian Savulescu (2009). Brain-Damaged Patients and the Moral Significance of Consciousness. Journal of Medicine and Philosophy 34 (1):6-26.
Alexander A. Fingelkurts, Andrew A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2012). EEG Oscillatory States as Neuro-Phenomenology of Consciousness as Revealed From Patients in Vegetative and Minimally Conscious States. Consciousness and Cognition 21 (1):149-169.
Nicholas Shea & Tim Bayne (2010). The Vegetative State and the Science of Consciousness. British Journal for the Philosophy of Science 61 (3):459-484.
Andrew A. Fingelkurts, Alexander A. Fingelkurts, Sergio Bagnato, Cristina Boccagni & Giuseppe Galardi (2012). Toward Operational Architectonics of Consciousness: Basic Evidence From Patients with Severe Cerebral Injuries. Cognitive Processing 13 (2):111-131.
Eelco F. M. Wijdicks, William R. Bamlet, Boby V. Maramattom, Edward M. Manno & Robyn L. McClelland (2006). Does the FOUR Score Correctly Diagnose the Vegetative and Minimally Conscious States?: Reply. Annals of Neurology 60 (6):745.
Steven Laureys, Marie-Elisabeth E. Faymonville & M. Ferring (2003). Differences in Brain Metabolism Between Patients in Coma, Vegetative State, Minimally Conscious State and Locked-in Syndrome. European Journal of Neurology 10.
Jukka Varelius (2009). Minimally Conscious State and Human Dignity. Neuroethics 2 (1).
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