Locked-in syndrome

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Locked-in syndrome
Classification and external resources
Locked-in syndrome can be caused by stroke at the level of the basilar artery denying blood to the pons, among other causes.
ICD-10 G46.3
ICD-9 344.81
MeSH D011782

Locked-in syndrome is a condition in which a patient is aware and awake, but cannot move or communicate due to complete paralysis of nearly all voluntary muscles in the body. It is the result of a brain stem lesion in which the ventral part of the pons is damaged. The condition has been described as "the closest thing to being buried alive". In French, the common term is "maladie de l'emmuré vivant", literally translated as walled-in alive disease; in German it is sometimes called "Eingeschlossen sein". [1]

Locked-in syndrome is also known as cerebromedullospinal disconnection,[2] de-efferented state, pseudocoma,[3] and ventral pontine syndrome.

The term for this disorder was coined by Plum and Posner in 1966.[4][5]


[edit] Presentation

Locked-in syndrome is usually the result of quadriplegia and inability to speak in otherwise cognitively-intact individuals. Those with locked-in syndrome may be able to communicate with others by coding messages by blinking or moving their eyes, which are often not affected by the paralysis. Patients who have locked-in syndrome are conscious and aware with no loss of cognitive function. They can sometimes retain proprioception and sensation throughout their body. Some patients may have the ability to move certain facial muscles, most often some or all of the extraocular eye muscles.

[edit] Causes

Unlike persistent vegetative state, in which the upper portions of the brain are damaged and the lower portions are spared, locked-in syndrome is caused by damage to specific portions of the lower brain and brainstem with no damage to the upper brain.

Possible causes of locked-in syndrome include:

[edit] Number of cases

In the United States, there are no statistics available on how many people have locked-in syndrome but it is estimated that several thousand patients each year survive the kind of brain-stem stroke that causes the condition.

[edit] Treatment

There is no standard treatment for locked-in syndrome, nor is there a cure. Stimulation of muscle reflexes with electrodes (NMES) has been known to help patients regain some muscle function. Other courses of treatment are often symptomatic.[6] Assistive computer interface technologies, such as Dasher in combination with eye tracking may be used to help patients communicate.[1] New direct brain interface mechanisms may provide future remedies.[7][8]

[edit] Prognosis

It is extremely rare for any significant motor function to return. The majority of locked-in syndrome patients do not regain motor control, but devices are available to help patients communicate. Within the first four months after its onset, 90% of those with this condition die. However, some people with the condition continue to live much longer periods of time.[9]

[edit] Notable cases

[edit] Jean-Dominique Bauby

Parisian journalist Jean-Dominique Bauby suffered a massive stroke in December 1995, and when he awoke 20 days later he found that his body was almost completely paralyzed: he could control only his left eyelid. By blinking this eye, he dictated a letter at a time and in this way he wrote his memoir The Diving Bell and the Butterfly. A few days after it was published in March 1997, Bauby died of pneumonia.[10] The 2008 film The Diving Bell and the Butterfly is a screen adaptation of Bauby's memoir.

[edit] Julia Tavalaro

In 1966, Julia Tavalaro, then aged 32, suffered two strokes and a brain hemorrhage and was sent to Goldwater Memorial Hospital on Roosevelt Island, New York. For six years, it was believed she was in a vegetative state. In 1972, a family member noticed her trying to smile after she heard a joke. After alerting doctors, a speech therapist, Arlene Kratt, discerned cognizance in her eye movements. Kratt and another therapist, Joyce Sabari, were eventually able to convince doctors that she was in a locked-in state. After learning to communicate with eye blinks in response to letters being pointed to on an alphabet board, she became a poet and author. Eventually, she gained the ability to move her head enough to touch a switch with her cheek, which operated a motorized wheelchair and a computer. She gained national attention in 1995 when The Los Angeles Times Magazine published her life story. It was republished by Newsday on Long Island and in other newspapers across the country. She died in 2003 at the age of 68.[9][11]

