For Some Brain-Injured Patients, a Deep Coma Is the Treatment
Laura Gagliardi awoke from a coma on her 17th birthday, three months after she suffered traumatic brain injury in a car accident. It was an event her family and doctors had hoped for but did not expect.
Gagliardi had arrived at the hospital unconscious and unresponsive. But rather than battling to keep the teenager out of a coma, Dr. Hilary Onyiuke, a neurosurgeon who directs the brain injury unit at Hartford Hospital in Connecticut, put her into a deeper one--an increasingly common, though still experimental, treatment.
The idea of putting a patient into a coma to help heal injury sounds like science fiction, but the technique, known as medically induced coma, has been around since the 1970s. It was, and still is, a treatment of last resort, an attempt to save the life of a critically injured person.
“Her prognosis was terribly poor,” Gagliardi’s mother, Linda Cromer of Plainville, Conn., said of the near-fatal September 1994 accident.
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The technique is somewhat controversial, however, because, despite its use in critical-care units, no controlled studies have been conducted to scientifically determine its effectiveness.
“I think there are questions. For one thing, does it work?” said Dr. Leslie Wolfson, chairman of the neurology department at the University of Connecticut School of Medicine. “I’m not sure the study that would prove its effectiveness has ever been done.”
The treatment is not standard care for people with brain injury, said Dr. Anthony Morgan, who heads the trauma unit at Hartford’s St. Francis Hospital and Medical Center, “because, while we do know that with a select population it does seem to work, no one to date has been able to select in advance who is going to respond.”
Morgan, who has written a book on brain-injury treatment and recovery, said the trend is toward gene therapy and techniques such as hypothermia, which, like medically induced coma, slow the brain’s metabolic rate.
The research “is using gene therapy to regenerate cells, to induce growth to replace brain cells that have been damaged,” he said.
But other neurologists working with critical-care patients have used the induced-coma technique over the years and come to believe it can save lives.
At Yale-New Haven Hospital’s neural-intensive-care unit, an occasion to use the treatment arises several times a month, said Dr. Issam Awad, who heads the unit. Victims who experience traumatic brain injury in car accidents, near-drownings or severe falls are the usual candidates.
In the mid-1980s, the technique started to be used in cases where there was hope of recovery, not just nearly hopeless cases, Awad said.
“By the ‘90s, it has now become almost routine for complex neurological cases at technologically sophisticated medical centers,” he said.
The theory behind the technique is that decreased brain-wave activity can help to dramatically reduce internal pressure in the brain when it has been severely injured. The absence of brain activity lessens the metabolic demands on the brain, allowing it to rest and heal. The patient lies in the deepest realm of unconsciousness possible for a living person.
“It’s electro-cerebral silence, with no brain-wave activity. The patient is flat-line,” said Onyiuke.
When the brain experiences injury, swelling occurs. With no room to expand inside the skull, pressure builds, decreasing the oxygen that is carried to the brain by the blood flow. Using an intra-cranial fiber-optic monitor inserted into the brain and a fast-acting barbiturate such as pentobarbitone, the patient rapidly descends into a deep coma. All bodily functions, including breathing and blood pressure, are maintained by life-support machines. Involuntary movements are suppressed by another drug that acts as a paralyzing agent.
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Gagliardi’s mother remembers those anxious days. “We weren’t allowed to touch her,” she said. “They did not want her to be stimulated in any way.”
The patient can be maintained in that state for days or, in some cases, weeks. Then, over three to five days, the patient is gradually brought out of the deep coma. In about 10% of cases, Onyiuke said, pressure in the brain continues to rise, unaffected by the treatment.
“If you have 100 patients, about 30% of them will benefit, though you cannot predict in advance who that will be,” Onyiuke said, although it appears to be less effective in patients older than 60.
“It’s not a panacea, but I know from my own practice that it works. I’ve seen people we almost gave up on who are now walking around, living miracles.”
Onyiuke counts Gagliardi as one of those miracles. Days after the treatment, Gagliardi began to show small signs of improvement. “Her eyes were open, and she turned her head when her father called her name,” Cromer said. Then came the call on Dec. 10, her daughter’s birthday. “A social worker called to say she had responded to commands. She told her to squeeze her hand and let go, and she did.”
While patients may experience paralysis and require extensive rehabilitation, those effects are the result of the injury that led to the coma, not the coma itself, experts say.
Gagliardi has no memory of the accident or her hospital treatment.
“I just remember getting a new job about two weeks before the accident,” she said.
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Gagliardi has undergone months of rehabilitation, relearning to walk, dress herself and perform everyday tasks. She graduated from high school in June 1998.
“I started out in a wheelchair, then I had a quad cane, then a single cane and now nothing,” said Gagliardi, who is now 21. “I can do most things except drive.” For that, she has her fiance. They plan to marry this month.
Gagliardi continues to progress and still periodically visits Onyiuke.
“They just look at her and smile,” her mother said. “They don’t know how she’s doing what she’s doing. She was very lucky.”
As she continues to rebuild her life, Gagliardi doesn’t think much about that these days. “I’m just glad they did it,” she said. “It saved my life.”
