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Neuropathology in vegetative and severely disabled patients after head injury

From the University Departments of Neurosurgery (Dr. Jennett) and Neuropathology (Dr. Adams and D. Graham), Institute of Neurological Sciences, Southern General Hospital; and the University Department of Medicine and Therapeutics (Dr. Murray), Western Infirmary, Glasgow, United Kingdom.

Address correspondence and reprint requests to Dr. Bryan Jennett, University Department of Neurosurgery, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF UK.

OBJECTIVE: To discover if the neuropathology differs in head-injured patients who were in a vegetative state (VS) or were severely disabled at time of death.

METHODS: Review of 35 VS cases and 30 severely disabled cases treated in this institute in the acute stage, surviving at least a month; all brains were fixed for 3 weeks before full neuropathologic examination.

RESULTS: The severely disabled cases were older, had a higher incidence of skull fracture and of evacuated intracranial hematoma, and they had more cortical contusions. Diffuse axonal injury (DAI) was less common in the severely disabled cases, particularly its most severe grade. Structural damage in the thalamus was much less common in severely disabled cases. Half of the severely disabled patients had neither grade 2 or 3 DAI nor thalamic damage and 10 of these 15 cases did not have ischemic brain damage either. These combinations did not occur in a single VS case. However, some severely disabled cases had similar lesions to VS cases, and this included some patients who were in a minimally conscious state as well as some who were out of bed and mobile.

CONCLUSIONS: Half the severely disabled cases had only focal brain damage, a feature not found in any VS cases. In the severely disabled patients with lesions similar to those of VS cases it is likely that a greater quantitative amount of damage occurred in the VS cases.

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