Implants offer hope in brain injury cases
His skull crushed in a brutal mugging, the man had been left severely brain-damaged. For six years, he had lain in a stupor, eyes almost always closed, unable to communicate, fed through a tube. His mother visited him in the nursing home every day, she says, and every time she cried.
But now, she says, her 38-year-old son can eat, drink from a cup, laugh, watch a movie, and say, "I love you, Mommy." She still cries when she sees him, she says, "but it's tears of joy."
The son, whose identity has been withheld to protect his privacy, underwent a marked recovery after doctors implanted a pacemaker-like device to "jump-start" his brain, the journal Nature reports today.
Researchers say the 38-year-old is the first patient in a "minimally conscious state" to be im planted with a Deep Brain Stimulator, a device that uses tiny electrodes to send electrical signals into precisely targeted areas of the brain.
Tens of thousands of Americans are minimally conscious: Much of the time their condition resembles a vegetative state, but they sometimes show signs of awareness, such as mouthing a word or nodding in response to a question. The 38-year-old's progress suggests that such patients may benefit from more rehabilitation than they typically receive and that more research is needed into treatments for them, the researchers say.
They also cautioned, however, that the implants were used only on a single minimally conscious patient and that the improvement must be replicated on many more people to be considered scientifically valid. Also, certain key areas of the 38-year-old's brain were still intact, raising questions about whether deep brain stimulation would help patients with more damaged brains.
"It's an exciting finding," said Dr. Douglas I. Katz, a neurorehabilitation specialist at Braintree Rehabilitation Hospital who was not involved in the research. "It's not the first time that electrical stimulation has been tried in people with impaired consciousness, but it's the first well-designed, scientifically controlled study to prove the effect of the stimulation on improving brain function."
The man is the first in a planned 12-patient study using the stimulators on the thalamus, a bundle of cells deep in the brain known to activate other areas of the brain.
The multisite study is being led by Dr. Nicholas Schiff of Weill Cornell Medical College of Cornell University in New York, a pioneer in research into the minimally conscious state.
Earlier work by Schiff and others had suggested that in minimally conscious patients, some brain networks remained functional, but were simply not being activated enough because of damage.
Deep brain stimulation has been used for years in tens of thousands of patients with Parkinson's disease. Although it is still unclear precisely why the stimulation works, it is now being tried in the treatment of a variety of brain diseases, from psychiatric illnesses to movement disorders.
In patients with Parkinson's, the pulses appear to block or jam bad signals that travel through malfunctioning circuits in the brain. In the minimally conscious patient, researchers say, they seem to give a kind of jump-start through the thalamus to the brain.
Once the electrodes are implanted in the brain, and hooked up to batteries implanted for easy access in the patient's chest, they can be turned on or off and adjusted.
Such electrodes have been tried before in patients who suffered worse brain damage and were nonresponsive, but to no avail. One such patient was Terri Schiavo, the Florida woman whose situation became a political showdown.
In the Schiff experiment, the electrodes were implanted during a 10-hour operation. Later, when they were turned on, the researchers saw immediate change, they said.
"It was a defining moment for all of us that we'll never forget, the day we activated the pacemakers," said Dr. Ali R. Rezai, the Cleveland Clinic neurosurgeon who performed the operation. The patient immediately became noticeably more alert, he said, and the medical team "looked at each other, humbled in many ways and at the same time excited about the prospects."
Prior to the operation, the patient had kept his eyes closed almost all the time, and when asked to perform simple movements, would do so, but with his eyes still closed. Very rarely, he would mouth words, but he could not communicate reliably. He could move his arms and hands, but not in a coordinated way.
After the operation, he regained normal eye-opening movement and would follow the activity around him with his eyes. He now speaks audibly, usually in phrases of one to three words, and recently, researchers say, he even said the first 16 words of the Pledge of Allegiance from memory. He takes all his food by mouth now, though his stomach tube remains as a backup.
The electrodes are implanted permanently, and are now turned on each day for 12 hours, then turned off at night. Researchers say there is good reason to believe he will continue to improve.
Katz, who is also an associate professor of neurology at Boston University, said the patient's improvement "helps hammer home the point that we have to give people with severe brain injury a chance."
"Even people who don't respond should have periodic reevaluations even years after the injury," he said, "especially if family and others notice improvement."
The patient's mother, who spoke tearfully at a news conference yesterday, said that at one point, she had signed a "Do Not Resuscitate" order for her son, because she saw so little hope for him to be more than "a vegetable."
"I can only imagine what other mothers are going through when they have sons and daughters coming back from the war with all sorts of injuries," she said. "And I would like to say to them, 'Don't give up hope.' "
Carey Goldberg can be reached at goldberg@globe.com. 