[edit] Gary Griffin

Gary Griffin was a veteran of the United States Air Force who became immobile due to ALS (Lou Gehrig’s disease). He was later equipped with a device called the NeuroSwitch which allows him to control a computer and communicate with his family. Sensors are attached to the skin over a patient’s muscles and signals are sent to an interface that translates the slightest muscle contractions into usable code. A video of Griffin and his use of the NeuroSwitch has been posted on Youtube.[12]

[edit] Erik Ramsey

In 1999, 16-year-old Erik Ramsey suffered a stroke after a car accident that left him in a locked in state. His story was profiled in an edition of Esquire Magazine in 2008. Erik is currently working with doctors to develop a new communication system that uses a computer that, through implants in his brain, reads the electronic signals produced when he thinks certain words and sounds. At present, Erik is only able to communicate short and basic sounds. However, doctors believe that within a few years, Erik will be able to use this system to communicate words, phrases and eventually, to "talk" normally.[9][13]

[edit] Popular culture

  • Thrash metal band Metallica's song One is based on the book/film adaption of Johnny Got His Gun where a soldier in World War I has lost all of his limbs and wishes to be killed, or be put in a "freak show" to show the world the horrors of war.
  • On the TV program CSI New York's first season episode Blink, a disgraced Russian doctor working in New York as a cabbie experiments on his female passengers and a woman who was staying with the doctor and his wife. Detective Mac Taylor is only able to communicate with the final victim by her blinking twice for yes and once for no.
  • Locked-in syndrome secondary to leptospirosis was the case study for Dr. Gregory House and his team in the season 5 episode Locked In of the US TV Drama House, MD.
  • In a play named "Pills, Thrills and Automobiles," one of the characters (Eddie) is left in a locked in state due to a car crash.[citation needed]

[edit] References

  1. ^ "Scientists seek to help 'locked-in' man speak", CNN, 14 December 2007
  2. ^ Nordgren RE, Markesbery WR, Fukuda K, Reeves AG (1971). "Seven cases of cerebromedullospinal disconnection: the "locked-in" syndrome". Neurology 21 (11): 1140–8. PMID 5166219. 
  3. ^ Flügel KA, Fuchs HH, Druschky KF (1977). "[The "locked-in" syndrome: pseudocoma in thrombosis of the basilar artery (author's transl)]" (in German). Dtsch. Med. Wochenschr. 102 (13): 465–70. PMID 844425. 
  4. ^ "eMedicine - Stroke Motor Impairment : Article by Adam B Agranoff, MD". http://www.emedicine.com/pmr/topic189.htm. Retrieved on 2007-11-29. 
  5. ^ Plum F. and Posner J.B. 1966. The diagnosis of stupor and coma. F.A. Davis Co. Philadelphia, Pennsylvania, USA. 197 pp.
  6. ^ lockedinsyndrome at NINDS
  7. ^ Parker, I., "Reading Minds," The New Yorker, January 20, 2003, 52-63
  8. ^ Turning Thoughts into Words By Chris Berdik, Research at Boston University 2008 magazine (reprinted in BU Today), October 15, 2008.
  9. ^ a b c The Unspeakable Odyssey of the Motionless Boy by Joshua Foer, Esquire Magazine, October 2, 2008.
  10. ^ "The Diving Bell And The Butterfly". http://www.avclub.com/content/cinema/the_diving_bell_and_the. Retrieved on 2007-11-29. 
  11. ^ Julia Tavalaro, 68; Poet and Author Noted for Defying Severe Paralysis, Los Angeles Times, Page B16, December 21, 2003.
  12. ^ NeuroSwitch Enables Veteran with Locked in Syndrome at Youtube.com.
  13. ^ Out of silence, the sounds of hope by S.I. Rosenbaum, The Boston Globe, July 27, 2008.

Mentioned in a episode of House Md. Season 5, Episode 19.

[edit] External links

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